1. Lessons from Thailand in achieving universal health coverage: Contributing factors and key challenges
Phusit Prakongsai, MD. Ph.D.
Director of Bureau of International Health (BIH)
Ministry of Public Health, Thailand
Presentation to the 2nd Thailand-Pacific Island Countries Forum(TPIF)
30th May 2015
Sukosol Hotel, Bangkok, Thailand

2. Long march to UHC: Health financing reform GNI per capita, 1961-2013
1997: $2710
Asian financial crisis
2002: $1870
Achieving UHC
1990: $1490
SSS
1983: $760
Voluntary Health Card
1975: $390
Low Income Card
1963: $120
CSMBS

3. Three public health insurance schemes in Thailand after achieving UHC in 2002
Civil Servant Medical Benefit Scheme
(CSMBS)
Social Security Scheme
(SSS)
Universal health coverage
(UHC)
Introduced in
1963
1990
2002
Target beneficiaries
Govt employees & dependents, retirees
Private sector employee
Informal sector who are neither covered by CSMBS nor SHI,
Population Coverage 7%
13%
78%
Funding
Govt budget
Payroll contribution, Tripartite
Payment to health facilities
Fee-for-service for OP, and DRG for IP
Capitation
(use DRG in risk adjusted part)
Capitation for OP
+ DRG with global budget for IP

4. UHC cube: what has been achieved in Thai universal health coverage?
X axis:
99% pop coverage by 3 public H insurance schemes [UCS 78%, SHI 13%, CSMBS 7%]
Y axis:
Free at point of services, very minimum OOPs,
Low incidence of catastrophic health expenditure and health impoverishment,
Z axis:
Extensive and comprehensive benefit package, very small exclusion list,
Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines including Essential Drug List (EDL).

5. Health interventions and medical treatments included into the UHC benefit package
Basic health Care (on capitation basis)
A very comprehensive benefit package with a very minimum exclusion list
ARV drug
Renal replacement therapy
(2nd prevention for DM/HT)
Mental health
(medicines)
Liver and heart
transplantation
Benefit starting year
2002
2006
2009
2010
2011
2012

6. Increased utilization, low unmet needs
Prevalence of unmet need OP IP
National average
1.44%
0.4%
Civil Servant Medical Benefit Scheme (CSMBS)
0.8%
0.26%
Social Security Scheme (SSS)
0.98%
0.2%
Universal Health Coverage Scheme (UCS)
1.61%
0.45%
What are the outcomes of Thai UHC?
National household surveys and routine reporting system from NHSO consistently demonstrated improved utilization both outpatient and inpatient services.
OP utilization rate increased from 2.4 visits per person per year in 2003 to 3.6 in 2011.
Annual per capita hospitalization rate increased significantly from in in 2012
Unmet need was low when OECD standard questionnaire was applied; the unmet needs incidence was as low as 1.4% of OP and 0.4% of IP, on par with OECD good performer countries.
Source: NSO 2009 Panel SES, application of OECD unmet need definitions

7. Changes in utilization: primary secondary and tertiary 1977-2010
46%
(5.5)
29%
(3.5)
24%
(2.9)
1977
Regional H./General H.
Rural Health Centres
Community H.
27%
(11.0)
35%
(14.6)
38%
(15.7)
1987
2000
46.1%
(51.8)
35.7%
(40.2)
18.2%
(20.4)
2010
54.0%
(78.0)
33.4%
(33.4)
12.6%
(18.1)
As a result of investment in health infrastructure and gradually extend financial risk protection for target population; the service utilization had gradually reorient in favour of primary and secondary care, from the tertiary care dominance in 1977, to the primary care dominance in 2010.
This was clearly shown in an upside down triangle to the upright triangle.

8. Financial risk protection Protection Thai HH against health impoverishment
UHC achieved
High level of financial risk protection prevents a large number of non-poor household falling under poverty line as a result from out of pocket payment for health.
The Red dotted line is number of households would be impoverished if there were not UHC.
The Blue solid line is the actual number of household impoverished from health payment, even with UHC.
The difference is the number of household protected from being poor from health payment.
This is one of the most exciting outcomes. All governments acknowledge this positive message and continue to fully support the UHC Scheme.

