1. Assessing the impact of a policy on universal coverage on financial risk protection, health care finance, and benefit incidence of the Thai health care system Phusit Prakongsai, MD Supon Limwattananon, PhD Walaiporn Patcharanarumol, BSc MPH Kanjana Tisayatikom, MPH Viroj Tangcharoensathien, PhD International Health Policy Program (IHPP) - Thailand Presentation to the 6 th IHEA World Congress 9 July 2007, Copenhagen

2. Outline of presentation Background Health insurance coverage after UC implementation in 2003 Changes in health service use and benefit incidence Changes in the incidence of catastrophic health payments Discussion and conclusions

3. Health care finance and service provisions of the Thai health care system after implementation of the universal coverage policy General tax General tax Standard Benefit package Tripartite contributions Payroll taxes Risk related contributions Capitation Capitation & global Co-payment budget with DRG for IP Services Fee for services Fee for services - OP Population Patients Ministry of Finance - CSMBS (6 million beneficiaries) National Health Insurance Office The UC scheme (47 millions of pop.) Social Security Office - SSS (7 millions of formal employees) Voluntary private insurance Public & Private Contractor networks

4. Methods and data sources Benefit incidence (BIA) and financial incidence analyses (FIA) were employed, Two different approaches of BIA: Using household income per capita and asset indexes; Using aggregated and regional unit government subsidies. Data sources Nationally representative household surveys on health insurance coverage and health service use in the 2001 and 2003 HWS, National household surveys on household income and consumption expenditure, Unit government subsidies for public and private health care providers in 2001 & 2003.

5. Health insurance coverage in 2003 Source: The 2003 Health and Welfare Survey conducted by the National Statistical Office of Thailand (NSO) Note: PHI = private health insurance, UC = the UC scheme11 Source: The 2003 Health and Welfare survey Note: Q1 = the poorest quintile, Q5 = the richest quintile

6. The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities 2001 2003 Concentration indices of ambulatory service use among different types of health facilities in 2001 & 2003 Type of health facilities20012003 Health centers - 0.2944- 0.3650 Community hospitals- 0.2698- 0.3200 Provincial and regional hospitals- 0.0366- 0.0802 Private hospitals0.43130.3484

7. The distribution of hospitalization among different income quintiles of Thais in 2001 and 2003, by types of health facilities Types of health facilities20012003 Community hospitals - 0.3157- 0.2934 Provincial and regional hospitals- 0.0691- 0.1375 Private hospitals0.31990.3094 Overall hospitalization- 0.0794- 0.1208 Concentration indices of hospitalization among different types of health facilities in 2001 & 2003 2003 2001

8. 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

9. Benefit incidence in 2003 between using aggregate and regional unit subsidies Benefit incidence in 2003 between using household income per capita and an asset index to rank individuals

10. The incidence of catastrophic health payments in 2000, 2002, and 2004 200020022004 Q1 (poorest) 4.0 %1.7 %1.6 % Q26.6 %2.1 %2.4 % Q35.4 %3.6 %2.7 % Q45.6 %4.0 %2.9 % Q5 (richest) 5.6 %5.0 %4.3 % All quintiles5.4 %3.3 %2.8 % Note: Catastrophic health expenditure refers to household out-of-pocket payments for health over 10% of total household consumption

11. Conclusions (1) The UC policy has improved equity in access to and utilization of health services in Thailand through four strategies: The expansion of public health insurance to nearly universal coverage The removal of financial barriers to essential health services The comprehensive benefit package of the scheme The promotion of primary care use as the main contracting unit The distribution of government health subsidies in Thailand was pro-poor before UC, and the re-distributive effect is getting better after implementation of the UC policy. Health services at primary and secondary care levels were more pro-poor than health services at tertiary care and private facilities.

12. Conclusions (2) Using different figures of government unit subsidies (aggregated vs regional unit subsidies) and different measures to categorize individual socio-economic status (income and asset index) does not provide different pictures of improvements in health care use and the distribution of government health subsidies in Thailand. The incidence of catastrophic health expenditure after UC is better than the situation before UC, particularly in poorer quintiles, but some expensive health services such as RRT for end-stage renal disease patients is still excluded from the UC benefit package and causes households to be financially catastrophic. Changes in the allocation method of government health resource and health financing mechanisms appear to be a key factor in the success of UC in improving equity in the Thai health care system.

13. Limitations of the study Differences in questions and answer choices between the 2001 and 2003 HWS questionnaires, Lack of rigorous welfare indicators to categorize individuals into different socio-economic status, Variations of unit government subsidies among different regions and health care levels, The estimates of unit subsidies for CSMBS and SSS beneficiaries, Limitations in identifying UC members before implementation of the UC policy.

14. Acknowledgements National Statistical Office of Thailand (NSO) Ministry of Public Health (MOPH) Thailand Research Fund (TRF) Health Systems Research Institute (HSRI) World Health Organization (WHO)