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Global, Regional, and Thailand

Movements on Universal Health

Coverage and the Important of

Quality Health Services

Dr. Suwit Wibulpolprasert, Senior Adviser on Disease Control, MoPH.

Presented at the CAP UHC Workshop on UHC and HA

November 25th 2013, Narai Hotel, Silom, Bangkok, Thailand.

The Universal Health Coverage

• Universal access to quality comprehensive

(promotion, prevention, treatment,

rehabilitation and palliative care) essential

health services and technologies, without

financial barriers

• Free but low quality health services is not UHC

• Three dimensions to target on Who, What and

How much to cover in the UHC in each

country?

Suwit Wibulpolprasert, MoPH, Thailand

Thai UC – three dimensions of UC cube

• X axis: Who is covered?– Universal (100%) Coverage by

3 public schemes

• Y axis: Proportion of the costs covered?– Total health cost– Low incidence of catastrophic

health expenditure and medical impoverishment

• Z axis: Which services are covered?– Essential comprehensive

services and drugs– High cost services are

covered e.g. Renal Replacement Therapy, chemotherapy, ARVs

UHC is feasible and sustainable

• UHC can be started and achieved at low level

of income – don’t wait until you are rich

• UHC is effective for poverty reduction

• Fiscal spaces and innovative financing are

possible for additional resources mobilization

• Mechanisms are there to ensure quality, value

for money, sustainable financing and meeting

the emerging challenges


UHC can be started and achieved at low level of income –

Economic Crisis is an opportunity not a threat

390

710

760

1490

2,700

1,900

0

1,000

2,000

3,000

4,000

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

US $

1997: Asian

financial crisis

1990 SHI

introduced

1980 CSMBS

introduced

1983 CBHI

introduced

1975 Low Income

scheme introduced

2002 Universal

Coverage for entire

population achieved

2001: 29% of

population are

uninsured

year

GD

P/ca

pit

a

29%

42%

53%

The children n elderly 71%

100%


6

Paths Towards Universal Health Coverage

• 1963 – Civil servants medical benefits scheme 9%

• 1975 – Free medical care for the low income +20%

• 1978 - 91 - Extensive rural health systems development

• 1990 - Voluntary public HI (health card) +13%

• 1992 - Compulsory Social Security HI +11%

• 1993 - Free med care for children +16%

• 1995 - Free med care for elderly +6%

• 2000 – Total health insurance = 71 %

• 2001 - Universal HI – 30 Baht co-pay per visit

• 2003 - Universal Access to ARVs

• 2006 - Free care for all – no co-payment

• 2008 – RRT and Flu vaccine coverage

30 years of gradual coverage to Universal Health Insurance

“One of the success factor: Don’t listen to the IGOs” Suwit Wibulpolprasert, MoPH, Thailand

7

Three schemes for Universal Health Insurance

2012

NHS Act CSMBS decree SS Act Contribution

2001

National Health

Security Office Comptroller Dept

Social

Security Office

Capitation 100 $US/y

“Fee for service”380 $US/y

Capitation 75 $US/y

Designated Public /

Private Providers

47.8 mil. 5.5 mil. 9.5 mil.

Private roomnon- ED

The population

TAX1991

Service

s

1963

Rest of Pop Civil servants Formal employees

8

• Extensive expansion of rural health services in

early 80s – in spite of economic crisis

• How? – Budget shifting - Freeze new capital

investment in urban health facilities for 5 years and

reallocate to rural health facilities.

• Extensive production of motivated Rural Health

Workers with compulsory public services and

incentives

• Establishment of Hospital Accreditation Institute

Ensuring availability

of quality health services


9

Building up quality rural health facilities - Reallocation

of budget to rural facilities and HRH

3.1

2.73

2.432.272.232.15

2.041.88

3.68

3.153.013

2.92.64

2.4

1.68

0

0.5

1

1.5

2

2.5

3

3.5

4

1982 1983 1984 1985 1986 1987 1988 1989

Year

Bu

dg

et

(billio

n B

ah

ts)

Provincial

District

Fast tracking rural health

No investment in urban areas for 5 yrs.


10

Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population

Adequate and appropriately manned rural health facilitieis

Rural community hospital with 2-8

doctors cover 30-100,000 population

Extensive production

of appropriate cadres

and motivated health

personnel with

mandatory public

works and adequate

support are essential.


