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 Financing

Phnom 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 NHP 1962-76 Provincial hospitals

Health Infrastructure

extension--wide

geographical coverage

Historical development of the Thai health system: Infrastructure development + financial protection extension

1975 LIC

1990

Establishment of prepayment schemes

1983 CBHI

1980 CSMBS

1990 SSS

Universal Coverage

CSMBS

2002 full achieve

Universal Coverage

SSS

LIC MWS 1994

Pub VHI

CSMBS

SSS

Expansion consolidation of prepayment schemes

4th -5th NHP (1977-86) District hospitals Health centers

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How health care providers are paid by 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 Benefit

package

Tripartite contributions

Payroll taxes

Risk related

contributions

Capitation

Capitation & global

Co-payment budget with DRG for IP

Services

Fee for services

Fee 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 OP Direct 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

54.5

42.0

25.1

13.810.2 9.6

5

20.3

30.7

47.6

58.1 66.761.2

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

% to

tal h

ospi

tal

developing Level 1 Level 2 accredited HA

after Pay by quality based pay before

หมายเหต ุ ปี 2554 เป็นขอ้มลู ณ ไตรมาส 2 Sources : Healthcare Accreditation Institute (Public Organization), 2011.

adapted by Bureau of Service Quality Development, NHSO.

Increased hospital accreditation status in 2005-2011

17.43 17.77

16.95

17.87

16.68 16.42

15.58

14.00 14.50 15.00 15.50 16.00 16.50 17.00 17.50 18.00 18.50

48 49 50 51 52 53 54*

Case Fatality rate ST-elevation MI (%)

Case Fatality rate ST-elevation MI (%)

0.49 1.71 5.38

9.88

17.41

32.15 36.88

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

48 49 50 51 52 53 54*

Injection or infusion rate of thrombolytic agent in ST-elevation MI (%)

Injection or infusion rate of thrombolyticagent in ST-elevation MI (%)

Starting

special pay

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

9.61 8.90 8.74 8.46 8.05 8.21 7.65

-

2.00

4.00

6.00

8.00

10.00

12.00

48 49 50 51 52 53 54*

Case Cerebral Infarction Fatality rate (%)

Case Cerebral Infarction Fatality rate (%)

0.05 0.08 0.04

0.38 0.55

0.89

1.53

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

48 49 50 51 52 53 54

Injection or infusion rate of thrombolytic agent in Cerebral infarction (%)

Injection or infusion rate of thrombolyticagent in Cerebral infarction (%)

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

-

50

100

150

200

250

300

350

400

Social Security Civil Servant Medical Benefit Universal Coverage

Per capita health budget (2009 USD)

15

Inequity in quality of care and health service provision:

Percentage of caesarian section to total deliveries

by 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%

2004

Qtr1

2004

Qtr2

2004

Qtr3

2004

Qtr4

2005

Qtr1

2005

Qtr2

2005

Qtr3

2005

Qtr4

2006

Qtr1

2006

Qtr2

2006

Qtr3

2006

Qtr4

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%

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

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%

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

2004 2005 2006 2007

CS

SS

UC

Cesarean section Laparoscopic cholecystectomy

Use of expensive procedures Variations 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

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

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

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Clopidogrel

0

5

10

15

20

25

30

35

40

45

50

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Coxibs

0

5

10

15

20

25

30

35

40

45

50

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

Jan

Ap

r

Ju

l

Oct

2003 2004 2005 2006 2007

CS

SS

UC

Use of expensive OP medicines Variations 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 prevention

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

BM I

Cholestero l

Low intake of fruit and vegetable

Illicit Drugs

Physical Inactivity

Air Pollution

WSH

M alnutrition-Inter

M alnutrition-Thai

Non-Seatbelt

DALYs('000)

1999

2004 Health administration

and health insurance

8.5%

Medical goods

4.3%

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

Th

ou

sa

nd

s

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol0

50

100

150

200

250

300

350

400

450

500

Q1 Q2 Q3 Q4 Q5

Th

ou

san

ds

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol

DALYs attributable to risk factors

21

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

2007 2008 2009 Total Expenditure:

Total AIDS expenditure, million Baht 6,728 6,928 7,208 Total Health Expenditure, million Baht 248,852 363,771 383,051 Total AIDS expenditure, as

per capita population, Baht 105 110 114 per capita PLWHA, Baht 11,600 14,275 14,417 % GDP 0.08% 0.08% 0.08% % THE 2.7% 1.9% 1.9%

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 p

er

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

800-3,305 3,306-6,274 6,245-9,272 9,243-12,300

Dentists

5,500-15,143 15,144-25,767 25,768-36,390 36,391-47,011

Nurses 280 - 652

653 - 904 905 - 1,156 1,157 – 1,408

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Economic loss of 12 priorities BOD in Thailand for prioritization of health investment in the 10th NHDP

diseases DALY loss

(1)

Curative expenditure

(2)

Productivity loss due to premature death(3)

Productivity loss due to

absenteeism (4)

Total (2+3+4)

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

2 Traffic 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 row 22% 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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Conclusions 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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Key stakeholders and participatory processes in topic selection for economic evaluation of UC benefit package

Academic

Medical specialists

Civil Society

Patients

Focus group discussion

Policy maker

Medical specialists

Academic group

Civil Society

General population

Patients

Industry

Topic selection meeting

Ke

y s

tak

eh

old

ers

Ke

y s

tak

eh

old

ers

Research working groups

UC Benefit Package

Subcommittee

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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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