Achieving Universal Coverage: Thailand experiences

1
Achieving Universal Coverage Thailand
experiences

• Viroj Tangcharoensathien MD. Ph.D.
• IHPP-Thailand
• General Health Insurance in Financing of Health
  Services
• in Turkey and Restructuring of the MOH,
• Istanbul,
• 31 March - 1 April 2006

2
Outline

• Thailand experiences on gradual extension of
  health insurance coverage until reaching
  Universal Coverage for the whole population
• Key context of reform
• Current and future challenges
• Radical changes to the Ministry of Public Health
  

3
International experiences speed of transition
towards Universal Coverage
Source WHO 2004
4
Taking-off major social protection schemes,
Thailand

• 1975 Social Welfare Scheme
• For the poor, then to cover the elderly and
  children lt12 years
• General tax funded scheme
• 1978 Civil Servant Medical Benefit Scheme
  (CSMBS) for public sector employee
• Government employee and retirees, plus their
  dependents (parents, spouse, three children
  lt18years)
• General tax funded scheme
• 1974 Mandatory Social Health Insurance for
  private sector employee
• 1974 Workmen Compensation scheme -- employer
  financed scheme
• 1990 Social Health Insurance scheme financed
  by equal contributions from 3 parties the
  employer, employee and government.
• Voluntary health insurances
• 1983 Voluntary Health Card Scheme
• Flat rate premium by household government
  subsidy

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Milestones Social Welfare Scheme

• 1975
• Free care for Low Income Household, through fee
  exemption upon hospital discretions
• 1981
• Formal scheme established, covered 11 million
  (23 total), income testing needed before cards
  issued. Government budget allocation to the
  Scheme but usually under-funded.
• 1992
• Expansion to cover the elderly, gt60 years.
• 1994
• Expansion to social disadvantage group, and
  children lt12 yr.
• 1998
• Capitation based budget high cost reimbursement
  schedule

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Milestones CSMBS

• 1978
• Decree entitle government employee and dependants
  free medical care
• 1992
• Health Systems Research Institute research
  towards reforms
• 1997-98
• Economic crisis
• Interim measure introduction of co payment,
  while maintain fee for services
• 2002 - 2003
• Electronic claim for IP using case base (DRG),
  resistance to set up global budget
• 2004
• No significant reform actions taken
• Fee for service results in cost escalation

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Milestones Social Health Insurance

• 1954
• The first Social Security Act promulgated, but no
  implementation for political reasons
• 1974
• Implement Workmen Compensation Scheme, 7 years
  phasing in throughout the country,
• Employer pays the scheme for work related
  injuries and death
• 1990
• Social Security Act 1990, enforced in gt20
  employee,
• Capitation low cost contract model
• 1993
• Expansion to cover gt10 employee
• 2002
• Expansion to cover gt1 employee, though large
  proportion of small firms not comply to the law

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Milestones Voluntary Health Card Scheme

• 1983 Phase I community financing for MCH
  services
• 1984 Phase II community financing for family
  health services
• 1991 Phase III full scale voluntary health
  insurance
• 1994 Phase IV 50 government subsidy,
  reinsurance for high cost and cross boundary
  services

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Insurance coverage profile, 2000various source
estimations
Significant proportion of uninsured with a poor
potential increase of insurance coverage by other
schemes.
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Concluding remarks

• Lessons on strategies
• 1975- Targeting the poor, draw lessons, gradual
  extension to others (the elderly, children lt12)
• 1983- Voluntary Health Card Scheme seen as
  transitional measures, build up social capital
  and institutional capacity to manage insurance
  fund.
• 1990- Introduce Social Health Insurance using
  capitation, this is the predecessor of current
  Universal Coverage system design,
• 1992- Reform of Civil Servant Medical Benefit
  Scheme aims to contain cost, but not
  successful, strong resistance.
• 2001- strong political will to adopt
  universality

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A long march towards UC

• Really a long march,
• 27 years of gradual coverage extension to formal
  and informal sector, since a pro-poor financing
  policy in 1975, Thailand achieved Universal
  Coverage (UC) for the whole population completely
  by April 2002.
• By early 2002, only three public insurance scheme
  covers the whole population
• Social Health Insurance for private sector
  employee
• Civil Servant Medical Benefit Scheme for
  government employee and dependants
• The UC Scheme for the rest of population
• The design of UC scheme applies the model of
  Social Health Insurance
• This ensure harmonization with the existing
  scheme, close down the gap.

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Platforms for reform towards UC

• Context window of opportunity opens January
  2001 General Electionuniversal coverage is a
  major campaign
• National capacity to generate evidence and
  identify problems warrant reforms
• Contributions by WHO since 1995
• National Health Account
• Inefficiency and cost escalation in Civil Servant
  Medical Benefit Scheme under Fee For Service
• Fragmentation and inadequate social protection
• Bridging of research community and politicians by
  reformists, hence evidence based reform.
• Prior experience of capitation contract model
  from Social Health Insurance Scheme since 1991
• Cost containment merits
• Programmatic feasible, social acceptability, good
  quality and utilization
• Health systems capacity to manage changes during
  the transition

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Outcome of UC Scheme

• UC Schemes covers the poor, half belongs to Q1
  and Q2 (the poorest 40 of the population)
• Significant increase in utilization more on OP
  than IP
• The Scheme is not adequately funded in view of
  high utilization
• Empirical evidence indicates
• Pro-poor budget subsidy,
• District health system is a major hub of
  fostering the pro-poor nature of financing
  healthcare
• Significant relief of household expenses on
  health
• Very small percent of impoverishment due to
  medical expenses.
• Long term 20 year forecast of resource needs for
  UC scheme, is within fiscal capacity of the
  government.

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Current and future challenges

• Major changes in the Ministry of Public Health
  (MOPH) role and function
• From inclusive financier and healthcare provision
  to healthcare provision only
• The purchasing role was transferred to National
  Health Security Office (purchaser provider split)
  
• In view of decentralization Act, healthcare
  delivery systems would be
• either become autonomous with its governing board
  or under the local government
• MOPH has lost its financing role and will
  eventually lose the provision function a major
  change
• Needs for revisit MOPH role
• Stewardship function needs to improve
• Standard setting, rules, law and enforcement
• More steering and less rowing
• Evidence based reform is ongoing, do not
  under-estimate the strong resistance from the
  MOPH.

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Acknowledgments

• National partners
• Thailand Research Fund for institutional grants
  to the International Health Policy Program (IHPP)
  
• National Statistics Office (NSO) for national
  household surveys
• National Health Security Office (NHSO) and other
  partners who initiate, design and steer the UC
  scheme
• MOPH as major healthcare providers