Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

 

The 3rd Global Symposium on Health Systems ResearchCape Town International Convention Center, Cape Town, South Africa

October 1st, 2014

Reducing impoverishment from health payments:

Impact of universal health care coverage in Thailand

Phusit Prakongsai 1

Supon Limwattananon 2

Viroj Tangcharoensathien1

1 International Health Policy Program, Ministry of Public Health, Thailand2 Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand

2

Long march to achieve UHC in Thailand: from targeting to universality, GNI per capita, 1961-2009

1963: $120CSMBS

1975: $390Low Income Card

1983: $760Voluntary Health Card

1990: $1490 SSS

1997: $2710 Asian financial crisis 2002: $1870

Achieving UHC

3

Three health insurance schemes cover the entire population of Thais since 2002

• Civil Servant medical benefit Scheme (CSMBS):– Tax financed scheme for government employees and

dependants, around 5 millions, • Social Security Scheme (SSS):

– Payroll tax financed scheme for private sector employees, around 11 millions,

• Universal Coverage Scheme (UCS): – Tax financed scheme for the remaining population who are

neither CSMBS nor SHI members, around 49 millions.

4

UHC cube: Thailand status

• X axis: – 99% of population coverage

• Y axis: – Free at point of services,

very minimum OOP, – Low incidence of

catastrophic health expenditure and health impoverishment,

• Z axis: – Extensive comprehensive

package, small exclusion list, almost all high cost interventions covered.

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

5

ObjectivesObjectives

• To assess impact of the universal health care

coverage (UHC) on household impoverishment due to

direct health payments

Our focus is on the informal sector households:

- Economically inactive

- Self-employed

- Independent work

- Family business

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

6

MethodologyMethodology

• Comparing pre-UC (1996-2000) vs. post-UC (2002-2009)

- Descriptive analyses

- Difference-in-difference (DID) approach

• Health impoverishment refers to

(Total consumption expenditure – Health payments) < Poverty lines

– Expenditure-based poverty lines as reported annually by NESDB

• Specific to urban-rural areas in 4 regions + Bangkok

– Consumption expenditures based on nationally representative household

Socio-economic Survey (SES) by National Statistical Office (NSO)

– Health payment including

• Medicines/medical supplies

• OP + IP services

• Household is the unit of analysis

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

7

Results (1)Results (1)

1. At national level

2. At sub-national level• Regional level (urban / rural / Bangkok)• Provincial level

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

8

13.7

4.2

5.0

4.4

17.3

5.0

5.9

5.1

16.0

4.8

4.9

4.6

19.7

5.4

5.5

4.9

18.1

5.3

5.1

4.9

22.3

6.6

6.2

5.3

13.5

4.4

4.3

4.4

16.1

5.3

5.0

5.1

10.1

3.9

4.2

4.0

12.9

4.8

5.1

4.5

8.7

3.4

3.7

3.7

11.5

4.5

4.8

4.6

8.0

3.1

3.4

3.9

10.9

4.0

4.3

4.7

8.4

3.4

3.9

3.9

11.2

4.4

4.8

4.8

7.1

3.2

3.6

3.7

9.9

4.0

4.3

4.4

0

10

20

30

40

1996 1998 2000 2002 2004 2006 2007 2008 2009

All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf

PL: Poverty lines; Inf: Informal employment sector

All vs. Informal sector, 1996-2009

Poor and near-poor households

Consumption expenditure: < PL < 110% PL < 120% PL < 130% PL

Source: Limwattananon S et al. (2011)

Distribution of 76 provinces in ThailandDistribution of 76 provinces in Thailandaccording to impoverished households (informal sector)according to impoverished households (informal sector)

(Year 1996 pre-UC)

% Households with number of adult members in the informal employment sectors

% Households impoverished by health payments

2.24.410.0

22.7

60.7

13.3

16.6

20.0

23.0

27.0

23.2

22.9

21.9

19.5

12.5

2.65.7

11.2

23.8

56.7

13.6

18.3

19.5

21.9

26.7

23.4

22.9

21.5

19.6

12.6

2.75.1

13.9

29.5

48.8

12.0

19.8

17.9

21.7

28.5

24.2

23.0

22.0

18.6

12.2

3.55.510.0

24.4

56.7

10.9

19.0

20.6

22.9

26.7

23.9

22.8

22.1

19.0

12.3

3.45.9

11.6

20.7

58.4

13.0

20.5

18.7

21.9

25.9

23.5

22.5

22.0

19.8

12.1

3.76.7

10.5

22.8

56.2

13.9

18.7

21.6

20.2

25.6

23.2

22.9

23.2

18.3

12.3

0

20

40

60

80

100

0

20

40

60

80

100

CS SS UC CS SS UC CS SS UC

CS SS UC CS SS UC CS SS UC

2003 2004 2005

2006 2007 2009

20% Poorest (Q1) Quintile 2 Quintile 3 Quintile 5 20% Richest (Q5)

