Universal Health Coverage

(UHC) :Thailand Case Study

Beijing, China
1 December 2012
Thailand: country profiles
• Population - 64 million
• GNI 2010 US$4,210 per capita, Gini
40
• Health status
 Life expectancy at birth 74 years
 U5MR 14/1000, MMR 48/100,000
 Physicians per capita 4/10,000
 ANC & hospital delivery 99-100%
(2009)
• Total Health Expenditure
 US$280 per capita, 5.4% GDP
 Health service network facilities
Facilities units beds In UC
Regional hospital 25 17,233 25
Provincial hospital 69 22,585 69
District hospital 736 28,366 736
Health Center 10,848 - 10,848
University hospital 15 8,792 15
Private hospital 322 33,678 68
Private clinics 17,671 - 165
Drug stores 17,017 -
Local authority matching
fund 7,776 7,776
Health volunteers 1,008,297 1,008,297

Source: Thailand Health Profile 2007, MOPH 2011 3

 Historical development of the Thai health system:
Infrastructure development + financial protection extension
User fees
Informal user fee exemption
1945

Establishment of prepayment
1970 schemes
1975 1980
1-3rdNHP CSMBS
LIC
1962-76
Provincial 1980 1990
1983 Expansion consolidation of
hospitals SSS
CBHI SSS prepayment schemes
4th -5th NHP 1990 CSMBS
(1977-86) LIC  MWS 1994 Universal
District
Pub VHI Coverage
hospitals
Health centers 2000 SSS

CSMBS
Health Infrastructure 2002 full achieve
extension--wide Universal Coverage
2002
geographical coverage
Long march towards universal health coverage in Thailand
using National Health Accounts (NHA) data
GNI per capita, 1970-2009
 Since 2002, three public health insurance
schemes cover whole population
CSMBS SSS UC scheme
Scheme Fringe benefit Mandatory Citizen entitlement
nature
Population Government employees, Formal-sector private employees, The rest of population
pensioners and their establishments/ firms of more who are not covered by
dependants (parents, spouse, than one worker since 2002 SSS and CSMBS
children under 18) 9.84 Million (15.8%) 47 Million (75%)
5 Million (8%)
Source of General tax Tripartite from employer, General tax
finance (~400 US$/Cap*) employee, government rate (84 US$/Cap)
1.5% of salary
(maximum salary: 500 US$)

Management Comptroller general under Social security office under National Health Security
organization ministry of finance ministry of labor and welfare Office (NHSO)

Benefit No preventive care Small number of limited Small number of limited

package No explicit exclusion condition eg. Non medical condition
Special bed plastic surgery Prevention & promotion

•30 Baht= 1 dollar , year 2010

•CSMBS = Civil Servant Medical Benefit scheme, SSS = Social Security Scheme, UC scheme = Universal Coverage Scheme
Adapted from: Mills et al. 2005; Srithamrongsawat S. Thammatacharee J. 2009
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 Three public health insurance schemes
cover whole population
CSMBS SSS UC scheme
Providers Public provider only, Private Public and private hospital more Public and private
in emergency, selected than 100 beds (50% private) contracting unit for
disease (2011) primary care(CUP)
Choice of Free choice public Contracted hospital and its Primary care contractor
provider network services, plus referral

Payment OP: Fee-for-service Capitation OP and IP OP: Capitation

IP: DRGs (2year) (DRG for IP DRG RW> 2) IP: DRGs with global
budget

•Year 2008,
•CSMBS = Civil Servant Medical Benefit scheme, SSS = Social Security Scheme, UC scheme = Universal Coverage Scheme
Adapted from: Mills et al. 2005; Srithamrongsawat S. Thammatacharee J. 2009 7
 UHC cube: what has been achieved in Thai UHC?
• X axis:
– 99% pop overage by 3 schemes [UCS
75%, SHI 20%, CSMBS 5%]
• Y axis:
– Free at point of services, very
minimum OOP,
– Low incidence of catastrophic health
expenditure and health
impoverishment
• Z axis:
– Extensive and comprehensive benefit
package, very small exclusion list,
– Most high cost interventions were
covered: dialysis, chemotherapy,
major surgery, medicines (Essential
drug list)

