Evaluating ten years of universal health coverage in Thailand

1. Evaluating ten years of universal health coverage in Thailand Viroj Tangcharoensathien, MD. Ph.D. Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to the 13th Annual Scientific Conference (ASCON XIII) ICDDR,B, Dhaka, Bangladesh 15 March 2011

2. Objectives • Review achievements of universal coverage • Propose a conceptual framework for 10 years UC assessment [2001-10] to generate evidence and stimulate international debates

3. Background 1 • Thailand, • LMIC, GNI/capita 3,760, THE: US$136/capita, 3.4% of GNI, OOP<18% of THE (2008) • A long march: 27 years of gradual coverage extension • Application of piecemeal targeting approaches • The poor, children, elderly, vulnerable: tax financed social welfare schemes • Formal sector • Civil servants and family: tax financed medical welfare • Private employee: payroll tax financed SHI • Informal non-poor sector : CBHI, transform to public subsidized voluntary insurance • The 30% uninsured was “last pushed” by general tax financed scheme • By 2002 Thailand achieved full population coverage, by 3 public insurance schemes • Formal sector • Private employee by SHI • Civil servants and dependants, tax financed scheme. • The rest of population by tax financed scheme, free at point of service

4. Background 2 • Strong institutional capacities • Generate evidence and evidence informed policies • Policy relevance researches • Maintaining normative works • NHA, BOD, National Drug Account, National AIDS Spending Account, national household datasets for routine equity monitoring • Health technology assessment capacities: • HITAP institutional relation with UK NICE • Key platforms for evidence informed decision • National Essential Drug List sub-committee • Benefit package sub-committee • ICER, budget impact assessment are pre-requisites for inclusion of new interventions into drug list or UC benefit packages

5. GNI per capita, US$ on a road towards UHC, 1970-2009

6. Evidence on outcome: before and after UHC

7. Equity in financial contribution: Kakwani indexes, 2000-2006

8. Financial risk protection 1: Household OOP as % household income, 1992-2008 Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

9. Financial risk protection 2: Incidence of catastrophic health expenditure 2000-2006 Source: Analysis from NSO SES 2000-2006

10. Financial risk protection 3: Trend of health impoverishment 1996-2008

11. Equity in utilization OP and IPConcentration index by levels 2001-2007 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). 11 11

12. Equity in budget subsidies: Benefit Incidence Analysis, 2001-2007

13. Summary: achievements • Evidence on achievements • Financing sources • Public sources of finance [general tax and SHI contribution], the dominant source [67.6% THE], is the most progressive source of financing healthcare and positive Kakwani index, • OOP reduced to 18% of THE (2008), minimum rich-poor gap of OOP • Financial risk protection • Very low level of catastrophic health spending and impoverishment • Service utilization and public subsidies • Pro-poor utilization both OP and IP • Pro-poor public subsidies

14. Summary: contributing factors • Contributing factors • Systems design: most important for equity and efficiency outcomes • Prakongsai et al, the equity impact of the universal coverage policy: lessons from Thailand, in Chernichovsky and Hanson (eds), Innovations in health system finance in developing and transitional economies 2009. • Supply side capacity to deliver services • Extensive geographical coverage of functioning primary health care and district health systems • Sustainable institutional capacities • Generate evidence • Maintain normative works as foundations for monitoring evaluation • Platforms for evidence informed decisions

15. Scope of assessment of Thai UCS: 2001-10 how who why 1. UC Policies process & system design 2. Contextual environment - MOPH structural reform -downsizing public sector -Decentralization -Medical hub -Compulsory Licensing -health information & IT -Governance of overall health system Structure 4. governance Power UCS Governance NHSO 3.implementation MOPH NHSO Purchaser-provider split Strategic purchasing Harmonization 5. Impact Macroeconomics Providers Population Health system • Primary care development • Medical service delivery • Public health functions • Information system • Human resources • Resilience of system • Service pressure • Financial • Efficiency • Perception • Utilization • Financial protection • Perception • Before UCS • After UCS

16. Assessment of 10 years UCS • Teams • International experts • Tim Evans (BRAC chair), Armin Fidler WB, Magnus (WB), Mushtaque (RF), Anne (LSHTM), Xenia (ILO), David (WHO) • Thai experts • Five team leads • Deliverables • Prelim report Oct 2011, • Final report launched in Prince Mahidol Award Conference, Jan 2012 on UHC • Scientific publications