financial protection from the universal health care coverage in thailand: the evidence
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Delivering Effective Health Care for AllMonday 29th March, 2010
Financial Protection from the Financial Protection from the
Universal Health Care Coverage in Universal Health Care Coverage in
Thailand: The Evidence Thailand: The Evidence
Supon LimwattananonSupon Limwattananon
International Health Policy Program (IHPP), THAILANDInternational Health Policy Program (IHPP), THAILAND
Outline
1. Trends in population coverage by health insurance
2. Poverty impact of health payment before and after
UC
3. Who pay for health care during UC?
4. Who benefit from health care use during UC?
5. Why is that so? The long (3-decade) march of health infrastructure development
and financing innovation
1. What do we mean by the universal coverage?
Population coverage by health Population coverage by health
insuranceinsurancebefore and after the 2001 UC reformbefore and after the 2001 UC reform
Source: Analysis of Health and Welfare Surveys (HWS, various years)
5.1% 5.7% 4.9% 4.0% 3.7%
66.5%
29.0%
54.5%
14.2% 27.9% 52.3% 74.7% 73.4% 72.2% 74.3% 73.6%
0%
20%
40%
60%
80%
100%
1991 1996 2001 2003 2004 2005 2006 2007
Uninsured LIC/VHC UC SS CSMB Other
LIC: Low-Income Card Scheme Tax-funded, public welfare program (defunct)
VHC: Voluntary Health Card Scheme Subsidized, voluntary, community-based health insurance (defunct)
UC: Universal Coverage Scheme Tax-funded, entitlement scheme for the rest of all Thai population
SS: Social Security Scheme Compulsory, contributory, social health insurance (SHI) for formal private employees
CSMB: Civil Servant Medical Benefit Scheme Tax-funded, fringe benefit for government employees/pensioners, dependants
2. Impoverishment by health payment before and after UC
Household impoverishment from healthHousehold impoverishment from health
1996 (Pre-UC) 2008 (Post-UC)
Health impoverishment
per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Source: Analysis of Socio-Economic Surveys (SES, various years)
3. Progressive tax-based health financing of UC
0
1
2
3
4
5
6
1995 2000 2005
Total health expenditure per GDP (%)
0
1
2
3
4
5
6
7
1995 2000 2005
Poorest quintile Richest quintile All
Catastrophic health expenditure (%)
0
10
20
30
40
50
60
70
80
1995 2000 2005
Government Private, total Household
Health expenditure share (%)
0
1
2
3
4
5
6
7
8
1995 2000 2005
Poorest decile Richest decile
OOP health expenditure per income (%)
UC 2001
Source: National Health Accounts
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
2000 2002 2004 2006
OOP payment Direct tax Indirect tax
Concentration Index
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
2000 2002 2004 2006
OOP payment Direct tax Indirect tax
Kakwani Index
Progressivity in health financing -Thailand
SourceSource: CREHS year-2 Report: CREHS year-2 Report
4. Pro-poor utilization and pro-poor public subsidy of district health services during UC
Utilization shares (%) by income quintileUtilization shares (%) by income quintile
Ambulatory visits and hospital admissions, 2001-2007Ambulatory visits and hospital admissions, 2001-2007
SourceSource: CREHS year-2 Report: CREHS year-2 Report
25%
33%
26%
28%
22%
27%
25%
20%
23%
23%
24%
23%
23%
23%
18%
14%
14%
15%
17%
15%
16%
17%
12%
14%
14%
16%
16%
17%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
IP admissions
OP visits
IP admissions
OP visits
IP admissions
OP visits
IP admissions
2001
2003
2006
2007
20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest
Public subsidy shares (%) by income quintilePublic subsidy shares (%) by income quintile
Ambulatory visits and hospital admissions, 2001-2007Ambulatory visits and hospital admissions, 2001-2007
