Financial Protection from the Universal Health Care Coverage in Thailand: The Evidence
Delivering Effective Health Care for All Monday 29 th March, 2010 Financial Protection from the Universal Health Care Coverage in Thailand: The Evidence Supon Limwattananon International Health Policy Program (IHPP), THAILAND
Outline <ul><li>Trends in population coverage by health insurance </li></ul><ul><li>Poverty impact of health payment before and after UC </li></ul><ul><li>Who pay for health care during UC? </li></ul><ul><li>Who benefit from health care use during UC? </li></ul><ul><li>Why is that so? </li></ul><ul><li>The long (3-decade) march of health infrastructure development </li></ul><ul><li>and financing innovation </li></ul>
Population coverage by health insurance before and after the 2001 UC reform Source : Analysis of Health and Welfare Surveys (HWS, various years) 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 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
5. The message to go! Health infrastructure and human resources are the prerequisite of the demand-side financial risk protection introduced by UC
Source : MOPH BPS Health Resource Surveys The birth of district hospitals (Rural health development -1977) Trends in expansion of hospitals
Source : MOPH BPS Health Resource Surveys Mandated rural service of new medical graduates -1972 Production of technical nurses -1982 Trends in expansion of health workers
2000 1970 1 st -3 rd NHP (1962-76) Mandatory rural services for new MDs and nurses 100% provincial hospitals 1. Infrastructure development UC: the long march LIC 1975 1990 CSMB 1980 CHF 1983 SS 1991 4 th -5 th NHP (1977-86) Expansion of district hospitals and health centers UC 2001 VHC 1994 1980 MOPH established 1942 15 provincial hospitals 300+ health centers 2. Innovative financing Source : Adapted from Srithamrongsawat Prospective payment system (PPS) - Capitation for SS (OP-IP) - Diagnostic-related groups (DRG) for LIC/VHC (IP) <ul><li>PPS expansion </li></ul><ul><li>- Capitation for UC (OP) </li></ul><ul><li>DRG for UC (IP) </li></ul><ul><li>DRG for CSMB (IP) </li></ul><ul><li>Direct billing for CSMB (OP) </li></ul>LIC + 1996 SS + 1994 SS + 2002 Formal and informal user fee exemption
A recent history of health financing systems reveals a substantial drop in the number of population who had no health insurance after the Universal Health Coverage (UC) scheme was introduced in 2001. In 2007, the uninsured were down to less than 4% of the total population.
Over the same periods, spending in health increased at about the same rates as total economy, at a ratio of 3.5-4%. A major achievement is the health share by household payment has reduced over time, while the public share consistently increased to almost 75% in 2007. A decreasing trend in the rich-poor gap in health payment is largely due to a reducing OOP burden shouldered by the poor households.
Analysis of two household surveys, HWS and SES, shows impacts on equity in health service use and financing as well as the time trends. Here, the ambulatory visits and hospitalization at the district health facilities concentrated among the poor (a negative CI), whereas utilization of private hospitals was pro-rich (a positive CI). Health financing by direct tax was very progressive with respect to household wealth (a positive CI). However, OOP payment and indirect tax were relatively less progressive as compared to the income gap (as shown by a negative Kakwani index).
The last six decades observed two major policy development. By 1990, geographic coverage of health infrastructures was completed in the first five National Health Plans. Major development is Rural Health Programs which established district hospitals beginning in 1977. Innovative health payment mechanisms in terms of prospective payment systems (PPS) began in 1990 when social health insurance scheme was implemented.