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Expanding coverage to the poor: the experiences from Thailand Samrit Srithamrongsawat Deputy Secretary General, National Health Security Office

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Outline of presentation Thailand country profile Development of health service delivery system Expanding health insurance to the poor and vulnerable groups achievements, problems and constraints Lessons learned

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3 Country profile: Thailand Population 65.7 million GNI (2012) $ 5,210 Gini 40 Fiscal space: Tax 17.6% GDP (2011), Revenue21.3% GDP (2011) GGHE15.3% GGE (2011) Total Health Expenditure (2012 NHA) US$215 per capita, 3.9% GDP, Public 68%, SHI 8%, Private 24%, OOP 14% of THE HRH density: doctor/nurse/midwife 24.7/10,000pop. Health status Life expectancy at birth 74.1 Total fertility rate 1.5 (2011) U5MR 14 MMR 48 ANC & hospital delivery 99% (2009)

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4 Health system development 1970s-2010s: Pro-poor and Pro-rural Development Source: U5MR was analysed from IHME data Under-five mortality per 1,000 live births 1975 Low income card scheme 2002 UHC 1980 Civil Servant Medical Benefit Scheme 1983 Voluntary health card 1991 Social security scheme Scaling up of district health system Village health volunteers National EPI MD mandatory rural service MOPH nursing colleges Technical nurse National Economic and Social Development Plans 3 th 4 th 5 th 6 th 7 th 8 th 9 th 10 th 1997 Asian economic crisis 1 2 3

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Reallocation of government budget to health and education Percentage Year Source: Bureau of Budget

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Reallocation of MOPH budget to build rural facilities and HRH Fast tracking rural health No investment in urban areas for 5 yrs during the 5 th 6 th National Health Plan.

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7 Health systems development: 1960s-2000s Source: Health Resource Surveys (various years) The advent of district hospitals (1977) Public service mandate of new MDs (1972) First batch of two-year technical nurses (1982)

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Current health service delivery system in Thailand Health centers 9,768 Community Medical Centers 365 District hospitals 734 Provincial hospitals 71 Pharmacy 11,154 Private clinics 17,671 Other public hospitals 60 Private hospitals 322 Regional hospitals 26 25 University hospitals 11 Specialized hospitals 48 MOPH facilities Local government Sub-district District Province

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Shifting of service utilization toward primary care

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Expanding health insurance to the poor and vulnerable groups 1945 The policy on charges for drugs and medical services in public facilities 1975 The Low Income Scheme (LIC) was lunched after the general election, and the Low Income Card was first issued in 1981 Since 1989, it had been gradually extended to cover other vulnerable groups i.e. elderly, children under 12, disabled, veteran, monk, health volunteer, and community leaders, and renamed to be Medical Welfare Scheme 1998, reforming financial management of the scheme Management committees at national and provincial level Moving toward demand side financing-per capita budget allocation Piloting capitation and DRG payment Reinsurance policy was introduced for high cost services and portability of benefit Registration of beneficiary and database

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Characteristics of the Medical Welfare Scheme NatureSocial welfare Populations The poor (direct targeting by mean-test) Vulnerable groups i.e. elderly, children, disabled Those contributed to the society i.e. veteran, monk, community leader, health volunteer Source of financeGeneral revenue Management organization Ministry of Public Health and Provincial Health Office Benefit packageComprehensive services including OP, IP, dental, ProvidersPublic only, mainly MoPH facilities Choice of provider They were assigned to their local health center and district hospital and strict to referral system to higher level of facilities PaymentGlobal budget

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Approaches in covering the poor and vulnerable groups in Thailand Sliding scale [since 1945] All public facilities receive government budget and can not refuse to provide services to the patients then those who are unable to pay could get partial or full exemptions. Targeting [1975-2001] Direct targeting by mean-test for the poor, made by community committees and approved by the district governor Indirect targeting by personal characteristics i.e. age, disability, occupation, etc. Universalism or Right-based approach [since 2002] Several mechanisms to protect beneficiarys rights i.e. hotline call center, complaint management, no-fault compensation,

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Achievement: Expansion of health insurance coverage, 1991 - UHC Source: HWS 1991, 1996, 2001, 2003 CSMBS = Civil Servant Medical Benefit Scheme, SSS = Social Security Scheme, MWS = Medical Welfare Scheme, HC = Voluntary Health Card Scheme, UCS = Universal Coverage Scheme UCS 2002

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Achievement: enable access and use of health services for the poor and vulnerable groups Source: NSO, HWS 1991 and 1996

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Achievement: enable access and use of hospital care for the poor and vulnerable groups Source: NSO, HWS 1996

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Problems and constraints in providing health coverage to the poor and vulnerable groups 1980198819901998 CoverageNA30%32%17% Leakage12, 9 % of LIC at hosp. and HC were not poor 21% of LIC were not poor 55% of LIC were not poor 65% were not poor Problems of direct targeting: under coverage and leakage of subsidy Stigmatization Discrimination in prescribing medicines Therefore, some LIC cardholders did not show the card until they were asked for the payments Under financed of the scheme

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Universalism approach better protects the poor: Benefit Incidence Analysis, 2001 and 2003 Note: -Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were 80,678 million Baht (in 2001-value) - The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was - 0.123

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UHC achieved UHC has further reduced health impoverishment

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District health system was key contributing factor of equity in OP & IP utilization Equity in OP utilization Equity in IP utilization Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).

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Lessons learned from the Thai case Pro-poor and pro-rural development of several successive national development plans that put emphasis on district health system was key contributing factor for improving equity in access to car for the poor and vulnerable groups Direct targeting by mean-test is both technical and practical problematic esp. in developing countries Specific health insurance program for the poor and vulnerable groups did enable access to and use of health care; however, stigmatization and discrimination was found Universal program is better protect the poor and vulnerable groups and further improve equity in service utilization and financial risk protection