1111

From reverse to upright triangle: PHC utilization (OP visits)


UHC achieved

UHC is effective for poverty reduction

UHC achieved

Source: Viroj Tangcharoensathien

Suwit Wibulpolprasert, MioPH, Thailand

13

Fiscal Space to health from peace and economic growth

Per

cen

tage

Year

Source: Bureau of BudgetSuwit Wibulpolprasert, MoPH, Thailand

Mechanism to ensure Better Value for Money and

Cost Control for Sustainable Financing

• 20% of UC budget to P&P & community H fund

• Health Intervention and Technology Assessment to

ensure ‘value for money”

• Strategic purchasing – Central purchasing w VMI and

TRIPs flexibilities – internal fiscal space

• Close end capitation budget with mixed payment

mechanisms and PC gate keeper

• Improve quality of health services – HA+++Suwit Wibulpolprasert, MoPH, Thailand

Central purchasing and bargaining of drug and instrument

Items

Unit cost (Baht)

Saving (Baht)Before After Number (unit)

1.Instrument

Folding lens 4,000 2,800 64,100 76,920,000

Unfolding lens 4,000 700 7,197 23,750,1o0

Balloon stent 20,000 10,000 26,655 266,550,000

Coronary stent 30,000 5,000 10,575 264,375,000

Drug elutent stent 85,000 17,000 33,794 2,297,992,000

DES Alloy stent 55,000 25,000 343 10,290,000

2. Drug (sample)

ARV (AZT 300 mg caps.) 1201.22 891.23 47,000 14,569,530

ARV (EFV 600 mg tabs.) 304.89 149.51 400,000 62,152,000

ARV (LPV/RTV 200/50 mg (CL) 2139.82 1481.91 170,000 111,844,700

Botulinum toxin type A 100 IU 10,750.00 7977.74 946 2,622,557.96

Docetaxel 80 mg inj 25654.32 4716.26 2,700 56,532,747.31

IVIG 5% 100 ml 9,649.62 5,479 19,200 80,075,904

Peg-interferon alpha 11,000 3,150 77,000 604,450,000

Influenza vaccine 200 150.28 643,319 31,985,820

Erythropoietin 671 229 1,634,239 722,333,638

CAPD fluid 200 105 19,095,657 1,814,087,415

Saving 6,440,531,412.27

From: NHSO 2012Suwit Wibulpolprasert, MoPH, Thailand

Rate of use of Lopinavir/Ritonavir (200/50mg)

bottles CL

0

5,000

10,000

15,000

20,000

25,000

UC Scheme

CL


Satisfaction of UC beneficiaries & providers

Percent

Expand financial incentives to Health personnel

83.0 83.4 83.2 84.0 83.1 88.3 89.3 89.8 92.8 90.8

45.6 39.347.7 50.9 56.5 50.7

60.3 78.866.9 68.5

0.0

20.0

40.0

60.0

80.0

100.0

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

UC People provider


The regional and global movements on UHC

• Countries with UHC - Brunei, China, Japan, Korea,

Malaysia, Singapore, Sri Lanka, Thailand, Brazil,

Mexico, Costa Rica, Chile, Cuba

• Asian countries committed - India, Indonesia, Laos

PDR, Maldives, Philippines, Vietnam, South Africa

• Joint Statement ASEAN plus three HMM – July 12

• UNGA resolution on UHC - December 2012

• UHC in the post 2015 and SDGs and ECOSOC 13


The UNGA resolution on UHC

• Include UHC in the discussion on the post 2015

development agenda

• ECOSOC consider UHC as part of its 2013 work

programs with WHO n WB – July 3rd 2013

• Continue consultation on UHC and possibility of a

HLM in UNGA – indicators and targets of UHC

developed by WHO and WB in September 2013

• UNSG and UN agencies to give high priority to UHC


The Role of Countries to move UHC

• Target UHC and move concretely and actively to

achieve it thru both HSS and HI development

• Global advocacy movement – to put UHC as the

post 2015 and the Sustainable Development Goals

• Capacity building (INNE) thru Knowledge

management – the Japan-WB trust fund on UHC,

the Joint Learning Network (JLN), the ASEAN plus

three UHC networks, the AAAH, the HTAsiaLink,

and the Thai CAP UHC program


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