ได้รับโอกาสจากสถาบันการสาธารณสุขอาเซี่ยน ร่วมกับ TICA ในการฝึกอบรมผู้แทนจาก 20 ประเทศ ที่มาฝึกอบรมเกี่ยวกับการดำเนินงานเพื่อการให้ประเทศต่างๆ บรรลุเป้าหมายแห่งการพัฒนาที่ยั่งยืน SDG / กรมอนามัย ในโครงการพัฒนาแพทย์เฉพาะทางสาขาเวชศาสตร์ป้องกัน แขนงสาธารณสุขศาสตร์ ซึ่งเป็นแพทย์จากประเทศในเอเชีย เสนอข้อมูลข้อเท็จจริงและความท้าทายในอนาคต ให้ท่านเหล่านั้นได้ร่วมแลกเปลี่ยน

1. Universal Health Coverage: Lesson
learnt in Thailand
Chuchai Sornchumni
Deputy Secretary General , NHSO
chuchai.s@nhso.go.th

2. 6-Jun-18 2
Topics
1. Review general principle
2. Experiences in Thailand
3. Success & Lessons learned
4. Future Challenge & Conclusion

4. Big picture of health system
4
Social determinants of health :SDOH
6-Jun-18

5. The human right to health and health
care
The human right to health
means that
• everyone has the right to
the highest attainable
standard of physical and
mental health, which
includes access to all
medical services, sanitation,
adequate food, decent
housing, healthy working

6. Dignity , Solidarity , Security
Universal Health Coverage #UHC and Global Health Security are two
sides of the same coin. To make the world safe, solidarity is the rule
of the game. No one is safe until everyone is safe.
Tedros Adhanom Ghebreyesus DG, WHO, 2018
• The human right to health
guarantees a system of
health protection for all.
• Everyone has the right to the
health care they need, and to
living conditions that enable
us to be healthy, such as
adequate food, housing, and
a healthy environment.
Countries that invest in UHC
make a sound investment in

7. 2016 - 203

8. 3.8 Achieve universal health
coverage, including financial
risk protection, access to
quality essential health-care
services and access to safe,
effective, quality and
affordable essential medicines
and vaccines for all.
SDG 3: Ensure healthy lives and promote well-being for all at all ages

9. Three dimensions of UC
• X axis: pop coverage
– Start from the poor, formal sector
employees and informal sector employees
• Y axis: financial protection
– Free at the point of service, minimum OOP
 Reduce catastrophic illness
• Z axis: service coverage
– Comprehensive benefit package with very
small exclusion list
– Basic : OP PP IP
– Vertical programs
9

10. 6-Jun-18 10
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001693
Widen to Social
Protection &
Base on
political will

11. 11
Goal and objectives of UHC : Health financing system
Health financing
arrangements
Revenue
collection
Pooling
Purchasing
Benefits
UHC intermediate
objectives
Equity in resource
distribution
Efficiency
Transparency and
accountability
UHC Goal
Utilization Need
(Equity in the use of
health service)
Quality
Universal financial
protection
Applied form : Diane McIntyre and Joseph Kutzin. Health financing country diagnostics: a foundation for national strategy development, WHO, 2016.6-Jun-18

12. Investing in health systems to reach UHC
and the SDGs
“Investing in the health system not only
saves lives, it is also a crucial investment in the
wider economy. This is because ill-health impairs
productivity, hinders job prospects and adversely
affects human capital development.”
Source: Bill Gates . https://www.weforum.org/agenda/2015/12/the-importance-of-investing-in

13. Thailand Experience
6-Jun-18 13

14. 14
1945
2000
2002
Universal
Coverage
of Health Care
Expand
Prepayment
Establish
Prepayment
Exemption
1990
First Social Security Act (not implemented)
1974 Workmen Compensation Fund
1975 Free Medical Care for the Poor
1980 CSMBS
1983 Health Card Project for near poor
1990 Social Security Act
1970
User fees
1962-76
Provincial
hospital
1977-86
district hospitals
and health centers
Health
Infrastructure
Thailand: Historical development
Legislation
1993 - Free care for children,
1995 – for elderly
2000 - Total health
insurance coverage = 71 %
6-Jun-18

