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Reducing impoverishment from health payments:
impact of universal health care coverage in Thailand
Phusit Prakongsai1
Supon Limwattananon1,2
Viroj Tangcharoensathien1
1 International Health Policy Program (IHPP)
2 Faculty of Pharmacy, Khon Kaen University
The First Annual Conference of HTAsiaLink
Grand Pacific Sovereign Hotel, Petchaburi,Thailand
May 14‐16, 2012
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• Background information
• Methodology
• Research findings
• Discussion
• Policy recommendations
2
Outline of presentation
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Background
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Universal Health Coverage – system changes
- Removal of financial barriers to access health services,
- Shift of the main source of health care finance from out-of-pocket payments to general taxation,
- Promoting the use of primary care by contracting a primary care unit (PCU) as the main contractor and gatekeeper,
- Changing provider payment mechanisms from historical allocations to close-ended payments,
- Increased access to, availability of and utilisation of quality health services, with a strong health infrastructure staffed by committed health professionals,
- Hospital Accreditation for all hospitals.
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ObjectivesObjectives
• To assess impact of the universal health care
coverage (UHC) on
household impoverishment due to direct health
payments,
households facing catastrophic health spending
(when household health expenditure exceeds 10%
of total household consumption or income)
Health impoverishment of households refers to
Total consumption expenditure – Health payments < Poverty lines
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MethodologyMethodology
• Comparing pre-UC (1996-2000) vs. post-UC (2002-2009)
- Descriptive analyses of health service use and household
health spending,
• Health impoverishment and catastrophic health spending
– Expenditure-based poverty lines as reported annually by NESDB
• Specific to urban-rural areas in 4 regions + Bangkok
– Consumption expenditures based on nationally representative
household Socio-economic Survey (SES) by National Statistical
Office (NSO)
– Health payment including
• Medicines/medical supplies
• OP + IP services
• Household is the unit of analysis
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Research findings
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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
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Incidence of catastrophic health spending
OOP>10% total consumption expenditure
Source: Analysis of Socio-economic Survey (SES)
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13.7
4.2
5.0
4.4
17.3
5.0
5.9
5.1
16.0
4.8
4.9
4.6
19.7
5.4
5.5
4.9
18.1
5.3
5.1
4.9
22.3
6.6
6.2
5.3
13.5
4.4
4.3
4.4
16.1
5.3
5.0
5.1
10.1
3.9
4.2
4.0
12.9
4.8
5.1
4.5
8.7
3.4
3.7
3.7
11.5
4.5
4.8
4.6
8.0
3.1
3.4
3.9
10.9
4.0
4.3
4.7
8.4
3.4
3.9
3.9
11.2
4.4
4.8
4.8
7.1
3.2
3.6
3.7
9.9
4.0
4.3
4.4
0
10
20
30
40
1996 1998 2000 2002 2004 2006 2007 2008 2009
All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf
PL: Poverty lines; Inf: Informal employment sector
All vs. Informal sector, 1996-2009
Poor and near-poor households
Consumption expenditure: < PL < 110% PL < 120% PL < 130% PL
15.5
13.1
18.3
9.2
7.8
5.4
3.6
5.0
3.8
19.7
18.2
27.1
12.512.0
7.6
5.5
6.8
4.9
2.5
1.00.2 0.1 0.0 0.2 0.0 0.1 0.0
10.2
5.3
9.3
3.8 3.4
1.50.8
1.70.8
13.6
11.0
12.0
8.5
5.44.6
2.4
4.74.0
All employment sectors
Informal sectors -all
Public employees -all
Private employees -all
Mixed groups
0
5
10
15
20
25
Imp
ove
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ed
ho
use
ho
lds p
er
1,0
00
no
n-p
oo
r h
ou
se
ho
lds
1996 1998 2000 2002 2004 2006 2007 2008 2009
Health impoverishment by employment status of household adult members
Reduction in health-impoverishment*Reduction in health-impoverishment*(A difference-in-difference approach)
Employmen
t sector1998
200
0
200
2
200
4
200
62007 2008 2009
All-informal -0.09 9.65 -4.85 -5.23 -9.87-
11.73
-
10.56
-
12.32
Mixed -1.13 0.75 -2.68 -5.70 -6.73 -8.62 -6.50 -7.07
All-private -3.46 1.40 -4.07 -4.27 -6.47 -6.86 -6.12 -6.95
*Absolute difference from 1996, as compared with all-public employeeall-public employee households households
in number of health-impoverished households per 1,000 non-poor households
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ResultsResults
1. National level2. Sub-national level
• Regional level (urban / rural / Bangkok)• Provincial level
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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
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20
8
11
27
15
14
34
2
11
1
18
8
1011
20
10
32
5
9
5
27
15
2021
36
19
38
11
24
1
13
4
67
98
24
3
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2
12
54
9
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7
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5 5
1
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2
76
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7
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6
21
5
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0 0
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0
2
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5
1 1
5
7
3
8
1
4
0
0
5
10
15
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25
30
35
Imp
ove
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ho
use
ho
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pe
r 1
,00
0 n
on
-po
or
ho
use
ho
lds
1996 1998 2000 2002 2004 2006 2007 2008 2009
' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S .
Region: C -Central; N -North; Ne -Northeast; S -South
Informal employment sector households
Health impoverishment by geographic region and area
Whole country
Urban area
Rural area
Bangkok
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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Conclusions (1)Conclusions (1)
• Reduction in health-impoverishment in the informal sector and
mixed groups was stronger than in the public sector.
• UCS-mitigated health impoverishment was also found at the
sub-national level
• Comprehensive benefit package and zero copayment at points
of services are key contributing factors of health financing
arrangement in reducing health impoverishment,
• In addition, the extensive geographical coverage of health
infrastructure, adequate finance and functioning primary
healthcare are other contributing factors.
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Conclusions (2)Effective 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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• Ministry of Public Health (MOPH) of Thailand,• National Health Security Office (NHSO),• National Statistical Office (NSO) of Thailand,• Health Systems Research Institute (HSRI)
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Acknowledgement