Healthcare Financing in Thailand: an update in 2007 Updated by International Health Policy Program (IHPP) Ministry of Public Health, Thailand

Outline presentation I. Background information on burden of disease and health care finance IA. Burden of Disease in 2004 & national health expenditure, 1994 – 2005 IB. Healthcare financing performance Fairness in financial contribution – EQUITAP results Incidence of catastrophic and impoverishment from OOPs Equity in utilization & benefit incidence analysis (BIA) II. Ongoing major works IIA. Universal offer of VCT IIB. Major program review of cervical cancer control IIC. Review of DCP2 and its application in chronic diseases management IID. Annual hospital report III. Future challenges: Renal replacement therapy, financial sustainability, and potential moral hazards, etc. Honourable Ministers, Ladies and Gentlemen, I wish to share the Thai lessons on Universal Coverage and the role of SHI in financing and systems design of UC Scheme, its achievement and future challenges

IA. Background information: BOD and financing healthcare

Profile: top 10 mortality, Thailand 2004 Total deaths 390,285 Top 10 deaths share 63% of total national deaths

Profile: top 10 YLL, Thailand 2004 Total YLL 6.07 million years Top 10 YLL shares 63 % of total national YLL

Profile: top 10 YLD, Thailand 2004 Total YLD 3.1 million years Top 10 YLD shares 71% of total national YLD

Profile: top 10 DALY loss, Thailand 2004 Total DALY loss 9 Profile: top 10 DALY loss, Thailand 2004 Total DALY loss 9.17 million years Top 10 DALY shares 52% of total national DALY loss

DALY loss by age group and gender, Thailand 2004

DALYs per 1,000 population, ranked 22 categories

Top 15 risk factors, men Thailand 2004

Top 15 risk factors, women, Thailand 2004

Total Health Expenditure, NHA 1994 – 2005 The total health expenditure (THE) of Thailand in 1994 was 127,655 million baht at current price including capital formation. The total health expenditure of Thailand had gradually increased during 1995 to 1997 and had sharply decreased in 1998 due to the economic crisis in 1997. However, the THE in 2000 to 2005 had slightly increased to 248,079.18 million baht (current year price) in 2005. Ratio of THE to GDP was 3.5 percent in 1994 and reached to 4 percent in 1997, the year which Thailand faced the economic crisis, after that period the ratios had decreased continuously to 3.3 percent in the year 2001.After UC implementation the ratios increased and reached to 3.7 % in 2002 then it was rather stable at 3.5 % GDP until 2005.

Real term growth GDP versus THE, 1994-2005 13 13

THE, Baht per capita NHA 1994-2005 current and constant price (2003) 14 14

Trend of financing sources NHA 1994-2005 Public financing source comprises of the Ministry of Public Health, other ministries that provide healthcare services, the Civil Servant Medical Benefit Scheme, Universal coverage, local government expenditure, Social Security Scheme and Workmen Compensation Fund. Share of public funding sources was 45 percent of THE in 1994. However, public sources of finance gradually increased and became dominant portion, 64 percent of THE in 2005. It was due to high average per capita growth rate of 9.7 percent which was greater than that of the non-government sources of finance, 2.2 percent growth per year.

Trends of financing agents, NHA1994-2005 This slid show trend of health financing sources focus on the major source of financing both central government and household In 1994 were central government (Ministry of Public Health and other related ministries) and household direct payment for healthcare, which accounted for 30.5 and 44.5 percent of THE respectively. Nevertheless, the share of each of the two main sources had become nearly one third of the total health expenditure in 2001. After 2001 central government played the major role of spending on health until 2005 around 40% while as household decrease share till 27.6 % at 2005.

Expenditure by financing agent NHA2005 in 2005.Gener Gov exclude social insurance accounted for 55.7 %, of this the central government provides 52.2 %, while local government provided 3.2%. the social security provides 8%. The non government funding swished from major part in 1944 at 55.3% to minor part in 2005 at 36.1% of total health expenditure. In 2005 Out of pocket payment played the major role in private sector at 27.6 % of THE while as the other private insurance, including with private insurance, private social insurance, Non profit and cooperation, represented 8.4 % of total health expenditure.

