1

Evaluating ten years of universal health coverage in

Thailand

Viroj Tangcharoensathien, MD. Ph.D.Phusit Prakongsai, MD. Ph.D.

International Health Policy Program (IHPP)Ministry of Public Health of Thailand

Presentation to the 13th Annual Scientific Conference (ASCON XIII)ICDDR,B, Dhaka, Bangladesh

15 March 2011

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Objectives

– Review achievements of universal coverage – Propose a conceptual framework for 10 years

UC assessment [2001-10] to generate evidence and stimulate international debates

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Background 1• Thailand,

– LMIC, GNI/capita 3,760, THE: US$136/capita, 3.4% of GNI, OOP<18% of THE (2008)

• A long march: 27 years of gradual coverage extension – Application of piecemeal targeting approaches

• The poor, children, elderly, vulnerable: tax financed social welfare schemes

• Formal sector• Civil servants and family: tax financed medical welfare • Private employee: payroll tax financed SHI

• Informal non-poor sector : CBHI, transform to public subsidized voluntary insurance

• The 30% uninsured was “last pushed” by general tax financed scheme

• By 2002 Thailand achieved full population coverage, by 3 public insurance schemes

• Formal sector • Private employee by SHI • Civil servants and dependants, tax financed scheme.

• The rest of population by tax financed scheme, free at point of service

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Background 2

• Strong institutional capacities– Generate evidence and evidence informed policies

• Policy relevance researches • Maintaining normative works

• NHA, BOD, National Drug Account, National AIDS Spending Account, national household datasets for routine equity monitoring

– Health technology assessment capacities: • HITAP institutional relation with UK NICE

– Key platforms for evidence informed decision • National Essential Drug List sub-committee • Benefit package sub-committee

• ICER, budget impact assessment are pre-requisites for inclusion of new interventions into drug list or UC benefit packages

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GNI per capita, US$ on a road towards UHC, 1970-2009

390

710

760

1490

2,7

00

1,9

00

0

1,000

2,000

3,000

4,000

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

US $

1997: Asian financial crisis

1990 SHI introduced

1980 CSMBS introduced

1983 CBHI introduced

1975 Low Income scheme introduced

2002 Universal Coverage for entire population achieved

2001: 29% of population are uninsured

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Evidence on outcome: before and after UHC

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Equity in financial contribution: Kakwani indexes, 2000-2006

Share of health care finance (% ) 2000 2002 2004 2006 Out of pocket payments 33.7 27.9 26.4 23.2 Direct tax 18.0 18.8 20.8 24.5 Indirect tax 33.4 38.2 37.1 35.2 Premium Insurance 9.6 9.2 8.9 9.2 SHI contribution 5.3 5.9 6.8 7.9 Premium insurance & SHI contribution na na na 17.1% Overall Kakwani index 100.0 100.0 100.0 100.0

Kakwani indexes 2000 2002 2004 2006 Out of pocket payments -0.150 -0.076 -0.076 -0.045 Direct tax 0.391 0.416 0.442 0.362 Indirect tax -0.096 -0.069 -0.043 -0.083 Premium Insurance -0.362 -0.391 -0.323 Na SHI contribution 0.165 0.112 0.105 Na Premium insurance & SHI contribution Na Na Na -0.049 Overall Kakwani index -0.0035 0.0374 0.0630 0.0406

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Financial risk protection 1: Household OOP as % household income, 1992-2008

8.17

4.82

3.74 3.65

2.87 2.57 2.451.99

1.641.27

4.58

3.673.29

2.782.38 2.22 2.06

1.68 1.55 1.27

2.05 1.95 1.69 1.66 1.74 1.68 1.66 1.83 1.742.18

0

1

2

3

4

5

6

7

8

Hea

lth

pay

men

t :

Inco

me

(%)

1992

1994

1996

1998

2000

2002

2004

2006

2008

Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

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Financial risk protection 2: Incidence of catastrophic health expenditure 2000-

