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Challenges to universal health

coverage

in 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 13th Annual Scientific Conference (ASCON XIII)ICDDR,B, Dhaka, Bangladesh

15 March 2011

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Health financing arrangements and three public Health financing arrangements and three public

health insurance schemes in Thailand after health insurance schemes in Thailand after

achieving UC in 2002achieving UC 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

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 + expansion of financial risk

protection

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

Significant reduction in catastrophic health expenditure and gaps of household out-of-pocket payments for health

between rich and poor

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

Decile

1

Decile

2

Decile

3

Decile

4

Decile

5

Decile

6

Decile

7

Decile

8

Decile

9

Decile

10

Hea

lth

pay

men

t :

Inco

me

(%)

1992

1994

1996

1998

2000

2002

2004

2006

2008

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

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Co

nsu

mp

tion

exp

en

ditu

re p

er

cap

ita (

Ba

ht)

0 10 20 30 40 50 60 70 80 90 100Cumulative percent (in ascending order of consumption expenditure)

Post-health OOP Pre-health OOP Poverty line

Health impoverishment -Thailand, 2008

0

1,000

2,000

3,000

4,000

5,000

0 5 10 15 20 25 30 35 40

11.0% 3.0%

0.71%

0.38%

0.75%

0.22%

0.57%

0.22%

0.37%

0.15%

0.56%

0.15%

17.1% 6.0% 12.8% 4.5% 11.1% 3.6% 10.3% 3.1%

Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban

2002 2004 2006 2007 2008

Pre-health OOP impoverished Post-health OOP impoverished

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

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Inequity in geographical distribution of doctors and nurses in 2007

Physicians

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

Nurses

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

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)

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Double-digit cost escalationDouble-digit cost escalationCSMBS’ OP-IP health expenditures CSMBS’ OP-IP health expenditures (1988-2010)(1988-2010)

8Source: 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

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Medium- and long-term HCF modeling by ILO experts in 2008

Expenditure 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

Mismatch between increasing burden of disease from NCD and pattern of health expenditure

DALY 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

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Structure of Health Information System Development in Thailand

MOPH

Thai Health Promotion Foundation

Health System Research Institute (HSRI)

Health Information System DevelopmentPlan and Networking

NHSO NESDB

Civil societies

NGOs

Professionals

NSO

Academics

Data owners

Steering committee

Management office

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Key challenges of the Thai health care system

• Need strong political commitment and support• New health technologies and expensive services long-term

sustainability of health care finance for the UC scheme and primary care,

• An increasing disease burden from chronic NCD and the situation of aging society reallocate more resources to HP and disease prevention,

• Inefficiency and inequitable access to quality health services among beneficiaries of different health insurance schemes harmonization,

• The pandemic of new emerging infectious disease and unsuccessful control of tuberculosis and HIV/AIDS need revitalization,

• Poor governance of the Thai health systems,• Mal-distribution and internal brain drain of human resources for health,• The impact of economic crisis and international trade/agreement on

health of the Thai population, • Adequate investment in health information system M&E, • Long-term capacity building of health system and policy research.

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ConclusionConclusion

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Health outcome

Good Poor

Cost

Low Good Health

Low Cost

Poor Health

Low Cost

High Good Health

High Cost

Poor Health

High Cost

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Acknowledgements• Ministry of Public Health (MOPH) of Thailand• National Statistical Office (NSO) of Thailand • National Health Security Office (NHSO) 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