International Health Policy Program -Thailand Financing for Universal Coverage Experiences from...
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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, India17 March 2011
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• 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.
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Health financing arrangements and three public Health financing arrangements and three public
health insurance schemes in Thailand after achieving health insurance schemes in Thailand after achieving
UHC in 2002UHC in 2002
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 with global budget
Full capitation
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Share of public and private sources of health care finance in Thailand, 1994-2008
56%45% 47% 47% 54% 55% 55% 56%
63% 63% 64% 64%
75% 73%
68%
55%53%
53% 46% 45% 45% 44% 44%
36%36%37%37%
25%
27% 32%
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
Year
Millio
n B
ah
t
Public f inancing sources Private f inancing sources
Achieving UC
Total health expenditure during 2003-2008 ranged from 3.49 to 4.0% of GDP, THE per capita in 2008 = 171 USD
Progressive health financing sources lead to equitable 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
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
Financial risk protection (2)Incidence of catastrophic health expenditure 2000-2006
Incidence 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+
Distribution of budget subsidies for health: BIA, 2001 and 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
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Long-term financial projection, 2006-2026 based on 1994-2005 NHA, by ILO and Thai experts in
2008Expenditure Share in GDP of Financing Agencies - Long-term Trends
0.0
1.0
2.0
3.0
4.0
5.0
6.0
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026
Per
cent
MoPH OthMin LocGovt StateEnterprise CSMBS SocSec UC WCF PrivIns TrafficIns ERBenefits PrivHH NonProfit RoW
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
The impact of different provider payment methods onThe impact of different provider payment methods onuse of expensive procedures across 3 public insurance schemesuse of expensive procedures 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
FFS payment of CSMBS and use of expensive OP medicinesFFS payment of CSMBS and use of expensive OP medicinesVariations across 3 public insurance schemesVariations across 3 public insurance schemes
Source: Limwattananon et al. (2009)
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Double-digit cost escalationDouble-digit cost escalationCSMBS health expenditure CSMBS health expenditure (1988-2010)(1988-2010)
13Source: Comptroller General Department, Ministry of Finance
-2%
23%
12%13%
20%
12%
6%
10%
-2%
15%
12%
16%
20%46,588
61,304
37,004
54,904
46,481
17,058
26,043
20,476
16,44013,587
9,954
3,1566,000
4,316
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
Annual growth (real term) Total expenditure (million Baht) Outpatient (million Baht) Inpatient
(Expenditures in nominal term)
1997 Asian economic crisis
and conservative reform
2006 implementation:
- IP DRG system
- OP direct billing
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
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.
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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