Expenditure by public financing agents, NHA2005 Within the public expenditure, the health spending for health insurance accounted for 60% of THE, of which the UC contributed 27 %, CSMBS contributed 19% and social security contributed 12 % of total public expenditure on health.

Expenditure by healthcare Function NHA2005 19 19

CSMBS total expenditure and growth 1988-2006 million of employees/pensioners Source: Comptroller General Department, Ministry of Finance (various years) 20 20

IB. performance of UC scheme

Why general-tax-financed UC Scheme? Contributory UC Scheme was not in the policy agenda during 2001 general election, Feasible to apply general tax, additional budget requirement was in fiscal capacity Not feasible to collect premium Urgency to nation-wide scale up immediately, political obligations to the constituency Subsequent studies indicate the Concentration Index of various sources of healthcare finance – Thailand 2002 (O’Donnell et al 2005) CI weight NHA Direct tax 0.9057 0.1868 Indirect tax 0.5776 0.3155 Social insurance 0.5760 0.0582 Private insurance 0.3995 0.0668 Direct payments 0.4864 0.3728 Total Health Financing 0.5929 General Tax 0.6996 Note: CI, an index of the distribution of payments, ranges (-1 to 1), a positive (negative) value indicates the rich (poor) contributes a larger share than the poor (rich), a value of zero is everyone pays the same irrespective of ability to pay Based on macro financing using the National Health Account, and micro-level household survey by NSO SES; empirical evidence indicates the total health financing in Thailand is quite progressive, the CI equals to almost 0.6. Direct tax is the most progressive source, with the largest CI of 0.9057. Indirect tax and social insurance contribution are similar less progressive than direct tax, CI equals to 0.57. We also estimate that the general tax which today finances UC scheme is progressive, 0.6996. This means the rich pay more than the poor. The UC Scheme achieve the societal objective that health payment according to capacity to pay. General tax was applied for UC scheme not only the progressivity, it is not possible, technically, at this moment, to collect premium contribution from the informal rural sector. Enforcement is too difficult. There is no choice that Thai UC applies general tax, instead of contributory scheme like SHI.

Contribution of Social Health Insurance (SHI) to UC Scheme system design SHI as a predecessor of UC Contract model contractual arrangement with competitive public and private provider contractors Contract is feasible in the context of comprehensive geographical coverage of MOPH healthcare infrastructure Closed-ended provider payment method Among a few developing countries, Thailand pioneers capitation payment method Additional pay for A&E, high cost care, based on fee schedule Purchaser Provide split Social Security Office and National Health Security Office as purchasers – design packages and payment methods MOPH, other public and private medical institutions as major providers Comprehensive coverage Comprehensive service package, OP, IP, Prevention, Promotion Neither deductibles nor co payment at point of services, UC scheme has nominal pay of US$ 0.75 per visit or admission SHI is the predecessor of systems design of UC Scheme: especially capitation contract model. Among a few developing countries, Thailand pioneers capitation contract model and proves a decent quality of services with very well cost containment. Also separate role of purchasers and providers. SHI and UC Scheme provide a comprehensive coverage. Literally there is neither deductibles nor co payment at point of services.

Advanced characteristics of the UC Scheme UC scheme further modified the systems design: notably Primary Care Network as the service contractor, unlike SHI applies 100 bed hospital as main contractor. UC beneficiaries have limited choice to registered primary care network but they are ensured with referral to tertiary care. Ambulatory care applies capitation while admission services apply global budget and DRG system, this is to prevent under-admission in inclusive capitation of SHI. While SHI has a separate package of dental and maternity, UC Scheme integrates them into curative package to avoid different payment method and high administrative cost UC scheme covers every members, while SHI cover the workers only.

