Integrating Financing Schemes to Achieve Universal Coverage in Thailand:Analysis of the Equity Achievements
1. Integrating Financing Schemes to Achieve Universal Coverage in Thailand: Analysis of the Equity Achievements Phusit Prakongsai Supon Limwattananon Viroj Tangcharoensathien International Health Policy Program (IHPP) Presentation to the 7thWorld Congress of Health Economics Beijing International Convention Centre, Beijing, China 13 July 2009
3. 1945 2000 2002 Informal user fee exemption 1980 1970 User fees 1-3 rd NHP 1962-76 Provincial hospitals Health Infrastructure extension--wide geographical coverage Evolution of achieving universal coverage in Thailand: 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 4 th -5 th NHP (1977-86) District hospitals Health centers
6. Total health expenditure 1994-2005 Total health expenditure during 2003-2005 ranged from 3.49 to 3.55% of GDP, THE per capita approx 100 USD 36 64 36 64 37 37 63 63 56 56 44 44 Achieving UC 45 45 55 55 46 54 53 47 47 53 55 45
8. The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities 2001 2003 Concentration index Source: Prakongsai P (2008). The Impact of the Universal Coverage Policy on Equity of the Thai Health Care system. Type of health facilities 2001 2003 Health centers - 0.2944 - 0.3650 Community hospitals - 0.2698 - 0.3200 Provincial and regional hospitals - 0.0366 - 0.0802 Private hospitals 0.4313 0.3484
9. Equity in utilization: Concentration Index of OP service by type of health facilities: 2001 to 2005 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).
12. The incidence of catastrophic health payments from 2000 to 2007 Note: Catastrophic health expenditure refers to household out-of-pocket payments for health exceed 10% of household consumption expenditure 2000 2002 2004 2006 2007 Q1 (poorest) 4.0% 1.7% 1.6% 0.9% 1.9% Q5 (richest) 5.6% 5.0% 4.3% 3.3% 2.8% All quintiles 5.4% 3.3% 2.8% 2.0% 2.2%
13. Kakwani indexes of different health care finance from 2000 to 2006 (Kakwani = Conc. Index – Gini) 2000 2002 2004 2006 Out of Pocket -0.1502 -0.0755 -0.0764 -0.0450 Direct tax 0.3913 0.4159 0.4424 0.3617 Indirect tax -0.0964 -0.0691 -0.0435 -0.0831 Premium Insurance -0.3623 -0.3906 -0.3233 na Social health Insurance Contribution 0.1650 0.1121 0.1046 na Premium Insurance + SHI Contribution na na na -0.0491
15. How 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
We can say that it took almost three decades in using the piecemeal and targeting approaches for social protection expansions. This started from the LIC scheme for the poor in 1975, and CSMBS for civil servant medical benefit schemes, and their dependants in 1980. Then in 1990, SHI scheme was introduced, followed by voluntary health insurance scheme in 1994. Despite using many health insurance schemes for almost two decades, evidence in 2001 which was before achieving UC, indicates that approximately 30% of Thais were still uninsured.
After achieving universal coverage in 2002, the Thai health care system comprised three main public health insurance schemes: 1) the CSMBS which covers approximately six million of government employees and their dependants. The SSS which protects nine millions of employees in the formal sector from non-work related health care expenditure, and the UC scheme which covers those who are not CSMBS or SSS beneficiaries. These three public health insurance schemes have different health financing sources, provider payment methods, but similar benefit package.
After achieving UC, an analysis of the distribution of scheme beneficiaries in 2004 shows that a) approximately 50% of the UC beneficiaries were in the first and second quintiles. While approximately 50% of the CSMBS and SHI were in the richest quintiles. This indicates that the UC scheme is the public health insurance scheme for the poor and those residing in the rural areas.
How burdensome has been the UC policy on the Thai health care system? According to the NHA, total health expenditures of Thailand did not increase much as expected after the introduction of UC policy. Total health expenditures in 2003-2005 were around 3.55 – 3.49% of GDP. This could be explained by the increase rate of total health expenditures was not greater than the increase rate of GDP. There was increase amount and share of public expenditures in opposite to private expenditures.
As a result from the UC policy and other piecemeal approaches, the proportion of HH spending on health in income in the first decile decreased from 8.2% of income in 1992, to 2.2% in 2004, while that of the richest decile was approximately 1.1-1.3% in the same period.
An analysis of ambulatory service use from the Nationally representative household surveys in 2001 and 2003 indicates that after UC, ambulatory service use of the first and second quintiles increased significantly, especially at health centers and community hospitals. The concentration indexes show the more pro-poor nature of ambulatory service use at health centre, community, and regional hospitals; while the concentration indexes of private hospitals reveal the pro-rich nature of ambulatory service use both situations of before and after UC.
The analyses of the concentration indexes of ambulatory service use from 2001 to 2005 show that after achieving UC, ambulatory service use at HC and community hospitals tended to be more pro-poor, while the CI of ambulatory service use of private hospitals tended to be less pro-rich. However, the overall CI of ambulatory service use was more pro-poor because the CI shows the increasing negative value of -0.090 in 2001 to -0.177 in 2005.
When we analyzed government subsidies on health gained by different income quintiles, we found that in 2003, the first and second quintiles gained higher percentage of net government health subsidies, compared to the situation before UC. In contrast, the proportion of the net government health subsidies in the third to the fifth quintiles decreased after implementation of universal coverage. The concentration indexes of the net government health subsidies in 2003 had a higher negative value than the subsidy in 2001, which means the poorer gained more government health subsidies in 2003 than the situation before UC.
We also analyzed the incidence of catastrophic health expenditure which refers to the level of household out-of-pocket payments for health care over 10% of total household expenditure. The incidence of catastrophic health expenditure decreased from 5.4% in 2000 to 2.0% and 2.2% in 2006 and 2007, respectively. The decrease of catastrophic health expenditure was greater in poorer quintiles because most of them are covered by the UC scheme, while those in richer quintiles are beneficiaries of SSS and CSMBS.
I like to conclude key enabling factors which help achieve UC, not only strong political supports, capacity to generate evidence, and translate evidence into systems design and the systems capacity and resilience to implement program are very important. SHI informs us to adopt capitation contract model. Capitation helps long term cost containment and financially affordable. It sends a proper message towards efficiency while accreditation and quality monitoring are important tools. CSMBS tells us a “no go” direction of fee for services reimbursement model. It sends a wrong signal towards inefficiency. It is not possible to achieve UC through voluntary health card scheme due to adverse selection and financial non-viability. Voluntary health insurance is a temporary step towards UC, it helps build up capacity in insurance management; an important social asset. Not only lessons learned from SHI, reformist and system designers also take a more advance steps than SHI.
UC scheme covers the poor, but under-funded than it should be. There is a danger of poor services and serious hospital fiscal constraint. Good news that UC Scheme benefits more to the poor, through the functioning of DHS, it reduces incidence of catastrophic illnesses and impoverishment thereof. Studies on long term projection with technical supports from ILO indicates that by 2020, the THE would be 3.88% of GDP, and is within the fiscal capacity of the government The Prime Minister recently, decides to finance UC scheme totally by excise tax from tobacco and alcohol in FY2007 onwards.