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 FinancingPhnom Penh, Cambodia

2-4 May 2012

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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

1945

2000

2002

Informal user fee exemption

1980

1970

User fees

1-3rd NHP1962-76Provincial hospitals

Health Infrastructure extension--wide geographical coverage

Historical development of the Thai health system:

Infrastructure development + financial protection extension

1975LIC

1990

Establishment of prepayment schemes

1983CBHI

1980CSMBS

1990SSS

Universal Coverage

CSMBS

2002 full achieve

Universal Coverage

SSS

LIC MWS 1994Pub VHI

CSMBS

SSS

Expansion consolidation of prepayment schemes

4th -5th NHP (1977-86) District hospitalsHealth centers

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How health care providers are paid by How health care providers are paid by

insurance ?insurance ?Financing sources and payment methods for CSMBS, UCS, and

SSS

Health care finance and service provision of Thailand after achieving universal coverage (UC)

General tax

General tax Standard Benefitpackage

Tripartite contributionsPayroll taxes

Risk relatedcontributions

CapitationCapitation & global

Co-payment budget with DRG for IP

Services

Fee for servicesFee for services - OP

Population Patients

Ministry of Finance - CSMBS(6 million beneficiaries)

National Health Insurance Office The UC scheme (47 millions of pop.)

Social Security Office - SSS(9 millions of formal employees)

Voluntary private insurance

Public & Private Contractor networks

Source: Tangcharoensathien et al. (2010)

Traditional FFS for OPDirect billing FFS(2006+) for OP

FFSuntil 2006, DRG for IP

Capitation for OP

DRG under global budget

Full capitation

5

Increased access to and utilization of health services with very low unmet needs

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

Distribution of government subsidies for health:

BIA from 2001 to 2007

28%

31%

28%

29%

20%

22%

26%

24%

17%

15%

20%

20%

17%

16%

14%

14%

18%

15%

11%

12%

0% 20% 40% 60% 80% 100%

OP&IP

OP&IP

OP&IP

OP&IP

2544

2546

2549

2550

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

More pro-poor health care system and distribution of government subsidies for health after achieving UHC in 2002

24%

1%9%

26%

1% 3%

24%

4%

6%

24%

7% 6%

18%

34% 21%

16%

38%

23%

11%

48% 55%

12%

35%

57%

0%

20%

40%

60%

80%

100%

UC SS CS UC SS CS

2003 2007

20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest

7

Incidence of catastrophic health spending

OOP>10% total consumption expenditure

Source: Analysis of Socio-economic Survey (SES)

8

UHC achieved

Protection against health impoverishment

9

Sub-national health impoverishment 1996 to 2008

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

1996 1998 2000 2002

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

2004 2006 2007 2008

17.69.4 7.8 5.0

2.6 0.9 0.9

63.6

54.542.0

25.113.8 10.2 9.6

5

20.330.7

47.658.1 66.7 61.2

13.9 15.8 19.6 22.3 25.5 22.1 28.3

0

10

20

30

40

50

60

70

80

90

100

2005 2005 2005 2005 2005 2005 2005

% t

ota

l h

osp

ita

l

developing Level 1 Level 2 accredited HA

after Pay by quality based paybefore

หมายเหตุ� ปี 2554 เปี�นข้�อม�ล ณ ไตุรมาส 2Sources : Healthcare Accreditation Institute (Public Organization), 2011.

adapted by Bureau of Service Quality Development, NHSO.

Increased hospital accreditation status in 2005-2011

Starting

special pay

*54 = estimation from Aug. 2010 – Jul.2011 Source : IP individual record 2005- 2011 , NHSO

Starting Refer-back networking devlop.

Starting

Special pay

*54 = estimation from Aug. 2010 – Jul.2011

Source : IP individual record 2005- 2011 , NHSO

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

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Remaining key challenges in financing UCH in Thailand

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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

Inequity in quality of care and health service provision:

Percentage of caesarian section to total deliveriesby health insurance schemes

15.4% 15.9% 16.4% 17.0% 17.2% 17.8% 18.3% 18.9% 19.8% 20.0% 20.0% 20.1%

17.0% 17.3% 16.2% 16.8% 18.4%20.2% 20.3% 21.6% 20.6% 20.1% 19.3% 19.7%

28.8%

36.3%

30.5%

24.3%

35.9%

42.3%

37.7%41.4%

45.6%

40.1%

48.4% 48.1%

9.8%

14.3%

6.0%

9.3%

14.0%12.2% 12.7%

18.5%16.4% 16.4%

20.4%

15.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2004Qtr1

2004Qtr2

2004Qtr3

2004Qtr4

2005Qtr1

2005Qtr2

2005Qtr3

2005Qtr4

2006Qtr1

2006Qtr2

2006Qtr3

2006Qtr4

UC SSS CSMBS ROP

Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

49% 48%51%

47% 47%

52%50% 51% 53%

55% 55% 55% 56%54%

51%

24%22% 23% 23%

25% 24%22%

18%

30%26% 26%

28% 27% 27% 26%

23%21%

22%20%

24%22%

24% 24% 24% 26%28% 27%

29% 28% 28%

0%

10%

20%

30%

40%

50%

60%

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

2004 2005 2006 2007

CS

SS

UC

45%47% 48%

50%52% 50% 51%

53% 54% 55% 56%54% 56% 58% 59%

17% 17% 16% 17%18%

20% 20% 22% 21% 20% 19% 20%

16% 16% 17% 17% 18% 18% 19% 20% 20% 20% 20% 20% 20% 21% 21%

0%

10%

20%

30%

40%

50%

60%

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

Qtr4

Qtr1

Qtr2

Qtr3

2004 2005 2006 2007

CS

SS

UC

Cesarean section Laparoscopic cholecystectomy

Use of expensive proceduresUse of expensive proceduresVariations across 3 public insurance schemesVariations across 3 public insurance schemes