15. Purchaser-Provider Split
MOPH
Facilities
Populations
•Command
•HR
•Finance
Providing
MOPH
FacilitiesPurchaser
Populations
•Command
•HR
•Finance
•Strategic
purchasing
Providing•Information
•Right protection
Prior to UC Post UC (2002)
Expected results
•Clear responsibility and functions of each unit
•More accountable and responsive to populations
•Shifting from supply side to demand side financing
156-Jun-18

16. 16
Public financial management: before 2002
Civil
Servant
Med Benefit
Scheme
Hospital rev kept and used by hospital
(more flexible)
Social
Health
Insurance
Scheme
Out-of-pocket from
households
Low
income
card
scheme
Voluntary
Health Card
Scheme
Govt line item
budget: Grant
30% of pop
- uninsured
people
MOPH facility
- Capital
e.g. building,
equipment
- Salary &
operating
Govt budget:
line item
CLOSE ENDED
BUDGET
Hospital line item budget
(not flexible)
Rigor financial audit (either report or onsite audits)
by Auditor General and monthly financial report to MOPH
Govt central
bgt
OPEN
ENDED
Contribut.
CLOSE
ENDED
BUDGET
6-Jun-18

17. 17
Public financial management: after UHC 2002
Civil
Servant
Med Benefit
Scheme
Hospital rev kept and used by hospital
(more flexible)
Social
Health
Insurance
Scheme
Govt central
bgt
OPEN
ENDED
Contribut.
CLOSE
ENDED
BUDGET
Govt line item budget: Grant
CLOSE ENDED BUDGET
UC Scheme managed by National Health Security
Office (NHSO)
[consolidate a) Low income scheme, b) voluntary H
Card, c) new budget US$ 1 billion for 18m
uninsured, d) previously operating budget held by
MOPH
MOPH facility
- Capital
e.g. building,
equipment
- Salary
Govt budget:
line item
CLOSE ENDED
Hospital line item budget
(not flexible)
Rigor financial audit (either report or onsite audits)
by Auditor General and monthly financial report to MOPH6-Jun-18

18. 18
Dynamics of health insurance status
and budgeting flow in Thailand
18
Civil Service Medical
Benefits Scheme
(CSMBS): gov. officers
and dependents
Social security scheme
(SSS):
private formal employees
Universal Coverage
Scheme(UCS):
the rest of Thai citizens
Thai citizens
Safety Net
BudgetBudgeting
Beneficiary Population Financing
Tax
Tripartite
contribution
Tax
6-Jun-18

19. 19
Thai Universal Health Coverage
Act 2002 Royal Decree 1980 Act 1990
Comptroller General
Dept, MOF
Social Security Office,
MOL
National Health Security
Office
Public (75%) & private (25%) health facilities
48 M. pop
(reside in rural areas; Q1-2; children,
elderly, informal wk)
8 M. pop
(urban; Q4-5; children,
elderly, public sector wk)
10 M. pop
(city; Q4-5; only adult
workers in private
sector)
Tax funded Tax funded Tripartite cont
UC Scheme Civil Servant Scheme Social Health Insurance
67 million Thai populations
6-Jun-18

20. Conceptual Framework : Three
dimensions of UHC
Pooled funds
• to extend coverage to
those individuals who
previously were not
covered,
• to services that
previously were not
covered
• to reduce the direct Source WHR: 2008 & 2010

