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

2. 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

3. Country profile: Thailand
Population 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 (2011)
U5MR 14
MMR 48
ANC & hospital delivery 99% (2009) 3

4. 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 th th th th th th th
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 , 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

5. 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

6. 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.

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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 [ ]
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,

13. Achievement: Expansion of health insurance coverage, 1991 - UHC
UCS 2002
Prior to achieving UHC, Rapid expansion of health insurance coverage during was 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

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

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

16. 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

17. 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 and in 2003 was

18. 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.

19. 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 Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).

20. 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