SourceSource: CREHS year-2 Report: CREHS year-2 Report
25%
35%
28%
30%
26%
30%
28%
19%
24%
24%
27%
25%
23%
25%
19%
13%
15%
13%
15%
15%
14%
20%
10%
12%
11%
11%
13%
12%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
IP admissions
OP visits
IP admissions
OP visits
IP admissions
OP visits
IP admissions
2001
2003
2006
2007
20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest
-0.4
-0.3
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
2001 2003 2005 2007
Hth Ctr Dist H Prov H Univ H Private H
Ambulatory visits
-0.4
-0.3
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
2001 2003 2005 2007
Dist H Prov H Univ H Private H
Hospital admissions
-0.4
-0.3
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
2001 2003 2005 2007
Hth Ctr Dist H Prov H Univ H Private H
Ambulatory subsidy
-0.4
-0.3
-0.2
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
2001 2003 2005 2007
Dist H Prov H Univ H Private H
Hospitalization subsidy
Concentration Index: Health use and public subsidy -Thailand
SourceSource: CREHS year-2 Report: CREHS year-2 Report
Pro-rich
Pro-poor
5. The message to go!
Health infrastructure and human resources are
the prerequisite of the demand-side financial risk protection introduced by UC
050100150200250300350400450500550600650700750800
0100200300400500600700800900
1,0001,1001,2001,3001,400
1965 1970 1975 1980 1985 1990 1995 2000 2005
All hospitals District Other public Private
Hospitals
05,00010,00015,00020,00025,00030,00035,00040,00045,00050,00055,00060,00065,00070,00075,00080,000
010,00020,00030,00040,00050,00060,00070,00080,00090,000
100,000110,000120,000130,000140,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
All beds District Other public Private
Hospital beds
5,00010,00015,00020,00025,00030,000
5,000
50,00060,00070,00080,00090,000
100,000110,000120,000130,000140,000150,000160,000170,000180,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
Hospital Health center
Population per health facility
400
500
600
700
800
900
1,000
1,100
1,200
1,300
1,400
1965 1970 1975 1980 1985 1990 1995 2000 2005
Population per bed
Health facility trends -Thailand
Source: MOPH BPS Health Resource Surveys
The birth of district hospitals(Rural health development -1977)
Trends in expansion of hospitalsTrends in expansion of hospitals
05,00010,00015,00020,000
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
120,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
Doctors (MDs) Nurses (RNs/TNs)
Doctors and nurses
05,00010,00015,00020,00025,00030,000
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
RNs TNs PNs Midwives
Nurses and midwives
5001,000
1,5002,0002,500
3,0003,5004,000
4,5005,000
500
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
Doctor (MD) Nurse (RN/TN)
Population per doctor and nurse
01,0002,0003,0004,0005,0006,0007,0008,0009,00010,000
0
5,000
10,000
15,000
20,000
25,000
30,000
1965 1970 1975 1980 1985 1990 1995 2000 2005
HC personnel Health centers
Health centers and personnel
Health workforce trends -Thailand
Source: MOPH BPS Health Resource Surveys
Mandated rural service of new medical graduates -1972
Production of technical nurses -1982
Trends in expansion of health workersTrends in expansion of health workers
2000
19701st-3rd NHP (1962-76)
Mandatory rural services
for new MDs and nurses
100% provincial hospitals
1. Infrastructure development1. Infrastructure development
UC: the long marchUC: the long march
LIC1975
1990
CSMB1980
CHF1983
SS1991
4th -5th NHP (1977-86)
Expansion of district hospitals
and health centers
UC2001
VHC1994
1980
MOPH established 1942
15 provincial hospitals 300+ health centers
2. Innovative financing2. Innovative financing
Source: Adapted from Srithamrongsawat
Prospective payment system (PPS)- Capitation for SS (OP-IP)
- Diagnostic-related groups (DRG) for LIC/VHC (IP)
PPS expansion- Capitation for UC (OP)
- DRG for UC (IP)
- DRG for CSMB (IP)
- Direct billing for CSMB (OP)
LIC+1996
SS+1994
SS+2002
Formal and informal user fee exemption