21. THREE DIMENSIONS OF THAI UCS
Z axis: Depth of
services
Comprehensive package
with small exclusion list.
P&P, All essential drugs,
Renal Replacement
Therapies, organ transplant,
CABG, cataract, dental
services and dentures, etc.
Y axis: Financial
protection - High
Free at the point of
service
(Out of pocket 12% of
THE)
X axis: Population coverage
universal population coverage (99.95% of population)
Under three public health insurance schemes (CSMBS (5%), SSS (20%), UCS (75%)

22. BENEFIT PACKAGE
• Benefit package in a desirable universal health
coverage should include health services from
health promotion, disease prevention, curation,
and rehabilitation.
• However, extending these health service
coverage will affect coverage of the other
dimensions.
• It is difficult to cover 100% of these dimensions.
• Therefore, some services may not cover or
require co-payment.
• In order to balance the coverage of these
dimensions, four related dimension of
effectiveness outcomes may be considered.

23. UNIVERSAL HEALTH COVERAGE
• Towards UHC implementations are not only using financial mechanisms to extend coverage
but also promoting new relationship of key stakeholders in UHC.
• Roles of purchasers include to reimburse health care cost to service providers according to
service agreements, to prepare optimal benefit packages to be able to promote effective
outcomes and remove financial risks from the beneficiaries, to ensure appropriate
distribution of services between regions.
• Consumer right protections and stakeholder participations are also important to promote
good relationship with stakeholders.

24. 24

25. 25

26. 6-Jun-18 26
Z axis:
Extensive comprehensive
package, small
exclusion list, almost all
high cost interventions
covered
Needs
SuppliesDemands
Z-axis to solve Health Needs or Effective Coverage

27. 27
National Health Security Fund : categories
Basic health
care
• OP PP IP
• IP
• CR : (AE ,HC)
• Rehabilitation
• Capital
replacement
• Thai
traditional
• No-fault
liability
• ect.
Basic health Care (on capitation basis)
ARV drug
Renal replacement therapy
2002
Chronic (2nd prevention for DM/HT)
Mental health
(medicine)
20112006 2009 2010
(Pilot project in FY2007 / the whole country in
FY2009)
27
2012 20162015
Liver (Age <18) & Heart transplant
Any CD 4
LTC
6-Jun-18

28. Thailand success
&
lessons learn
6-Jun-18 28

29. NHSO Branches

30. 6-Jun-18 30
Population Coverage

31. INCREASED UTILIZATION AND REDUCED UNMET NEEDS
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
OP use
rate
2.42 2.55 2.75 3.12 3.06 3.07 3.07 3.12 3.34 3.52 3.59
IP use
rate
0.1 0.105 0.11 0.112 0.116 0.116 0.116 0.12 0.118 0.12 0.12
1.5
2.13
2.75
3.38
4.
2006 2008 2010 2012 2014 2016
OP use rate
0.09
0.1
0.11
0.12
0.13
2006 2008 2010 2012 2014 2016
IP use rate
31

32. COST SAVING FROM CENTRAL PROCUREMENT ($US)
Year ARV-NonCL ARV_CL ED Cat E(2) EPO/CAPD Total Saving
2010 8,907,677 24,750,922 3,037,543 15,258,756 51,954,898
2011 17,871,763 49,509,529 49,670,753 23,111,379 140,163,424
2012 29,500,819 66,257,010 33,501,682 28,237,894 157,497,405
2013 43,745,449 67,915,751 40,828,581 42,295,357 194,785,139
2014 52,219,778 82,000,880 64,246,998 55,159,629 253,627,285
2015 44,649,801 107,097,868 20,091,332 48,943,980 220,782,981
2016 48,006,380 75,873,013 78,358,114 55,544,497 257,782,004
Total 244,901,666 473,404,974 289,735,003 268,551,493 1,276,593,137
Saving based on Purchasing price in 2009 Source: National Health Security Office

