Expanding coverage to the poor: the experiences from Thailand Samrit Srithamrongsawat Deputy Secretary General, National Health Security Office

Outline of presentation Thailand country profile Development of health service delivery system Expanding health insurance to the poor and vulnerable groups achievements, problems and constraints Lessons learned

Country profile: Thailand Population 65.7 million GNI (2012) $ 5,210 Gini 40 Fiscal space: Tax 17.6% GDP (2011), Revenue 21.3% GDP (2011) GGHE 15.3% GGE (2011) Total Health Expenditure (2012 NHA) US$215 per capita, 3.9% GDP, Public 68%, SHI 8%, Private 24%, OOP 14% of THE HRH density: doctor/nurse/midwife 24.7/10,000pop. Health status Life expectancy at birth 74.1 Total fertility rate 1.5 (2011) U5MR 14 MMR 48 ANC & hospital delivery 99% (2009) 3

Health system development 1970s-2010s: Pro-poor and Pro-rural Development Under-five mortality per 1,000 live births 1975 Low income card scheme 2002 UHC 1980 Civil Servant Medical Benefit Scheme 1983 Voluntary health card 1991 Social security scheme Scaling up of district health system Village health volunteers National EPI MD mandatory rural service MOPH nursing colleges Technical nurse National Economic and Social Development Plans 3th 4th 5th 6th 7th 8th 9th 10th 1997 Asian economic crisis 1 2 3 This slide shows declining of under 5 mortality rate of Thailand together with parallel developments under previous National Economic and Social Development Plans during 1970s – 2010s. There were three main developments contributing to this achievement. First, a broader social and economic development during 1970s-1980s that put emphasis on rural development such as improving basic infrastructure of rural areas, schooling, income generation, and so on. Second, the MOPH also put emphasis on development of rural District Health System during the same period, expanding basic health infrastructures to cover all district and sub district and human resources development. Various interventions were implemented to strengthen district health system for example doctor mandatory rural service started 1972, reallocation of MOPH budget to support rural health facilities, establishment of MOPH nursing colleges and public health colleges to supply human resources for its own facilities including local recruitment of students. Third, financial risk protections schemes were subsequently developed for different segment of populations, started from the poor 1975 then for public formal sector in 1980, informal sector in 1983, and private formal sector in 1991 before achieved UHC in 2002. It should be noted that during 1965-1982, there had been movements of the Thai communist party in rural areas of all parts of the country so the pro-poor, pro-rural development was the key strategy of the government to compete with the communist party for the people. Second, the MOPH also put emphasis on development of rural District Health System during the same period, expanding basic health infrastructures to cover all district and sub district and human resources development. Various interventions were implemented to strengthen district health system for example doctor mandatory rural service, reallocation of MOPH budget to support rural health facilities, establishment of MOPH nursing colleges and public health colleges to supply human resources for its own facilities including local recruitment of students. Source: U5MR was analysed from IHME data

Reallocation of government budget to health and education Percentage Since 1980s, the government has reallocation more and more budgets to health and education sector. This resulted in gradually increased of government budget spending on health as shown in this figure. Year Source: Bureau of Budget

Reallocation of MOPH budget to build rural facilities and HRH Fast tracking rural health No investment in urban areas for 5 yrs during the 5th – 6th National Health Plan. During the same period, The MOPH has also reallocated it’s budgets toward more budgets for rural district health system.

Health systems development: 1960s-2000s The advent of district hospitals (1977) Public service mandate of new MDs (1972) First batch of two-year technical nurses (1982) Source: Health Resource Surveys (various years)

Current health service delivery system in Thailand University hospitals 11 Private hospitals 322 Specialized hospitals 48 Regional hospitals 26 25 Province Other public hospitals 60 Provincial hospitals 71 For efficiency and equity purposes, the health service delivery system has been organized as a multi-level……. District District hospitals 734 Health centers 9,768 Community Medical Centers 365 Private clinics 17,671 Pharmacy 11,154 Sub-district Local government MOPH facilities

Shifting of service utilization toward primary care Following several decades of primary care and rural district health system development, there was shifting of service utilization pattern, more and more people used the rural health facilities and changed the pattern of use of ambulatory care from that of a reverse triangle in late 1970s to that of an upright one, with broader and broader bases. 9 9