Capitation rate and components Baht per capita, approved fig Capitation rate and components Baht per capita, approved fig. 2002-2007, plan fig. 2008

Discrepancy: proposed & approved capitation rate FY2002-2006 The approved capitation rate is below the proposed figures that IHPP calculated based on utilization from national household survey conducted by NSO, and the unit cost of OP and IP services. The discrepancy is a result of the government fiscal constraint. The Scheme is therefore under-funded for the last 4-5 years. IHPP calculates capitation rate based on actual utilization rate and unit cost. Due to fiscal constraint, it results in discrepancy

Household health expenditure as % of household income by income deciles prior to UC (1992-2000) and after UC 2002-2006 Source: NSO SES (various years)

Distribution of households with health expenditures > 10% total consumption by consumption expenditure quintiles Source: NSO’s SES (various years)

Catastrophic health payments in Thailand, 1996-2002 % non food expenditure on health 1996 1998 2000 2002 0 to 0.5% 31.9 33.2 34.5 41.2 0.5 to 10% 51.3 51.5 50.8 48.1 10 to 25% 11.9 10.9 11.0 7.6 25 to 50% 3.5 3.6 3.1 2.5 More than 50% 1.4 0.8 0.7 0.5 Total 100.0 Source: National Statistic Office, Household Socio-economic Survey, various years.

Pre-post UC incidence of catastrophic expenditure Households with health payment > 10% of total consumption expenditures All households LIC/VHC UC–E/-P Year 2000 Quintile 1 4.0% 2.7% Quintile 5 5.6% 7.1% All Quintiles 5.4% 4.7% Year 2002 1.7% 5.0% 6.1% 3.3% 3.2% Year 2004 1.6% 4.3% 5.2% 2.8% 2.6% Year 2006 0.9% 3.0% 2.0% 1.9% Source: NSO’s SES (various years)

Impact of UC: Catastrophic illnesses, impoverishment Limwattananon et al 2005 Dataset: NSO SES 2000 (24,747 households), 2002 (34,785) and 2004 (34,843). Finding The incidence of catastrophic health expenditure (>10% of total HH consumption) reduced From 5.4% in pre-UC 2000 to 3.3-2.0% in post-UC 2002-2006 An increase in the poverty headcounts due to OOP payments dropped From 2.1% in pre-UC to 0.8-0.5% in post-UC. Conclusions Reduction in the catastrophe and impoverishment due to OOP health payments is evident after the UC reform which provides comprehensive coverage of health care with a very small nominal fee. Catastrophic illness is measured by more than 10% of total household consumption. Our Pre – Post UC assessment indicates the incidence of catastrophic illnesses reduced from 5.4% to 3.3% and 2.2% respectively. Not only the reduction in the incidence of catastrophic illnesses, the additional number of people fell under the national poverty line after the OOP, also reduced from 2.1% to 0.8% and 0.5% respectively. This is a positive message, that UC helps achieve two major societal goals, namely minimize catastrophic events to the households and the impoverishment from medical payment.

Healthcare Catastrophe vs. OOP Payments & Income data as of 2000 An interesting finding from EQUITAP project in Asia-Pacific region is that the low-income country with higher share of health payment from household’ OOP tends to face catastrophic health expenditure. Source: van Doorslaer et al. (2005)

Utilization by UC members source: NSO HWS2001, 2003, 2004, 2005 and 2006 In view of under funding, utilization among UC members increased significantly compare pre UC 2001 to post UC 2003 and 2004. Primary care unit and district hospitals are the major providers especially for ambulatory care. A good message emerges. There was a major shift of utilization from tertiary provincial hospital to Primary care unit and District hospital both outpatient and inpatient.

Total Ambulatory Visits (millions/yr) (HWS 2001, 03, 04, 05, 06) SSS LIC/VHC & UC-E/-P CSMBS

Average Ambulatory Visits (per member/yr) (HWS 2003, 04, 05, 06) 1.13 1.09 1.12 0.91 1.86 2.18 2.07 1.53 SSS 1.80 1.98 1.93 1.67 UC-E/-P CSMBS

Insurance Use for OP Visit (% compliance) (HWS 2003, 04, 05, 06) SSS UC-E/-P CSMBS

Total Hospital Admissions (millions/yr) (HWS 2001, 03, 04, 05, 06) SSS LIC/VHC & UC-E/-P CSMBS

Average Hospital Admissions (per member/yr) (HWS 2001, 03, 04, 05, 06) 0.06 0.06 0.07 0.06 0.07 0.09 0.08 0.09 0.08 0.08 SSS 0.10 0.09 0.12 0.11 0.08 LIC/VHS & UC-E/-P CSMBS