33. LIFE EXPECTANCY AT BIRTH IN THAILAND (1990-2015 )
Full Population
Coverage 2002
Source: World Bank
Pre-UHC Post-UHC

34. 112,831 113,610
16,450
39,840
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Final Consumption Intermediate
MillionsofBaht
Domestic Import
129,281
153,450
UHC is a good investment
34
1.2 times
UCS investment
20% return from investment
on UHC
Major return comes from
Chemical, Trade, Electricity
and Water, Mining and
Quarrying, and
Transportation and
Communication sector

35. 6-Jun-18 35
Quality
HA complete 45.09% . No PHC Accreditation

36. 2.8%
2.6% 2.6% 2.6%
2.4%
1.6%
2.2%
1.4%
1.5%
1.3%
1.0%
1.1%
1.0%
1.1%
1.0%
1.2%
1.0% 1.0%
0.9%
2.9%
3.2% 3.2%
3.6%
3.4%
2.9%
2.6%
2.5%
2.3%
2.4%
2.2%
1.9%
2.0%
1.8% 1.8%
1.7% 1.7%
1.6%
1.5%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
All Quintile 1 Quintile 5
UHC
Reduction of Catastrophic Health Expenditure
Data from: National Statistic Office
EQUITY

37. 6-Jun-18 37
Cost containment

38. Preventing Health Impoverishment
UH
C

39. Source: World bank and WHO, Tracking Universal Health Coverage: 2017 Global Monitoring Report, 2107.
* Consumption net of health expenditure < $3.10/day international poverty line
Impoverishing health expenditure*, 122 countries (2015)
6-Jun-18 39

40. Impoverishing health expenditure*, Thailand (1990-2016)
2.34 2.33
2.45
2.20
1.69
2.01
1.33
1.10
1.00
0.91
0.80 0.79
0.71
0.56 0.53 0.50
0.46
0.32 0.30
254.7
304.5
333.4 330.3
266.2
323.0
217.9
184.7
179.8
151.7
139.8
105.6
95.4
64.4
50,000
100,000
150,000
200,000
250,000
300,000
350,000
Numberofimpoverishedhouseholds
0.0
0.5
1.0
1.5
2.0
2.5
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
Source: SES (various years)
*Consumption net of health expenditure < national poverty lines
6-Jun-18 40

41. Source: World Bank, GMO
Increased share of consumption of the lowest quintile
6-Jun-18 41

42. Income redistribution
Source: SES & NHA (various years)
0.428
0.419 0.425
0.398 0.398
0.375 0.378
0.359
0.039
0.085 0.087
0.136 0.138
0.112
0.093
0.139
0.389
0.334 0.338
0.262 0.260 0.263
0.285
0.220
Gini index on consumption
Gini index after health financing
Kakwani index on health financing
0
0.1
0.2
0.3
0.4
0.5
2000 2005 2010 2015
Income redistribution by health financing, Thailand (2000-2015)
6-Jun-18 42

43. Challenges
6-Jun-18 43

44. 44
Fiscal reality:
Approved budget was lower than the evidence based estimations
NHSO budget for medical fund (million baht)
65,060
67,765
80,685
90,752
100,097 103,940
113,496
133,826
149,193
166,320
165,234
189,720
56,091
61,212
67,583
82,023
91,369
101,984
108,065
117,969
129,281
140,609 141,540
154,258
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
NHSO requested MOF approved
6-Jun-18

45. 45
UC Scheme: approved per capita budget, 2003-2016
Budget increases by three folds, cost drivers are a) expansion of benefit packages,
b) increased utilization of OP and IP, c) unit cost inflation: 3% annual wage
increases and medical products inflation
Approved per capita budget UCS, 2003-2016, THB
1,202
1,309 1,396
1,659
1,900
2,100
2,202
2,401
2,756 2,756
2,895 2,895
3,029
2,546
0
1,000
2,000
3,000
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Year
THBpercapita
6-Jun-18

