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«This study was funded by the Health Systems Research Institute, the Prince Mahidol Award Conference, the World Health Organization Regional Office ...»

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Thailand’s Universal Coverage Scheme:

Achievements and Challenges

An independent assessment of the first 10 years (2001-2010)

Synthesis Report

Thailand’s Universal Coverage Scheme: Achievements and Challenges

An independent assessment of the first 10 years (2001-2010)

This study was funded by the Health Systems Research Institute, the Prince Mahidol

Award Conference, the World Health Organization Regional Office for South-East

Asia and the National Health Security Office.

This publication may be reviewed, abstracted or reproduced in part when fully referenced, but may not be sold or used for commercial purposes.

First published: May 2012 Graphic design by: www.decemberry.com Published by: Health Insurance System Research Office Credit images: Society and Health Institute and Health Systems Research Institute/Roengrit Kongmuang Citation: Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010). -- Nonthaburi, Thailand: Health Insurance System Research Office, 2012.

120 p.

1. Insurance, Health--Thailand.

I. Evans, TG. II. Chowdhury, AMR. III. Evans, DB. IV. Fidler, AH.

V. Lindelow, M. VI. Mills, A. VII. Scheil-Adlung, X.

368.382 ISBN 978-974-299-181-4 Health Insurance System Research Office 5th Floor, Nursing College Building, Bamrasnardura Infectious Disease Institute, Tiwanon Road, Muang District, Nonthaburi 11000, Thailand Contributors International experts: Timothy G. Evans, BRAC University; A. Mushtaque R. Chowdhury, Rockefeller Foundation; David B. Evans, World Health Organization;

Armin H. Fidler and Magnus Lindelow, World Bank; Anne Mills, London School of Hygiene & Tropical Medicine; Xenia Scheil-Adlung, International Labour Organization.

Thai secretariat team: Viroj Tangcharoensathien and Walaiporn Patcharanarumol, International Health Policy Program; Pongpisut Jongudomsuk, Health Systems Research Institute; Samrit Srithamrongsawat, Aungsumalee Pholpark, Patchanee Thamwanna and Nutnitima Changprajuck, Health Insurance System Research Office.

Thai research team: Viroj Tangcharoensathien, Siriwan Pitayarangsarit, Hathichanok Sumalee, Phusit Prakongsai, Walaiporn Patcharanarumol, Jiraboon Tosanguan, Weerasak Putthasri and Nonglak Pagaiya, International Health Policy Program; Pongpisut Jongudomsuk and Boonchai Kijsanayotin, Health Systems Research Institute; Samrit Srithamrongsawat, Health Insurance System Research Office; David Hughes, Swansea University, UK; Jadej Thammatach-Aree and Yongyuth Pongsupap, National Health Security Office; Nucharee Srivirojana, Institute for Population and Social Research, Mahidol University; Vinai Leesmidt, Khlong Khlung Hospital; Pinij Faramunayphol, Health Information System Development Office; Nusaraporn Kessomboon, Supon Limwatananon, Chulaporn Limwatananon and Areewan Chiewchanwattana, Faculty of Pharmaceutical Sciences, Khon Kaen University; Kanchit Sooknark, Faculty of Management and Information Sciences, Naresuan University; Supasit Pannarunothai, Faculty of Medicine, Naresuan University; Songkramchai Leethongdee, Faculty of Public Health, Mahasarakham University; Paibul Suriyawongpaisal and Rassamee Tansirisithikul, Faculty of Medicine, Ramathibodi Hospital, Mahidol Unversity;

Thira Woratanarat, Piya Hanvoravongchai and Jiruth Sriratanaban, Faculty of Medicine, Chulalongkorn University; Watchai Charunwathana, Department of Health Service Support, Ministry of Public Health; Pongsa Pornchaiwiseskul, Worawet Suwanrada and Somprawin Manprasert, Faculty of Economics, Chulalongkorn University.

Writer: Joanne McManus All international experts, as well as Viroj Tangcharoensathien, Samrit Srithamrongsawat, David Hughes, Pongpisut Jongudomsuk, Paibul Suriyawongpaisal, Supon Limwatananon, Vinai Leesmidt and Walaiporn Patcharanarumol commented on various drafts of this report.