Graphs by year

Scheme beneficiaries by income quintile Scheme beneficiaries by income quintile (2003 - 2009)(2003 - 2009)

UHC scheme covers mostly the poor, approx 50% in Q1 & Q2UHC scheme covers mostly the poor, approx 50% in Q1 & Q2

Household OOPs as percent household income in Thailand, 2000-2011

Source: Analysis from household socio-economic surveys (SES) in various years 2000-2011, NSO

12

UHC achieved

Number of Thai HH prevented from health impoverishment, 2002-2009

15.5

13.1

18.3

9.2

7.8

5.4

3.6

5.0

3.8

19.7

18.2

27.1

12.512.0

7.6

5.5

6.8

4.9

2.5

1.00.2 0.1 0.0 0.2 0.0 0.1 0.0

10.2

5.3

9.3

3.8 3.4

1.50.8

1.70.8

13.6

11.0

12.0

8.5

5.44.6

2.4

4.74.0

All employment sectors

Informal sectors -all

Public employees -all

Private employees -all

Mixed groups

0

5

10

15

20

25

Imp

ove

rish

ed

ho

use

ho

lds p

er

1,0

00

no

n-p

oo

r h

ou

se

ho

lds

1996 1998 2000 2002 2004 2006 2007 2008 2009

Health impoverishment by employment status of household adult members

# Households (in thousands)# Households (in thousands)

- Not poor 12,971- Not poor 12,971 13,234 13,234 13,177 13,177 14,120 15,071 14,120 15,071 16,476 16,720 17,396 18,191 16,476 16,720 17,396 18,191

- Poor- Poor 2,0662,066 2,522 2,522 2,904 2,904 2,199 1,690 2,199 1,690 1,573 1,457 1,597 1,388 1,573 1,457 1,597 1,388

Reduction in health-impoverishment*Reduction in health-impoverishment*(A difference-in-difference approach)

Employmen

t sector1998

200

0

200

2

200

4

200

62007 2008 2009

All-informal -0.09 9.65 -4.85 -5.23 -9.87-

11.73

-

10.56

-

12.32

Mixed -1.13 0.75 -2.68 -5.70 -6.73 -8.62 -6.50 -7.07

All-private -3.46 1.40 -4.07 -4.27 -6.47 -6.86 -6.12 -6.95

*Absolute difference from 1996, as compared with all-public employeeall-public employee households households

in number of health-impoverished households per 1,000 non-poor households

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

15

Results (2)Results (2)

1. At national level

2. At sub-national level• Regional level (urban / rural / Bangkok)• Provincial level

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

16

20

8

11

27

15

14

34

2

11

1

18

8

1011

20

10

32

5

9

5

27

15

2021

36

19

38

11

24

1

13

4

67

98

24

3

8

2

12

54

9

12

7

23

5 5

1

8

2

76

8

5

12

7

2

0

6

21

5

9

6

8

0 0

4

7

2

1

6

8

3

13

0

2

0

5

1 1

5

7

3

8

1

4

0

0

5

10

15

20

25

30

35

Imp

ove

rish

ed

ho

use

ho

lds

pe

r 1

,00

0 n

on

-po

or

ho

use

ho

lds

1996 1998 2000 2002 2004 2006 2007 2008 2009

' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S .

Region: C -Central; N -North; Ne -Northeast; S -South

Informal employment sector households

Health impoverishment by geographic region and area

Whole country

Urban area

Rural area

Bangkok

17

Sub-national health impoverishment 1996 to 2008

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

1996 1998 2000 2002

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

2004 2006 2007 2008

18

Total Health Expenditure: 1994-2011

UHC inceptionEconomic crisis

Total health expenditure 3.49 to 4.1% of GDP (2003-2011)

THE per capita US$ 218 (2011)

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

19

ConclusionsConclusions• Reduction in health-impoverishment in the informal sector

and mixed groups was stronger than in the public sector.

• UCS-mitigated health impoverishment was also found at

the sub-national level:

– Impoverishment in the poorest rural Northeast dropped from

3.4% in 1996 to 2.3-2.4% in 2002-04 and 0.8-1.3% in 2006-09.

• Comprehensive benefit package and zero copayment at

points of services are key contributing factors of health

financing arrangements in reducing health impoverishment,

• In addition, the extensive geographical coverage of health

infrastructure, adequate finance and functioning primary

healthcare are other key contributing factors.

Inte

rna

tio

na

l H

ea

lth

Po

lic

y P

rog

ram

-T

ha

ila

nd

Inte

rnati

onal H

ealt

h P

olic

y P

rogra

m -

Thaila

nd

2020

Phusit Prakongsai

International Health Policy Program (IHPP)

phusit@ihpp.thaigov.net

Acknowledgement

• Ministry of Public Health (MOPH), Thailand

• National Statistical Office (NSO) ,Thailand

• National Health Security Office (NHSO), Thailand

• Health Equity and Financial Protection in Asia

(HEFPA)