46. Adequate public
investment in health
• four Goals of SAFE
• Total health
expenditure (THE) is
not less than the
status quo level of
4.6 % of GDP (NHA
2013)
• GGHE as % of GGE is
not less than the
status quo level at
17% of GGE (NHA
2013)
GNI: Gross National Income, GDP: Gross Domestic Product, THE: Total Health Expenditure, GGHE: General
Government Health Expenditure,
GGE: General Government Expenditure, OOP: Household Out of pocket payment
GNI per capita,
US$
THE, %
GDP
THE per
capita, US$
GGHE %
THE
GGHE %
GGE
OOP %
THE
Reference year 2105 2014 2014 2014 2014 2014
Cuba
5,984
(2013)
11.1 817 95.6 18.0 4.4
France 30,404 11.5 4,959 78.2 15.7 6.3
Japan 28,099 10.2 3,703 83.6 20.3 13.9
Republic of Korea 21,835 7.4 2,060 54.1 12.3 36.1
Mexico 7,836 6.3 677 51.8 11.6 44
Norway 61,977 9.7 9,522 85.5 18.2 13.6
Thailand 4,350 4.1 228 77.8 13.2 11.9
European Union 26,517 10.0 3,613 77.8 16.0 13.9
Upper middle income country 6,362 6.2 NA 55.0 NA 36.2
High income country group 33,537 12.3 5,266 62.3 17.9 13.3
East Asia and Pacific
(all income level)
7,539 6.9 640 66.0 NA 25.2
Source: World Development Indicators, update 15 September 2017 [access 28 December 2017]
6-Jun-18 46

47. 6-Jun-18 47
Health expenditure increasing trend

48. 6-Jun-18 48
Ambulatory Care Sensitive Conditions (ACSC)

49. Demographic Change in Thailand
6-Jun-18 49

50. 6-Jun-18 50
Regulator
(MOPH)
Providers
Public
(MOPH,
Other),
Private)
Citizen & Other
Public interests
Payers
(CGD,SSO
,NHSO)

51. 6-Jun-18 51

52. Future Challenge
1. Health
system
related
issues
• Strengthening health system by primary care approach
• Prevention and promotion to reduce cost of treatment
• Long term care for aging society
• Decentralized of service and commissioning
• Human resource distribution
• Quality assurance and Health technology assessment
• Development of a more equitable health facility plan and re-orientation of
existing system to fit with the health facility plan
• Reassuring people about quality of care provided by primary care provider and
the necessity to have a registration system based on primary care
• Special measures to target and to organize health services for the marginal and
specific groups of Thai citizen (e.g. migrant worker, solider, taxi- driver, prisoners
and etc.)
• Engaging private sector in the provision of health care especially in urban
areas and establish a system for public and private health-care providers in
Thailand
• Developing model to manage epidemiological transition and the aging of the
population

53. 2. Financing and
management
issues
• Ensuring long term financial sustainability and equity in financing of the UCS
(UCS relies on tax financing is sustainable? )
• Seeking innovation way to reduce cost of care and make health security system
sustainable
– Harmonization of benefit package and provider payment methods among
public health insurance schemes
– Standardization of provider payment methods and benefit packages among
schemes
– Establishment of active and effective health care purchaser (central and
local)
– Co-finance with community fund
• Using purchasing power to increase quality of care
Future Challenge

54. Future Challenge
3. Stakeholder
and
networking
• Balancing the use of financing mechanism and other
measures to maintain a good relationship between health
care providers, and between health care providers and
consumers
• Strong network of public and private participation
• Health protection for non-Thai citizen: a new agenda
(labor migrant :legal & Illegal)  ASEAN Issue

55. 6-Jun-18 55
Purchasers
Conclusion
PeopleProviders
Policy
maker
Efficiency Equity
Accessibility
& Quality
Social
accountability
Sustainable
Context based
learning & Action

56. 6-Jun-18 56
For UHC , NCD  SDG Challenges

57. นายแพทย์ ชูชัย ศรชานิ
chuchai.s@nhso.go.th