Delivering Effective Health Care for AllMonday 29th March, 2010

Financial Protection from the Financial Protection from the

Universal Health Care Coverage in Universal Health Care Coverage in

Thailand: The Evidence Thailand: The Evidence

Supon LimwattananonSupon Limwattananon

International Health Policy Program (IHPP), THAILANDInternational Health Policy Program (IHPP), THAILAND

Outline

1. Trends in population coverage by health insurance

2. Poverty impact of health payment before and after

UC

3. Who pay for health care during UC?

4. Who benefit from health care use during UC?

5. Why is that so? The long (3-decade) march of health infrastructure development

and financing innovation

1. What do we mean by the universal coverage?

Population coverage by health Population coverage by health

insuranceinsurancebefore and after the 2001 UC reformbefore and after the 2001 UC reform

Source: Analysis of Health and Welfare Surveys (HWS, various years)

5.1% 5.7% 4.9% 4.0% 3.7%

66.5%

29.0%

54.5%

14.2% 27.9% 52.3% 74.7% 73.4% 72.2% 74.3% 73.6%

0%

20%

40%

60%

80%

100%

1991 1996 2001 2003 2004 2005 2006 2007

Uninsured LIC/VHC UC SS CSMB Other

LIC: Low-Income Card Scheme Tax-funded, public welfare program (defunct)

VHC: Voluntary Health Card Scheme Subsidized, voluntary, community-based health insurance (defunct)

UC: Universal Coverage Scheme Tax-funded, entitlement scheme for the rest of all Thai population

SS: Social Security Scheme Compulsory, contributory, social health insurance (SHI) for formal private employees

CSMB: Civil Servant Medical Benefit Scheme Tax-funded, fringe benefit for government employees/pensioners, dependants

2. Impoverishment by health payment before and after UC

Household impoverishment from healthHousehold impoverishment from health

1996 (Pre-UC) 2008 (Post-UC)

Health impoverishment

per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Source: Analysis of Socio-Economic Surveys (SES, various years)

3. Progressive tax-based health financing of UC

0

1

2

3

4

5

6

1995 2000 2005

Total health expenditure per GDP (%)

0

1

2

3

4

5

6

7

1995 2000 2005

Poorest quintile Richest quintile All

Catastrophic health expenditure (%)

0

10

20

30

40

50

60

70

80

1995 2000 2005

Government Private, total Household

Health expenditure share (%)

0

1

2

3

4

5

6

7

8

1995 2000 2005

Poorest decile Richest decile

OOP health expenditure per income (%)

UC 2001

Source: National Health Accounts

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

2000 2002 2004 2006

OOP payment Direct tax Indirect tax

Concentration Index

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

2000 2002 2004 2006

OOP payment Direct tax Indirect tax

Kakwani Index

Progressivity in health financing -Thailand

SourceSource: CREHS year-2 Report: CREHS year-2 Report

4. Pro-poor utilization and pro-poor public subsidy of district health services during UC

Utilization shares (%) by income quintileUtilization shares (%) by income quintile

Ambulatory visits and hospital admissions, 2001-2007Ambulatory visits and hospital admissions, 2001-2007

SourceSource: CREHS year-2 Report: CREHS year-2 Report

25%

33%

26%

28%

22%

27%

25%

20%

23%

23%

24%

23%

23%

23%

18%

14%

14%

15%

17%

15%

16%

17%

12%

14%

14%

16%

16%

17%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IP admissions

OP visits

IP admissions

OP visits

IP admissions

OP visits

IP admissions

2001

2003

2006

2007

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

Public subsidy shares (%) by income quintilePublic subsidy shares (%) by income quintile

Ambulatory visits and hospital admissions, 2001-2007Ambulatory visits and hospital admissions, 2001-2007

SourceSource: CREHS year-2 Report: CREHS year-2 Report

25%

35%

28%

30%

26%

30%

28%

19%

24%

24%

27%

25%

23%

25%

19%

13%

15%

13%

15%

15%

14%

20%

10%

12%

11%

11%

13%

12%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IP admissions

OP visits

IP admissions

OP visits

IP admissions

OP visits

IP admissions

2001

2003

2006

2007

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

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

2001 2003 2005 2007

Hth Ctr Dist H Prov H Univ H Private H

Ambulatory visits

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

2001 2003 2005 2007

Dist H Prov H Univ H Private H

Hospital admissions

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

2001 2003 2005 2007

Hth Ctr Dist H Prov H Univ H Private H

Ambulatory subsidy

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

2001 2003 2005 2007

Dist H Prov H Univ H Private H

Hospitalization subsidy

Concentration Index: Health use and public subsidy -Thailand

SourceSource: CREHS year-2 Report: CREHS year-2 Report

Pro-rich

Pro-poor

5. The message to go!

Health infrastructure and human resources are

the prerequisite of the demand-side financial risk protection introduced by UC

050100150200250300350400450500550600650700750800

0100200300400500600700800900

1,0001,1001,2001,3001,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

All hospitals District Other public Private

Hospitals

05,00010,00015,00020,00025,00030,00035,00040,00045,00050,00055,00060,00065,00070,00075,00080,000

010,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000110,000120,000130,000140,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

All beds District Other public Private

Hospital beds

5,00010,00015,00020,00025,00030,000

5,000

50,00060,00070,00080,00090,000

100,000110,000120,000130,000140,000150,000160,000170,000180,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Hospital Health center

Population per health facility

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

Population per bed

Health facility trends -Thailand

Source: MOPH BPS Health Resource Surveys

The birth of district hospitals(Rural health development -1977)

Trends in expansion of hospitalsTrends in expansion of hospitals

05,00010,00015,00020,000

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

120,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctors (MDs) Nurses (RNs/TNs)

Doctors and nurses

05,00010,00015,00020,00025,00030,000

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

RNs TNs PNs Midwives

Nurses and midwives

5001,000

1,5002,0002,500

3,0003,5004,000

4,5005,000

500

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctor (MD) Nurse (RN/TN)

Population per doctor and nurse

01,0002,0003,0004,0005,0006,0007,0008,0009,00010,000

0

5,000

10,000

15,000

20,000

25,000

30,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

HC personnel Health centers

Health centers and personnel

Health workforce trends -Thailand

Source: MOPH BPS Health Resource Surveys

Mandated rural service of new medical graduates -1972

Production of technical nurses -1982

Trends in expansion of health workersTrends in expansion of health workers

2000

19701st-3rd NHP (1962-76)

Mandatory rural services

for new MDs and nurses

100% provincial hospitals

1. Infrastructure development1. Infrastructure development

UC: the long marchUC: the long march

LIC1975

1990

CSMB1980

CHF1983

SS1991

4th -5th NHP (1977-86)

Expansion of district hospitals

and health centers

UC2001

VHC1994

1980

MOPH established 1942

15 provincial hospitals 300+ health centers

2. Innovative financing2. Innovative financing

Source: Adapted from Srithamrongsawat

Prospective payment system (PPS)- Capitation for SS (OP-IP)

- Diagnostic-related groups (DRG) for LIC/VHC (IP)

PPS expansion- Capitation for UC (OP)

- DRG for UC (IP)

- DRG for CSMB (IP)

- Direct billing for CSMB (OP)

LIC+1996

SS+1994

SS+2002

Formal and informal user fee exemption