2006Incidence of catastrophic health expenditure 2000 to 2006,

Thailand, exceed 10% of total household income

0.9%

4.0%

3.3%

5.4%

2.0%

0%

1%

2%

3%

4%

5%

6%

2000 2002 2004 2006

Q1 (poorest) Q5 (richest) All quintiles

Source: Analysis from NSO SES 2000-2006

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Financial risk protection 3: Trend of health impoverishment 1996-2008

1996 2008

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

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Equity in utilization OP and IPConcentration index by levels 2001-2007

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Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).

OP utilization Facility levels 2001 2003 2004 2005 2006 2007 Health centers -0.294 -0.365 -0.345 -0.380 -0.267 -0.292 District hospitals -0.270 -0.320 -0.285 -0.300 -0.256 -0.246 Provincial, regional hospitals -0.037 -0.080 -0.119 -0.100 0.028 0.013 Private hospitals 0.431 0.348 0.389 0.372 0.516 0.528 Overall -0.090 -0.139 -0.163 -0.177 -0.054 -0.041

IP utilization Types of health facilities 2001 2003 2004 2005 2006 2007 District hospitals -0.316 -0.293 -0.294 -0.266 -0.242 -0.293 Provincial, regional hospitals -0.069 -0.138 -0.114 -0.156 -0.049 -0.114 Private hospitals 0.320 0.309 0.254 0.366 0.398 0.464 Overall -0.079 -0.121 -0.127 -0.114 -0.051 -0.080

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Equity in budget subsidies: Benefit Incidence Analysis, 2001-2007

Benefit incidence analysis, 2001-2007

2820 17 17 18

31

2215 16 15

28 2620

14 11

2924

2014 12

0

20

40

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

2001 2003 2006 2007

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Summary: achievements

• Evidence on achievements – Financing sources

• Public sources of finance [general tax and SHI contribution], the dominant source [67.6% THE], is the most progressive source of financing healthcare and positive Kakwani index,

• OOP reduced to 18% of THE (2008), minimum rich-poor gap of OOP

– Financial risk protection• Very low level of catastrophic health spending and

impoverishment

– Service utilization and public subsidies • Pro-poor utilization both OP and IP • Pro-poor public subsidies

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Summary: contributing factors

• Contributing factors – Systems design: most important for equity and efficiency

outcomes• Prakongsai et al, the equity impact of the universal

coverage policy: lessons from Thailand, in Chernichovsky and Hanson (eds), Innovations in health system finance in developing and transitional economies 2009.

– Supply side capacity to deliver services • Extensive geographical coverage of functioning primary

health care and district health systems – Sustainable institutional capacities

• Generate evidence• Maintain normative works as foundations for monitoring

evaluation • Platforms for evidence informed decisions

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• Before UCS• After UCS

UCS

1. UC Policies process & system design

who whyhow

4. governance

Structure

Governance NHSO

Power

2. Contextual environment- MOPH structural reform-downsizing public sector-Decentralization -Medical hub-Compulsory Licensing-health information & IT -Governance of overall health system

Population Providers Health system

• Utilization • Financial protection • Perception

• Service pressure• Financial • Efficiency • Perception

• Primary care development• Medical service delivery• Public health functions • Information system• Human resources• Resilience of system

Macroeconomics5. Impact

MOPH NHSO

Purchaser-provider split HarmonizationStrategic purchasing

3.implementation

Scope of assessment of Thai UCS: 2001-10

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Assessment of 10 years UCS

• Teams – International experts

• Tim Evans (BRAC chair), Armin Fidler WB, Magnus (WB), Mushtaque (RF), Anne (LSHTM), Xenia (ILO), David (WHO)

– Thai experts • Five team leads

• Deliverables – Prelim report Oct 2011, – Final report launched in Prince Mahidol Award Conference, Jan

2012 on UHC – Scientific publications