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 Key design of UHC scheme in Thailand

• Health financing strategies of the UHC policy:

– Removal of financial barriers to health services  30 Baht or 1USD co-
payment  zero baht copayment in 2006:
– Shift of the main source of HCF from out-of-pocket payments to general tax;
– Changing provider payment method from historical allocation to close-ended
provider payments  capitation for OP and DRG with global budget for IP
services;
– promoting the use of primary care by contracting a Primary Care Unit (PCU)
as the main contractor and gatekeeper;

• Generous and comprehensive benefit package of the UHC

scheme comprising OP services, hospitalization, health
promotion and disease prevention, most expensive health
services, dental care, medicines and operations.

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Outcome: Improving access to health services

• Increased utilization and pro-poor outpatient and inpatient utilization

 access to cancer treatment FY2005-2010

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

total cancer patients who were
74,626 78,647 83,285 89,315 96,160 110,599
treated

Note: data of members in UC Scheme only

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 Financial risk protection
Reducing the incidence of catastrophic health spending
out-of-pocket payments>10% total consumption expenditure

Source: Analysis of Socio-economic Survey (SES)

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Outcome: Sub-national health impoverishment

Per 100 households Per 100 households Per 100 households

Per 100 households
0 – 0.5 0 – 0.5 0 – 0.5
0 – 0.5
0.6 – 1.0 0.6 – 1.0 0.6 – 1.0
0.6 – 1.0
1.1 – 2.0 1.1 – 2.0 1.1 – 2.0
1.1 – 2.0
2.1 – 3.0 2.1 – 3.0 2.1 – 3.0
2.1 – 3.0
3.1+ 3.1+ 3.1+
3.1+

1996 1998 2000 2002

Per 100 households Per 100 households Per 100 households Per 100 households
0 – 0.5 0 – 0.5 0 – 0.5 0 – 0.5
0.6 – 1.0 0.6 – 1.0 0.6 – 1.0 0.6 – 1.0
1.1 – 2.0 1.1 – 2.0 1.1 – 2.0 1.1 – 2.0
2.1 – 3.0 2.1 – 3.0 2.1 – 3.0 2.1 – 3.0
3.1+ 3.1+ 3.1+ 3.1+

2004 2006 2007 2008

 Challenges of Thai health system 1
• Inequity among three public health insurance schemes
• System efficiency can still be improved
• Demand increases from increased access to health care
and high cost medicines/ demographic changes/high
technology?
 During 2003-2009: actual OP utilization increased by 33% and
IP by 67%
 Aging society: Pop > 60 yrs = 11.9% in 2010 and will be 25%
in 2030 (service utilization rate = 2.3 times of general pop)
 Emerging diseases and NCD
 Challenges of Thai health system 2

• Share of public finance increased from 45% of total health

expenditure in 1994 to 75% in 2010
 Challenges of Thai health system 3
• More limited fiscal capacity - the government decided to freeze
capitation rate of UC Scheme for three years (2012-2014)

Baht/Pop Capitation rate of UC scheme

4,000.0
3,500.0
3,000.0
2,500.0
2,000.0
1,500.0
The same
capitation rate
1,000.0
500.0
-

2012
2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2013
Request Approved
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Challenges of Thai health system 4
• Shortage and mal-distribution
problems of physicians and nurses
• Substantial increase of financial
incentives for rural MD to prevent
internal brain drain and its financial
consequence
– Cost increase but efficiency
improvement?
• Huge income difference (need
evidence)
– rural & urban,
– doctors & nurses,
– public & private practice
 Acknowledgements
• Ministry of Public Health (MOPH) of Thailand
• National Statistical Office (NSO) of Thailand
• National Health Security Office (NHSO) of Thailand
• Health Systems Research Institute (HSRI),
• Health Insurance System Research Office (HISRO) of Thailand,

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