Source: Limwattananon et al. (2009)

Angiotensin II receptor blockers

0

5

10

15

20

25

30

35

40

45

50

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Single source statins and new antihyperlipidemia

0

5

10

15

20

25

30

35

40

45

50

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Clopidogrel

0

5

10

15

20

25

30

35

40

45

50

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Coxibs

0

5

10

15

20

25

30

35

40

45

50

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

Jan

Apr Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Use of expensive OP medicinesUse of expensive OP medicinesVariations across 3 public insurance schemesVariations across 3 public insurance schemes

Source: Limwattananon et al. (2009)

Cost escalation: Consequence of fee for services in Civil Servant Medical Benefit Scheme

46,588

61,304

37,004

54,904

46,481

17,058

26,043

20,476

16,44013,587

9,954

3,1566,0004,316

62,196

13,905

21,896

30,833

38,803

9,5097,007

1,729 2,337 3,3745,8664,826

45,531

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Total expenditure (million Baht) Outpatient (million Baht) Inpatient

Evidence:

• In 2010, 62.196 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

Mismatch between increasing burden of disease from NCD and low investment in HP and disease

preventionDALY lost from Risk factors, Thailand 1999 and 2004

943

838

595

594

440

410

238

169

144

132

91

54

53

29

25

1,310

550

490

490

400

370

220

140

370

120

120

60

70

30

40

0 200 400 600 800 1000 1200 1400

Unsafe Sex

Alcohol

Blood pressure

Tobacco

Non-Helmet

BMI

Cholesterol

Low intake of fruit and vegetable

Illicit Drugs

P hysical Inactivity

Air P ollution

WSH

Malnutrition-Inter

Malnutrition-Thai

Non-Seatbelt

DALYs('000)

19992004 Health administration

and health insurance 8.5%

Medical goods4.3%

Ancillary services 0.4%

Prevention and public health services

4.8%

Services of curative & rehabilitative care

78.1%

Gross capital formation

3.9%

0

50

100

150

200

250

300

350

400

450

500

Q1 Q2 Q3 Q4 Q5

Thou

sand

s

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol0

50100150200250300350400450500

Q1 Q2 Q3 Q4 Q5

Thou

sand

s

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol

DALYs attributable to risk factors

21

HIV/AIDS Financing (Source: UNGASS Reports 2008 & 2010)

2007200

8

200

9

Total Expenditure:Total AIDS expenditure, million Baht

6728, 692

8 7208

Total Health Expenditure, million Baht2488,52

3 6 3 ,771

383,051

Total AIDS expenditure, as

per capita population, Baht 105 110 114

per capita PLWHA, Baht 1160,0

142,75

144,17

% GDP008

008 008

% THE27. % 19. % 19. %

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%

Sources: Analyses from the 2002, 2004, and 2006 SES

52 65

152

303

433

303

390433

650

867

47 6093 120

205

0

100

200

300

400

500

600

700

800

900

1000

Q1 Q2 Q3 Q4 Q5

Bah

t per

cap

ita

Income quintiles

Median (in Thai Baht) of household spending on tobacco, alcohol and health in 2006

Tobacco

Alcohol

Health

Household expenditure: tobacco, alcohol and health

Median household expenditure (Baht per month), 2002-2006

Inequity in geographical distribution of Health workforce in 2007

Physicians

800-3,3053,306-6,2746,245-9,2729,243-12,300

Dentists

5,500-15,14315,144-25,76725,768-36,39036,391-47,011

Nurses

280 - 652653 - 904905 - 1,1561,157 – 1,408

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Economic loss of 12 priorities BOD in Thailandfor prioritization of health investment in the 10th

NHDP

diseasesDALY loss

(1)

Curative expenditure

(2)

Productivity loss due

to premature death(3)

Productivity loss due

to absenteeis

m (4)Total

(2+3+4)

1 HIV/AIDS 19% 17% 35% 6% 30%

2Traffic accidents 15% 31% 26% 30% 27%

3 CVD 13% 7% 9% 5% 9%

4 DM 9% 18% 4% 32% 8%

5 Liver cancer 8% 1% 10% 1% 8%

Total 100% 100% 100% 100% 100%

Total top 12 disease burden

4,780,000 yr

61,936 million Baht

208,287 million Baht

11,273 million Baht

281,497 million Baht

Percent by row22% 74% 4% 100%

% of Thai GDP in 2005 4.0%Note:

1.Little success in controlling and preventing road traffic injuries, increasing incidence and prevalence of MDR- and XDR-TB,

2.Revitalizing HIV control and prevention in the light of universal ART.

3.Controlling the incidence and prevalence of ESRD patients who require renal replacement therapy (hemodialysis, PD, and KT)

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25

ConclusionsEffective 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.

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Key stakeholders and participatory processes in topic selection for economic evaluation of UC benefit

package

Academic

Medical specialists

Civil Society

Patients

Focus group

discussionPolicy maker

Medical specialists

Academic group

Civil Society

General population

Patients

Industry

Topic selection

meetingKey s

takeh

old

ers

Key

sta

keh

old

ers

Research working

groups

UC Benefit PackageSubcommittee

Submission of topics of concerns for consideration

- evidence on cost effectiveness,

-- budget impact analysis,

-- systems readiness to implement,

-- equity and ethical considerations

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27

Acknowledgement

27

• 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