Universal Coverage Scheme and the poor: Thai experiences Dr Pongpisut Jongudomsuk Director Health Systems Research Institute (HSRI)
Thailand in 2004 Source: World Development Indicators 2005. Indicators Thailand Lower middle income countries GNI per capita (USD) 2,490 1,666 GDP growth (%) 6.17 7.63 Life expectancy 70.52 70.25 IMR (per 1,000 LB) 18.2 32.68 Under 5 MR (per 1,000) 21.2 41.6 THE as %GDP in 2002 4.4 6.0 Private exp. on health % THE 30.3 54.6 Health exp per capita (USD) 90.0 84.0 Physicians per 1,000 pop. 2004 0.3 1.6 Hosp beds per 1,000 pop. 1995-2002 2.0 3.8
The poor in Thailand 50 1600 Proportion of the poor (%) and GDP growth (%) 40 30 20 10 0-10 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 1400 1200 1000 800 600 400 200 Poverty line (Baht) -20 0 The poor Economic growths Poverty line Source : NESDB
The poor in Thailand in 2006 Bangkok, 0.5% South, 7.8% Central, 8.7% North, 23.3% Northeastern, 59.8% Source : NESDB
Characteristics of poor families Large families in agricultural sector Landless farmers or farmers who own small land (less than 5 rais) Families with a high rate of dependency Large families with high rates of fertility and mortality, little education, family members who are disabled or have chronic diseases, migrant workers, lack of opportunity to access state services
Prior UC implementation Specific schemes for the poor Low Income Scheme (LIS): Began in 1975 to cover the poor (those whose income were below poverty line). In 1994 the scheme expanded to cover the elderly, children under 12 years old, the disabled, veterans and monks and renamed to the Medical Welfare Scheme (MWS). Fee Exemption Scheme: Started before LIS and applied only in public health facilities. The decision was made at the discretion of health personnel. Health Card Scheme: Implemented as part of PHC Strategy but was developed later as financing mechanism to cover near-poor families. Households paid 500 Baht and government subsidized 500 Baht (increased to 1,000 Baht before its termination) for 5 family members per year.
Prior UC implementation Some experiences learnt Effectiveness of targeting process (inadequate to cover the poor and ineffective to exclude the non-poor) Inadequate financing especially when compared to other schemes (Social Security Scheme-SSS and Civil Servant Medical Benefit Scheme- CSMBS) Unacceptable quality of care provided for the poor Discrimination and social stigmatization Selection bias and financial non-sustainable (in case of Health Card Scheme) About 30% of population remained uninsured
Before 1974 Fee Exemption System 1974 WCF 1975 LIS 1978 CSMBS 1981 Type B fee exemption 1990 SSS 1991 HCS 1993 1994 MWS 1999 SIP in 6 provinces Poor people Near poor Uninsured Oct. 2000 Fund-holding autonomous hospital (1 district) Apr. 2001 UCS in pilot 6 provinces Apr. 2002 UCS implemented nationwide Year Private formal sector employee Government employee Population covered by Universal Coverage Scheme (UCS) population covered by various public health insurance schemes
Main features of UC Beneficiaries: Thai citizens who are not covered by SSS and CSMBS Benefit package Comprehensive package including personal preventive and health promotion services Exclusion lists are minimal ARV has been included since 2006 but treatment for ESRD is still excluded Financing General tax revenue with minimal co-payment of 30 Baht (0.85 US$) per ambulatory visit or hospital admission (recently co-payment has been abolished since November 2006) Budget is calculated and obtained on a per capita basis
Main features of UC Public contract model Purchaser provider split (NHSO is the national purchaser) Primary care is the main contractor (Contracted Unit for Primary Care-CUP), a unit for beneficiaries registration and a gatekeeper Private healthcare providers could participate on a voluntary basis Provider payment method Capitation for ambulatory care and DRG with global budget for hospital care Capitation with performance payment (fee-for-service) for preventive and health promotion services Additional payment for health facilities with high utilization rate, better quality and the use of selected instruments and treatments
Universal Coverage Scheme: Benefit to all equally or a pro-poor scheme
Scheme beneficiaries in 2004 CSMBS, SHI covers the rich, 52% and 49% belongs to Q5 UC covers mostly the poor, 50% belongs to Q1+Q2 100% 80% 60% 52% 49% 10% 17% 23% 40% 26% 31% 25% 20% 0% 11% 14% 25% 7% 4% 5% 1% CSMBS SSS UC Q1 (poorest) Q2 Q3 Q4 Q5 (the richest) Source: Analysis of Health and Welfare Survey 2004, conducted by Thai National Statistical Office.
The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities-ihpp analysis Distribution of ambulatory services at different health facilities between the 2001 and 2003 HWS 6 Ambulatory visits per cap per year 5 4 3 2 1 0 2001 0.3 0.7 0.4 0.4 0.6 0.7 0.7 0.5 0.6 0.4 0.7 1.2 1.0 0.2 0.7 0.5 0.7 0.4 0.6 1.8 0.4 2003 0.6 1.3 0.3 0.7 0.4 0.6 0.9 1.9 0.7 0.6 0.6 1.3 0.3 0.2 0.7 0.6 0.3 0.1 0.2 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Income quintiles Health centre Community hospital Provincial and regional hospital Private clinic Private hospital 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
The distribution of hospitalization among different socio-economic groups in 2001 and 2003, by types of health facilities-ihpp analysis Distribution of hospitalization among different types of health facilities between the 2001 and 2003 HWS 0.25 Admission per cap per year 0.2 0.15 0.1 0.05 0 2001 0.02 0.03 0.04 district hospitals 0.03 0.05 0.05 0.05 0.05 prov / reg hospitals 0.03 0.02 0.03 0.05 0.06 2003 0.02 0.02 0.03 0.02 private hospitals district hospitals prov / reg hospitals 0.02 0.00 private hospitals Q5 Q4 Q3 Q2 Q1 Types of health facilities 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
Household health expenditure as % of household income by income deciles 8 8.17 1992 Health payment : Income (%) 7 6 5 4 3 2 1 0 4.82 5.46 3.74 3.65 4.58 4.58 2.87 2.57 2.45 3.67 3.32 3.29 1.99 3.16 2.93 1.64 2.78 1.27 2.52 2.23 2.38 2.22 2.36 2.06 1.77 1.75 1.97 1.62 1.68 1.4 1.37 1.57 1.32 1.35 1.55 1.15 1.27 1.07 1.1 1 2 3 4 5 6 7 8 9 10 1994 1996 1998 2000 2002 2004 2006 Source: NSO SES (various years)
Various Financing Sources for Healthcare Source Concentration index-ci* 2002 2004 2006 Direct tax 0.8221 0.8162 0.7687 Indirect tax 0.5594 0.5958 0.5512 Social insurance 0.4975 0.4561 0.4492 Private insurance 0.3785 0.4221 0.4188 Direct payment 0.4883 0.4626 0.4705 Total 0.5663 * CI Concentration Index based on Socio-Economic Survey (SES: 2002, 2004, 2006)
Conclusions UC is a pro-poor scheme although its nature is universal coverage Lower compliance of the rich may lead to relatively poor quality of service Tax based financing is recommended for countries with huge informal sector to achieve universal coverage Primary care and district health system (DHS) favor the poor and financing mechanism should be designed to strengthen their functions Increased access to care of population would threaten healthcare system with limited HRH (internal brain drain would happen as a consequence)
Acknowledgements National Health Security Office (NHSO) Ministry of Public Health (MOPH) Internal Health Policy Program (IHPP) National Statistics Office (NSO) EU supported Health Care Reform Project (HCRP)