Insurance Use for IP admission (% compliance) (HWS 2003, 04, 05, 06) SSS UC-E/-P CSMBS

Type of health facilities Provincial and regional hospitals The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities 2003 2001 Concentration indices of ambulatory service use among different types of health facilities in 2001 & 2003 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

Selected concentration curves of ambulatory service use among different types of health facilities in 2003 This slide demonstrates concentration curves of ambulatory service use in some health facility types in 2003. Findings of this study are similar to other studies which ambulatory service use of primary and secondary care levels at health centers and community hospitals is pro-poor; while ambulatory service use of tertiary care level such as university hospitals is pro-rich.

The distribution of hospitalization among different socio-economic groups in 2001 and 2003, by types of health facilities 2001 2003 Concentration indices of hospitalization among different types of health facilities in 2001 & 2003 Types of health facilities 2001 2003 Community hospitals - 0.3157 - 0.2934 Provincial and regional hospitals - 0.0691 - 0.1375 Private hospitals 0.3199 0.3094 Overall hospitalization - 0.0794 - 0.1208

Selected concentration curves of hospitalization among different types of health facilities in 2003 This slide demonstrates concentration curves of hospitalization in some types of health facilities in 2003. Hospitalization of community hospitals and provincial / regional hospitals was pro-poor, while that of university and private hospitals was pro-rich.

Who benefits from public subsidies Limwattananon et al 2005 Benefit Incidence Analysis: compare pre-UC 2001 and post-UC 2004 using NSO HWS2001, 2004 OP care Post UC 2004, the pro-poor subsidy was very pronounced at District Health System (DHS) Concentration Index = - 0.3326 and - 0.2921 for Health Centre and District Hospital respectively. Less progressive at provincial hospitals (PH) CI = - 0.1496. IP care More progressive in favour of the poor at DH CI = - 0.3130 in 2001 and - 0.2666 in 2004. Weaker progressive in favour of the poor at PH CI = - 0.1104 in 2001 and - 0.1221 in 2004 Conclusions The pro-poor subsidy were strongest for DHS. Lessons indicates DHS plays key role in fostering the pro-poor nature of public subsidy. Close to client services, better accessed Benefit Incidence Analysis was used to assess how public subsidies were distributed across household quintiles. CI ranges from minus 1 to plus one. The higher the minus, the higher subsidies go to the poor. Subsidies is more pro-poor at DHS than at the Provincial Hospital, for both ambulatory and admission services DHS plays an important strategic hub (so called close to client services) in fostering pro-poor nature of public subsidies; DHS is better accessed by the majority poor who resided in rural areas.

Percent distribution of net government health subsidies among different income quintiles in 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

Concluding remarks 1 Enabling factors for achieving UC Strong political supports Health systems capacity and its resilience to rapid nation-wide program scale-up in 6 months Lessons from predecessors SHI capitation contract model CSMBS “no go” fee for service, due to cost escalation and inefficiencies Voluntary Health Card Scheme – adverse selection and non-viable financially Linking evidence to policy decision Integral relationship among researchers – reformists – politicians Pragmatism Limited chance to achieve UC by contributory scheme, especially among informal sector, not feasible for contribution collection and enforcement Learning from SHI, UC takes further advanced steps, Well thought systems design towards efficiency, cost containment, ensure referral, advocates of primary care contractor 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.

Concluding remarks 2 UC Schemes covers the poor, half belongs to Q1 and Q2 However, the Scheme faced chronic under-funding, capitation was below than the proposed figures based on cost and utilization Significant increase in utilization more on OP than IP In view of under-funding and increased utilization  danger of poor quality of services and serious hospital financial constraints Empirical evidence indicates Pro-poor budget subsidy, DHS is a major hub of fostering the pro-poor nature of financing healthcare Policy msg.  invest more in DHS (further) reduction in the incidence of catastrophic illnesses (further) reduction of impoverishment from medical bills 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.