9. Sub-national health impoverishment 1996 to 2008

10. Government and non-government financing sources, 1994-2011
UHC inception
Million Baht
Economic crisis
Data from the National Health Accounts of Thailand shows that after achieving UHC, the share of public financing increased from 56% of total health expenditure in 2001 to 77% in 2011.
Total health expenditure during ranged from 3.5 to 4.1% of GDP, and per capita health spending in 2011 was 218 USD. Health expenditure for UHC beneficiaries in 2010 was approximately 82 USD per capita.
These financial indicators reflect the affordability of our economy to continue to support UHC.
The good news is the significant reduction of out of pocket payment to 14% of total spending in 2012.
Total health expenditure ranged from 3.49% to 4.1% of GDP
THE per capita in 2011 was 218 USD,
Expenditure for UC beneficiary in 2014 = 90 USD per capita

11. enabling factors of good UHC outcomes
Reflections
enabling factors of good UHC outcomes

12. Strong and expanded leadership with continuous evolution:
Systems design focus on equity and efficiency – diverse institutional arrangement for health policy and system development
Dynamic evolution over decades of rural focus integrated health system development and HRD
Extensive geographical coverage of functioning PHC and district health systems;
Rural compulsory services of new graduates medical doctors for three-years since 1972, rural based nursing production since 1980
Strong and expanded leadership with continuous evolution:
Continued political support despite changes in government,
Capable technocrats,
Active civil society – from VHV to CS for policy advocates
Institutional capacities re knowledge and evidence production and utilization:
Information systems for policy formulation and M&E,
Health economics and health systems research.
Health technology assessment

13. Mandatory rural services
Evolution of the Thai Health System
CSMBS 1980
Health Card 1983
SSS 1990
UCS
NHSO
Low Income Scheme
1997 Constitution
Economic crisis
1980s
1968
1975
2001
2007/08/09
1828
1888
1918
1942
1990s
1946
1978
1999
2006
King Rama 3
started the
Western medicine
Department of Public Health, MoI
Mandatory rural services
HFA/ PHC policy
1992
HSRI
Local Health Funds
HIA
LGs
EMIT
MoPH
Scaling up District Health System
(DH + HC)
1992
A decade of health center development
ThaiHealth
Siriraj Hospital
established
First MoPH nursing college
NHCO
MoPH = Ministry of Public Health, HSRI = Health System Research Institute, LGs = local governments
ThaiHealth = Thai Health Promotion Foundation, NHSO = National Health Security Office,
NHCO = National Health Commission Office, EMIT = Emergency Medical Institute of Thailand,
HAI = Hospital Accreditation Institute

14. Four decades of infrastructure and workforce development
The advent of
district hospitals (1977)
First batch of two-year
technical nurses (1982)
Now fully upgraded
to RNs
Public service mandate
of new MDs (1972)
This slide shows how important the health systems readiness as key success factor for implementing UHC
As a result of four decade government investment in health infrastructure focusing at district health system (including district hospitals and health centres) and government mandatory rural services for key health workforces not only contributed to good health at low cost, which was published in Lancet in 2012, it is the solid foundation for UHC implementation in 2002.
Source: Health Resource Surveys (various years)

15. KEY CHALLENGES

16. Proportion of elderly (>65 years old)
Japan
China
Thailand
Korea
World
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat,  World Population Prospects: The 2010 Revision 16

17. Changes in population pyramid of Thais from 1990 to 2030

19. Sources: Analyses from the 2002, 2004, and 2006 SES
Household expenditure: tobacco, alcohol and health Median household expenditure (Baht per month),
Sources: Analyses from the 2002, 2004, and 2006 SES

20. DALYs attributable to risk factors
Mismatch between increasing burden of disease from NCD and low investment in HP and disease prevention
DALYs attributable to risk factors

21. Framework of adult health development in 2015
Framework for health development in adults
Targets in 2015
Reduction in alcohol consumption for 10%
Reduction in tobacco consumption for 30%
Reduction in high blood pressure for 25%
Risk group of CVD can access to medicines and consultation for 50%
Reduction in premature deaths from NCDs 25%
Reduction in physical inactivity for 10%
Reduction in sodium intake for 30%
No increase in diabetes and obesity
Access to essential medicines and health technology 80%
Promoting healthy life styles in general population
Prevention of NCDs in high risk groups
Prevention and delay in disease complications
Reduction in health risk behaviors
Health management district
- law enforcement
- Improving NCDs clinics and disease management
- Qualified NCD clinics
DHS + system manager at provincial and district levels

22. Acknowledgements Ministry of Public Health (MOPH) of Thailand,
National Statistical Office (NSO) of Thailand,
National Health Security Office (NHSO), Thailand,
Health Systems Research Institute (HSRI), Thailand,
World Health Organization (WHO)
Thank you for your kind attention.