2. International Health Policy Program -Thailand Financing for Universal Coverage Experiences from Thailand Phusit Prakongsai, M.D. Ph.D. Viroj Tangcharoensathien, M.D. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to the Partners for Health in South-East Asia Conference Le Meridien Hotel, New Delhi, India 17 March 2011

3. International Health Policy Program -Thailand 2 Background After using targeting and piecemeal approaches for 27 years, Thailand achieved universal health coverage (UC) in 2002 by introducing a tax-financed health insurance scheme, the UC scheme, to approx. 47 million of Thais who were neither civil servant (CSMBS) nor social health insurance (SHI) beneficiaries, The benefit package of the UC scheme is very comprehensive comprising breadth and depth of health insurance coverage, Financing arrangements of the UC scheme are: – removal of financial barriers to health services; – shift of the main source of HCF from OOP to general tax; – promoting the use of primary care by contracting a PCU as the main contractor and gatekeeper; – changing provider payment from historical allocations to close-ended payments.

4. International Health Policy Program -Thailand 3 Health financing arrangements and three public health insurance schemes in Thailand after achieving UHC in 2002 Source: Tangcharoensathien et al. (2010) Traditional FFS for OP Direct billing FFS (2006+) for OP FFS until 2006, DRG for IP Capitation for OP DRG with global budget Full capitation

5. International Health Policy Program -Thailand 4 Share of public and private sources of health care finance in Thailand, 1994-2008 Achieving UC Total health expenditure during 2003-2008 ranged from 3.49 to 4.0% of GDP, THE per capita in 2008 = 171 USD

6. Progressive health financing sources lead to equitable financial contribution: Kakwani indexes, 2000-2006

7. Financial risk protection (1) Household OOP as % household income, 1992-2008 Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

8. Financial risk protection (2) Incidence of catastrophic health expenditure 2000-2006 Source: Analysis from NSO SES 2000-2006

9. International Health Policy Program -Thailand 8 Financial risk protection (3) Trend of health impoverishment 1996-2008

10. Distribution of budget subsidies for health: BIA, 2001 and 2007

11. International Health Policy Program -Thailand 10 Long-term financial projection, 2006-2026 based on 1994-2005 NHA, by ILO and Thai experts in 2008

12. Cesarean section Laparoscopic cholecystectomy The impact of different provider payment methods on use of expensive procedures across 3 public insurance schemes Source: Limwattananon et al. (2009)

13. FFS payment of CSMBS and use of expensive OP medicines Variations across 3 public insurance schemes Source: Limwattananon et al. (2009)

14. International Health Policy Program -Thailand 13 Double-digit cost escalation CSMBS health expenditure (1988-2010) 13 Source: Comptroller General Department, Ministry of Finance (Expenditures in nominal term) 1997 Asian economic crisis and conservative reform 2006 implementation: - IP DRG system - OP direct billing

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

16. Lessons learnt from Thailand Mixed health financing arrangements (general taxation, SHI contribution, community-based health insurance) tend to be the best choice for developing countries to achieve UC, Pragmatic approach: Thai experiences indicate targeting different population prior to achieving universal coverage is inevitable, Depth (comprehensive benefit package), height (minimum or zero copay) are vital for financial risk protection  catastrophic and impoverishment outcome, Purchasing and provider payment method vital for long term financial sustainability: stay away from fee for service, and apply close end payment such as capitation, global budget + DRG, Strong political support, movement from civil society, and strong research capacity are key success factors  ‘Triangle that moves the mountain’ Health systems capacity to deliver services as promise, translate rhetoric statement into reality.

17. International Health Policy Program -Thailand 16 Acknowledgements National Statistical Office (NSO) of Thailand National Health Security Office (NHSO) of Thailand Ministry of Public Health (MOPH) of Thailand Health Systems Research Institute (HSRI), Health Insurance System Research Office (HISRO) of Thailand, World Health Organization (WHO) London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom

18. Process and functions of healthcare financing Source of finance 1. Revenue Collection 2. Pooling3. Purchasing Health ServicesHealth Impact Direct payment A process of funding health care system

19. Pooling (risk sharing) Contribution Low High Net transfer Utilization Source: WHR(2000) Note: size of arrow represents amount of contributions Risk

20. Pooling (financial distribution) Income Low High Net transfer utilization Contribution Source: WHR(2000) Note: size of arrow represents amount of contributions