IIA. Ongoing major work: Universal offer of VCT

The potential VCT uptake with zero price 10.4% 32.6% Current price 11.7% 39.7% Current price

Predicted Demand for VCT by Regions Gen. Pop. SW MSM IDU

IIB. Ongoing major work: Major program review of cervical cancer control

National Coverage of Cervical Cancer Screening (Household Survey -2006) Source: NSO’s Sexual and Reproductive Health Survey (2006)

Reported Achievement by Set Targets (2005) Source: NHSO (2006)

Work Components

IIC. Review of disease control priorities (DCP-2) and its application to the 10th National Health Development Plan

Objectives of the study on DCP-2 and the 10th National Health Development Plan To review patterns of burden of disease and risk behavior of Thais in 1999 and 2004 To review cost-effective medical treatments and public health interventions suggested by DCP-2 in accordance to BOD of Thailand To explore similarity and dissimilarity of current practice for disease control and prevention on top-ten priority of disease burden in Thailand, compared to suggestions from the DCP-2 To estimate the magnitude of government investment in disease prevention and reduction in health risk behavior, health promotion, screening and early detection of disease in high priorities, compared to investment in curative interventions To provide policy recommendations on improving efficiency and efficacy of public investment in health promotion, disease prevention, curative interventions, and economic gains from more investing in health To develop plan and framework for investing in health and estimate the medium term expenditure framework (MTEF), compared to government health budgets

Estimate budget requirements for health investment in Scope of the study Review burden of disease (BOD) and risk behavior of Thais in 1999 and 2004 Select top-ten burden of disease contributing to highest DALY loss in 2004 as the scope of the study Review recommendations for effective medical treatments and public health interventions in DCP-2, compared to current practice and clinical guideline practices in Thailand Estimate public resources required for investment in health promotion, disease prevention, and public health program in reducing risk factors and behavior of each disease, compared to curative program and other sectors Provide policy recommendations for improving efficiency in health investment in health promotion, disease prevention, screening, curative and reducing risk behavior Estimate budget requirements for health investment in the 10th National Health Development Plan and present research findings for public hearing of all stakeholders

IID. Sustainable Development of Healthcare System Performance in Thailand

Objectives To review previous studies of Thai healthcare performance and current approaches from international perspectives Based on process of consultation and consensus agreement among major stakeholders in Thailand, to develop and conceptualize the Thai healthcare system performance framework To build up institutional capacity and foster networking with all stakeholders and technical partners for a long term national capacity in healthcare performance assessment To assess and produce a public report on Thai healthcare performance in for FY2007 (pilot phase in 4 Provinces) To develop strategy and policy approach to catalyze improvement in the performance in the positive ways

Conceptual Framework of Healthcare System Performance Review: Concept; Domain; Indicators; Information system Review Existing: Data source; Thai conceptual Framework: Goals; domain; Indicators; data Gap?: Data (available; quality) Information system; Develop Measure Level: Hospital and CUP Report: Level (province, region) Indicators Benchmarking Analyze, Synthesis Revised Improvement: Personnel; IT; Management Survey? Users: Public Central government Local government Healthcare planner Hospital manger Health insurer Academia Now comes to achievements of UC Scheme

III. Future challenges Now comes to achievements of UC Scheme

Prevalence Hypertension: 23% male, 21% female From the national health exam survey (NHES), the prevalence of hypertension was 23% among men, and 21% among women. Among men who were found hypertensive, only 23% were diagnosed by health care personnel; while a vast majority, 77% were not diagnosed. Among the diagnosed, 5% failed to treat, the treatment coverage of hypertension was only 17%. Among those treated with anti-hypertensive drugs, only 6% were well controlled. The situation is better among women, the treatment coverage was higher, 31% and effectiveness of the treatment is also higher, 12%. Prevalence Hypertension: 23% male, 21% female All samples are hypertensive, >140/90 mmHg,

Prevalence DM: 6% male, 7% female All samples have FBS, >126 mg/dl Compared with hypertension, the treatment coverage of diabetes (DM) was better, 49% among women, and 33% among men. But the effectiveness of treatment is still unsatisfactory, 15% among women and 9% among men were well controlled of their blood sugar. Prevalence DM: 6% male, 7% female All samples have FBS, >126 mg/dl