Expanding health insurance to the poor and vulnerable groups 1945 The policy on charges for drugs and medical services in public facilities 1975 The “Low Income Scheme” (LIC) was lunched after the general election, and the Low Income Card was first issued in 1981 Since 1989, it had been gradually extended to cover other vulnerable groups i.e. elderly, children under 12, disabled, veteran, monk, health volunteer, and community leaders, and renamed to be “Medical Welfare Scheme” 1998, reforming financial management of the scheme Management committees at national and provincial level Moving toward demand side financing-per capita budget allocation Piloting capitation and DRG payment Reinsurance policy was introduced for high cost services and portability of benefit Registration of beneficiary and database

Characteristics of the Medical Welfare Scheme Nature Social welfare Populations The poor (direct targeting by mean-test) Vulnerable groups i.e. elderly, children, disabled Those contributed to the society i.e. veteran, monk, community leader, health volunteer Source of finance General revenue Management organization Ministry of Public Health and Provincial Health Office Benefit package Comprehensive services including OP, IP, dental, Providers Public only, mainly MoPH facilities Choice of provider They were assigned to their local health center and district hospital and strict to referral system to higher level of facilities Payment Global budget

Approaches in covering the poor and vulnerable groups in Thailand Sliding scale [since 1945] All public facilities receive government budget and can not refuse to provide services to the patients then those who are unable to pay could get partial or full exemptions. Targeting [1975-2001] Direct targeting by mean-test for the poor, made by community committees and approved by the district governor Indirect targeting by personal characteristics i.e. age, disability, occupation, etc. Universalism or Right-based approach [since 2002] Several mechanisms to protect beneficiary’s rights i.e. hotline call center, complaint management, no-fault compensation,

Achievement: Expansion of health insurance coverage, 1991 - UHC UCS 2002 Prior to achieving UHC, Rapid expansion of health insurance coverage during 1991-2001was observed, this mainly came from the expansion of Low Income scheme to other indigent groups, the social security scheme, and the voluntary health card scheme. In 2002, the Universal Coverage Scheme was introduced by incorporating the previous MWS and HCS together and expanded coverage to the rest of the population. Currently, nearly all Thais are covered by three main public health insurance schemes. The Civil Servant Medical Benefit Scheme covers 8% of the population, the Social Security Scheme covers 16% of the populations. The UC scheme covers 75% of the populations. It is worth noting that majority of UCS members are those residing in rural areas and poor while CSMBS and SSS members are those the better off. Source: HWS 1991, 1996, 2001, 2003 CSMBS = Civil Servant Medical Benefit Scheme, SSS = Social Security Scheme, MWS = Medical Welfare Scheme, HC = Voluntary Health Card Scheme, UCS = Universal Coverage Scheme

Achievement: enable access and use of health services for the poor and vulnerable groups Source: NSO, HWS 1991 and 1996

Achievement: enable access and use of hospital care for the poor and vulnerable groups Source: NSO, HWS 1996

Problems and constraints in providing health coverage to the poor and vulnerable groups Problems of direct targeting: under coverage and leakage of subsidy 1980 1988 1990 1998 Coverage NA 30% 32% 17% Leakage 12, 9 % of LIC at hosp. and HC were not poor 21% of LIC were not poor 55% of LIC were not poor 65% were not poor Stigmatization Discrimination in prescribing medicines Therefore, some LIC cardholders did not show the card until they were asked for the payments Under financed of the scheme

Universalism approach better protects the poor: Benefit Incidence Analysis, 2001 and 2003 Note: Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were 80,678 million Baht (in 2001-value) The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123

UHC has further reduced health impoverishment UHC achieved Financial risk protection is direct result of providing universal health insurance. Financial burden from out-of-pocket payment for healthcare of the poor has been declining over time. Moreover, evidences from subsequent national household income and expenditure surveys showed that approximately 60,000 households were protected a year from medical impoverishments. Then UHC can be seen as a strategy for poverty reduction.

District health system was key contributing factor of equity in OP & IP utilization Equity in IP utilization Equity in OP utilization Measuring of concentration index of the use of outpatient and inpatient services in various years indicated that the poor disproportionately used more services than the rich for both services. District health system, health centers and district hospitals played crucial role in this achievement for OP services since more than half of OP services were provided by health centers and another 30% at district hospitals. For inpatient services, public hospitals play crucial role in the achievement. 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).

Lessons learned from the Thai case Pro-poor and pro-rural development of several successive national development plans that put emphasis on district health system was key contributing factor for improving equity in access to car for the poor and vulnerable groups Direct targeting by mean-test is both technical and practical problematic esp. in developing countries Specific health insurance program for the poor and vulnerable groups did enable access to and use of health care; however, stigmatization and discrimination was found Universal program is better protect the poor and vulnerable groups and further improve equity in service utilization and financial risk protection