Contents Executive Summary

Chapter 1. Introduction

• Why this report?

• How was the assessment undertaken?

• About this report

Chapter 2. Setting the scene: background to the UCS reform

• Building on a strong foundation

• The driving force behind the reforms and other contextual factors

Chapter 3. Why the UCS was launched in 2001:

the convergence of political commitment, civil society mobilization and technical know-how

Chapter 4. The UCS policy: a brief overview

• Goal and strategic objectives

• Tax-financed scheme free at the point of service

• Comprehensive benefits package with a primary care focus.................. 41

• A fixed annual budget and a cap on provider payment

• Not poor health care for poor people

Chapter 5. New institutions and new ways of working

Chapter 6. Implementing the UCS:

institutional conflicts and resistance to change

• Purchaser-provider split: anything but cut and dry

• Redefining institutional roles and relations: muddy and murky waters..... 58

• Health workforce: more difficult to redistribute according to need than anticipated

• Harmonization of public health insurance schemes

• High levels of satisfaction among UCS members and providers............... 64 Chapter 7. Governance: good, but room for improvement

• Participation, transparency, consensus and rule of law

• Responsiveness and accountability

• Effectiveness and efficiency

• Other accountability concerns

• Overall governance of the NHSB and its subcommittees

Chapter 8. Significant positive impacts in the first 10 years

• Increased utilization and low levels of unmet need demonstrate improved access

• Decreasing catastrophic expenditures and household impoverishment

• Difficult to measure but important impact indicators

• Spill-over effects on the health system

• Macroeconomic impacts of the UCS

Chapter 9. UCS in the next 10 years: the challenges ahead

• Continuing towards full implementation of the UCS

• Managing the growth of the UCS

Chapter 10. Recommendations and lessons

• Policy recommendations for Thailand

• Policy implications for the rest of the world

• Concluding remarks


Annex: Framework for assessing the Thai Universal Coverage Scheme........... 103 Biographies of the international experts

List of boxes, tables and figures Boxes Box 1: Thailand at a glance

Box 2: Civil society’s role in establishing universal health coverage in Thailand

Box 3: Coalitions, elections and a coup: Thai politics, 2001-2011................. 35 Box 4: Press clippings from 2006 illustrating the public debate over UCS funding

Box 5: Evidence drives expansion of the benefits package

Box 6: The impact of decentralization on the UCS

Tables Table 1: Thai Government’s measures to generate revenue and cut expenditure, 1997

Table 2: The rising UCS capitation budget approved by the Budget Bill, 2002-2011

Table 3: Characteristics of Thailand’s three public health insurance schemes after achieving universal coverage in 2002

Table 4: How the UCS is governed

Table 5: Registration profile for UCS members in Bangkok, 2010

Table 6: Call centre service output, 2004-2010

Table 7: Unmet need for outpatient and inpatient care, 2010

Figures Figure 1: Scope of the UCS assessment, 2001-2010

Figure 2: Thailand’s path to universal health coverage against GNI per capita, 1970-2010

Figure 3: Coverage of health insurance, 1991-2003

Figure 4: Health system developments, 1965-2005

Figure 5: Health expenditure as % GDP by source of finance, 1994-2008, current year price

Figure 6: UCS institutional arrangements

Figure 7: Satisfaction of UCS members and health-care providers, 2003-2010

Figure 8: UNESCAP’s eight attributes of good governance

Figure 9: Results of NHSB survey assessing governance of the UCS, 2011........ 73 Figure 10: Service utilization rates among UCS members, 2003-2010................. 76 Figure 11: UCS improved equity in service utilization (ambulatory care, concentration index)

Figure 12: Unmet need for health care due to costs in 11 OECD countries, by income group, 2010

Figure 13: Incidence of catastrophic health expenditure by wealth quintile, 1996-2009

Figure 14: Trend in health impoverishment of households in various employment sectors

Figure 15: Household health impoverishment map, prior to UCS (1996), at the time of UCS implementation (2002) and post-UCS (2008)...... 81 Figure 16: Number of households protected from health impoverishment, 1996-2009