Death from Diabetes Diabetes death Death rate Poorest Richest

Death from Ischemic Heart Disease Death rate IHD death Poorest Richest

CEA and CUA societal perspectives PD and HD at NPV 2005

Budget impact analysis 2 scenarios: universal versus limited access to RRT at the lowest cost estimate (250,000 Baht / case/ year) 2005 (year 1) 2009 (year 5) 2014 (year 10) 2019 (year 15) Universal access to RRT (million Baht) 3,994 18,058 32,255 43,804 As % of UC budget 5.5 18.4 23.7 23.6 As % of THE 1.7 5.9 7.7 RRT for KT eligible (mil Baht) 1,981 8,944 15,966 21,625 2.7 9.1 11.7 0.9 2.9 3.8 UC budget (million Baht) 73,136 98,074 135,987 185,248 Total health expenditure (million Baht) 230,836 303,931 417,522 572,659

Future Challenges (1) Most of the crude ground works had achieved PHC focus and reorientation, pro-poor achievement, extensive financial protection of the poor, very minimum catastrophic incidence, BUT Need to increase value for money Maintain decent quality of care and continued advancement in medical progress Evidence based and learning organization for MOF (CSMBS) SSO and NHSO BOB, MOF Fiscal Policy Office, NESDB Harmonization across 3 public insurance scheme Adequate and sustainable financing of the pro poor UC scheme There are many future challenges, I wish to highlight IHPP and its partners involvement in the policy formulation on the extension of Renal Replacement Therapy, RRT is the only one service not covered by UC Scheme while SHI and CSMBS fully covers. Cost effectiveness study by IHPP indicates that PD and HD was far too expensive, more than 10,000 USD per life saved, while ART spent 590 USD. RRT is 4 times of GNI per capita for one life year saved, and 18 times as expensive as ART. However, Kidney Failure is catastrophic for the household. There is an ethical problem of not extending RRT while patients under SHI and CSMBS are fully covered. IHPP and WHO HQ is conducting further policy analysis in this particular issue

Future Challenges (2) Focus more on effective coverage of increasing trend of chronic conditions and effective prevention of injuries Renal Replacement Therapy for chronic kidney disease patients is not covered by UC Scheme (while SHI and CSMBS cover fully) Results in catastrophic health expenditure by households Need serious informed policy decision and long term financial implications Cost per life year saved (Teerawatananon et al 2005) Peritoneal dialysis 10,170 US$ Hemodialysis 10,490 US$ Cost per life year saved (Lertiendumrong et al 2005) Antiretroviral Therapy 590 US$ GNI US$ 2,540 per capita (2004 WDR) Cost per life year saved for RRT 4 times of GNI per capita, 18 times as expensive as the current national ART program. Ethical dimension of not extend RRT to UC members There are many future challenges, I wish to highlight IHPP and its partners involvement in the policy formulation on the extension of Renal Replacement Therapy, RRT is the only one service not covered by UC Scheme while SHI and CSMBS fully covers. Cost effectiveness study by IHPP indicates that PD and HD was far too expensive, more than 10,000 USD per life saved, while ART spent 590 USD. RRT is 4 times of GNI per capita for one life year saved, and 18 times as expensive as ART. However, Kidney Failure is catastrophic for the household. There is an ethical problem of not extending RRT while patients under SHI and CSMBS are fully covered. IHPP and WHO HQ is conducting further policy analysis in this particular issue

Acknowledgments National partners International partners National Health Security Office (NHSO) and other partners who initiate, design and steer the UC scheme HSRI for supports on NHA development since day one until institutionalized HISRO, HISO for their technical and financial supports Ministry of Public Health (MOPH) major healthcare providers and steer the implementation of UC scheme. National Statistical Office (NSO) for national household surveys Thailand Research Fund (TRF) for institutional grants to IHPP International partners World Bank and MOPH partnership on Country Development Partnership in Health Sector ILO for peer reviews of capitation rate 2002, and long term financing forecast 2005-2020 WHO and Harvard for studies on ethical dimension of RRT extension to UC members EU funded Equity in financing, health utilization and public subsidies in Asia Pacific (EQUITAP) Finally, I wish to acknowledge the following international and national partners for their contributions