1. The Thai Experience on Achieving Universal Healthcare Coverage Samrit Srithamrongsawat Health Insurance System Research Office CHF best practice workshop Dar les Salaam 31 Jan – 2 Feb 2007

2. Thailand: Country Background Population in million (2006)63 Administrative areas (provinces)76 % Population in urban area31 GNI / Capita ($ in 2005)$2,750 % Growth GDP (2005)4.5 % Gov. revenue from direct taxes (2001) 30 %Total health exp. of GDP in 20053.5 % public financing in 200564 Per capita expense/ year 2005$98

3. 1945 2000 2001 Informal exemption 1980 1970 User fees 1-3 rd NHP 1962-76 Provincial hospitals Health Infrastructure Thailand: historical development 1975 LIC 1990 Establishment ofprepayment schemes Expansion ofprepayment schemes 1980 CSMBS 1983 HC(CHF) 1990 SSS 4 th -5 th NHP (1977-86) District hospitals Health centers UniversalCoverage CSMBS SSS 2001 Universal Coverage LIC  MWS 1994 HC(PVHI) SSS

4. Coverage of health insurance: 1991-2003 Source: HWS 1991, 1996, 2001, 2003

5. System design: ensuring sustainability Close-end budgets – Capitation Purchaser-Provider split Financial management reform –Capitation for OP –DRG weighted global budget for IP –Capitation and performance for prevention and promotion services –Reinsurance for accident and emergency services and high cost services Strengthening primary care: establishment of primary care unit (PCU) Prevention and promotion services Quality improvement: HA, service practice guideline Consumer protection: no-fault liability, call center

6. Characteristic of the UCS NatureEntitlement, tax-based system Financing modelPublic contracted model, capitation 1,899 THB in 2007 BeneficiariesThai citizens uncovered by SSS and CSMBS Benefit packageComprehensive package including prevention and promotion services (PP) and accredited alternative medicines with an exclusion list of some services Service providersContracted public and private hospitals and requiring all hospital to establish one primary care unit (PCU) for every 10,000-15,000 registered population Payment methodCapitation for OP,PP; DRG weighted global budget for IP Reinsurance for A/E and High cost care Co-payment30 Baht per visit with exemption for those previously under the Medical Welfare Scheme (it was abolished in 2006)

7. Some policy achievements 80% of UC members are those residing in rural areas and 60% are those in the two bottom quintiles Shifting utilization of service toward primary care Increase in access to high cost services i.e. open-heart surgery, malignancy, cataract Reduce catastrophic expenditure cases by 25% and prevent impoverishment according to paying medical care ~300,000 people in 2003 Decrease in the gap of burden of health expenditure between the poor and the rich

8. Utilization: increase access and use of PCU and district hospitals source: NSO HWS2001, 2003 and 2004

9. Improved fairness of financial contributions Source: Socio-Economic Survey 1992 - 2002 conducted by NSO. Declining of gap

10. Declining of financial catastrophic illnesses in Thailand 1996-2002 Source: National Statistic Office, Household Socio-economic Survey, 1996, 1998, 2000, 2002

11. Major constraints and further development Competing with other social objectives as depending totally government budgets Inequitable distribution of health infrastructure Fragmentation of health insurance schemes  harmonization Long term financial sustainability of the scheme need further exploration

12. Approved vs estimated capitation 2002 - 2006

13. TanzaniaThailand ContextsLimited basic health infrastructure Limited resources for health -1945 User fee in public facilities and collected fees were retained at facilities -1975 Low-Income scheme -1983 CHF  1994 PVHI -Well-establishment of basic health infrastructure ObjectivesMobilize resources for health -1983 Enable access to essential services -1994 Risk sharing Comparison of Tanzania & Thai CHF_1

14. TanzaniaThailand ContributionsVaries by districtA flat rate for all (500 THB) Matching fundEqual matching funds -1994-1998 equal matching -increase public subsidy 1999 - 2002 Cross-subsidy the poor ?Responsibility of the government. (Low Income scheme) Management of funds District-Province (~ district here) -National fund 2.5% for reinsurance policy covering A/E and high cost services MembersFamilyFamily up to five persons Benefit packageLimited benefits and varies by district Comprehensive package no limitation of use and ceiling -Referral care -High cost services -Portability of benefits Comparison of Tanzania & Thai CHF_2

15. TanzaniaThailand Enrollment-Health volunteers/ health centers - set a certain period of enrollment, 1- 2 per year, after the harvest season, divided payments -Provide incentives for sellers 2.5% -Mass media advertisement -Strong policy support from MOPH Coverage1-40% (total 15% of pop. In 1999) UtilizationOP 3 visits per year, IP 12% (1999) Cost recovery55% (1999) ProblemAdverse selection Comparison of Tanzania & Thai CHF_3