Figure 17: Total health expenditure as percentage of GDP, 1994-2020............ 90 Figure 18: Magnitude of population ageing, Thailand and Southeast Asia...... 92 Lists of abbreviations CSMBS Civil Servant Medical Benefit Scheme CUP contracting unit for primary care DRG diagnosis related group GGHE general government health expenditure GDP gross domestic product GNI gross national income HITAP Health Intervention and Technology Assessment Program HSRI Health Systems Research Institute ICER incremental cost-effectiveness ratio ILO International Labour Organization IHPP International Health Policy Program MWS Medical Welfare Scheme MOPH Ministry of Public Health NGO nongovernmental organization NHSB National Health Security Board NHSO National Health Security Office PCU primary care unit PHO Provincial Health Office QALY quality of life year SHI Social Health Insurance SQCB Standard and Quality Control Board SSO Social Security Office SSS Social Security Scheme TRT Thai Rak Thai Party UCS Universal Coverage Scheme WHO World Health Organization 9 Assessment of Thailand’s Universal Coverage Scheme Synthesis Report Executive Summary A fter four decades of health infrastructure development and three decades of designing and implementing a number of different financial risk protection schemes, Thailand achieved universal health coverage in 2002. This meant that all Thais were covered by health insurance guaranteeing them access to a comprehensive package of health services. Although many factors contributed to this achievement, the most significant was an ambitious reform known as the Universal Coverage Scheme (UCS).

Within one year of its launch in 2001, the UCS covered 47 million people: 75% of the Thai population, including 18 million people previously uninsured. The other 25% of the population were government employees, retirees and dependants, who remained under the Civil Servant Medical Benefit Scheme (CSBMS), and private-sector employees, who continued to have their health-care costs paid for by the contributory Social Security Scheme (SSS). The UCS was remarkable not only for the speed of its implementation, but also because it was pursued in the aftermath of the 1997 Asian financial crisis when gross national income was only US$ 1,900 per capita, and against the advice of some external experts who believed the scheme was not financially viable.

Even more impressive was the impact made by the UCS in its first 10 years.

The UCS improved access to necessary health services, improved equity of service utilization and prevented medical impoverishment. Between 2003 and 2010, the number of outpatient visits per member per year rose from 2.45 to 3.22 and the number of hospital admissions per member per year rose from 0.094 to 0.116. Data from 2010 point to a very low level of unmet need for health services in Thailand.

Impoverishment, as measured by the additional number of non-poor households falling below the national poverty line as a result of paying for medicines and/ or health services, decreased significantly from 2.71% in 2000 (prior to the UCS) to 0.49% in 2009.

The UCS led to a significant increase in government health spending and a marked decline in out-of-pocket expenditure and, importantly, the rich-poor gap in out-ofpocket expenditure was eliminated. Moreover, the UCS increased equity in public subsidies, and overall health expenditure was very “progressive” or pro-poor.

–  –  –

Despite this impressive list of accomplishments, in some other important areas that were part of the ambitious UCS reform, such as the strengthening of primary health care, effective primary prevention and reliable referral systems, there is less evidence of the anticipated impacts. Moreover, assessing the lack of significant progress towards harmonizing the three insurance schemes revealed a set of important challenges related to politics and the power dynamics of institutional reform.

These are some of the highlights from a comprehensive assessment of the UCS’s first 10 years. Conducted in 2011, the aims of this assessment were to review the scheme’s performance and to shed light on what did and did not work, and why.

The assessment was also undertaken in order to offer policy recommendations for the UCS in the future, and to provide lessons that may help other countries on the path towards universal health coverage.

Study teams focused on five areas of inquiry: policy formulation, the contextual environment, policy implementation, governance and impacts. The results of the assessment are shown in this synthesis report and in the individual papers from the study teams, which are available at www.hsri.or.th.

The UCS, with its overarching goal of an equitable entitlement to health care for all Thais, has three defining features: a tax-financed scheme that provides services free of charge (initially, a small copayment of 30 baht or US$ 0.70 per visit or admission was enforced, but this was terminated in 2006); a comprehensive benefits package with a primary care focus, including disease prevention and health promotion; and a fixed budget with caps on provider payments to control costs. A number of mechanisms have been set up to protect UCS beneficiaries, such as an information hotline, a patient complaints service, a no-fault compensation fund and tougher hospital accreditation requirements.

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