Supon Limwattananon, MPHM, PhD Viroj Tangcharoensathien, MD, PhD

1. Tracking progress in universal health access:Monitoring effectiveness of universal coverage in Thailand Supon Limwattananon, MPHM, PhD Viroj Tangcharoensathien, MD, PhD Prince Mahidol Award Conference, Bangkok Parallel Session 2.3 29 January 2010

2. Objectives • To describe the four-decade trend of key health indicators • To demonstrate relationship between health resource inputs, service outputs and health and financial outcomes • To assess existing data sources for tracking the UC progress

3. Where is Thailand standing at? Top ten MDG4 performers Good Health at Low Cost ! U5MR vs. THE per capita Low- and middle-income countries Rank Thailand 2000-05 * GNI < USD5,000 per capita; Births > 100,000/year Source: Rohde et al. (Lancet 2008) Source: Analysis of World Health Statistics

4. MDG1 0.4% 8.4% Source: Analysis of Socio-Economic Surveys (SES, various years)

5. UC scheme 2001 * * Health expenditure > 10% of total expenditure per household Asian economic crisis UC scheme 2001 UC scheme 2001 Source: National Health Accounts (NHA) and analysis of Socio-Economic Surveys (SES, various years)

6. Population coverage of health insurancebefore and after the UC reform in 2001 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 for formal private employees CSMB:Civil Servant Medical Benefit Scheme Tax-funded, fringe benefit for government employees/pensioners, dependants Source: Analysis of Health and Welfare Surveys (HWS, various years)

7. The path of health care coverage 15 provincial hospitals 300+ health centers 2. Innovative financing MOPH established 1942 1970 1st-3rd NHP (1962-76) 100% provincial hospitals LIC 1975 Prospective payment system (PPS) - Capitation for SS (OP-IP) - Diagnostic-related groups (DRG) for LIC/VHC (IP) CSMB 1980 1980 4th -5th NHP (1977-86) Expansion of district hospitals and health centers CHF 1983 1990 SS 1991 1. Infrastructure development VHC 1994 SS+ 1994 LIC+ 1996 • PPS expansion • - Capitation for UC (OP) • DRG for UC (IP) • DRG for CSMB (IP) • Direct billing for CSMB (OP) 2000 UC 2001 SS+ 2002 Source: Adapted from Srithamrongsawat

8. Four decades of health infrastructure development District hospitals Technical nurses MD mandated rural service Asian economic crisis National Health Plans 1-th 2-th 3-th 4-th 5-th 6-th 7-th 8-th 9-th 10-th Source: Analysis of Health Resource Surveys (HRS, various years)

9. Child mortality trends and health systems development Low-Income Card scheme 1975 Civil Servant Medical Benefit scheme 1980 Community health funds 1983 MD mandatory rural service 1972 Social Security Act 1991 Voluntary Health Card scheme 1994 • District hospitals 1977 • Village health volunteers 1977 • National EPI 1978 Universal Coverage scheme 2001 Technical nurses 1982 National Health Plans: 3-th 4-th 5-th 6-th 7-th 8-th 9-th 10-th Asian economic crisis 1997 Source: Analysis of IHME data

10. AR(1) time-series analysis U5MRt = – 16.75 + 2.9 * 103-Population per doctort + 12.2 * 103-Population per nurset + 38.1 * 103-Population per bedt – 0.1 * 103-USD GNI per capitat

11. Pro-rich Pro-poor utilization Progressive financing Source: Analysis of HWS (on health utilization) and SES (on health financing)

12. Source: Analysis of MICS2006 negative negative CI – 0.372 CI – 0.260 Inequity decomposition Stunting = 11.9% Underweight = 9.3%

13. (Richest : Poorest) Source: Health Resource Surveys; Civil Registration

14. Poverty head count ratio (%) 0-5 6-10 11-15 16-20 21+ GPP per capita (Baht) 1-30,000 30,001-50,000 50,001-70,000 70,001-100,000 100,001+ Provincial economic status Two distinctive indicators 1. Administrative reports 2. HH SES surveys + Pop. census Gross Provincial Product 2004 Small Area Estimation (GPP) Poverty Map 2004 r = – 0.4 Source: National Economic and Social Development Board (NESDB)

15. U5MR vs. Gross Provincial Product 2004 72 Provinces (Greater Bangkok excluded) Three deep south provinces R2 = 0.064

16. U5MR vs. Provincial poverty rate 2004 72 Provinces (Greater Bangkok excluded) Three deep south provinces R2 = 0.036

17. R2 = 0.089 R2 = 0.104 R2 = 0.136 Provincial variations

18. Data available for tracking

19. Summary • Four-decade investment in public health infrastructure in rural areas results in • High and equitable level of population health outcomes • Functioning health service is a prerequisite of extension of health insurance • Targeting scheme  public welfare • CBHI for informal sector  Universal coverage extending to the uninsured • SHI and CSMB for formal sector results in very low catastrophic and poverty impacts • Comprehensive national datasets plus analytical capacities  facilitate tracking the progress

20. Conclusions • Tracking a progress in the universal health access need to exploit wide variations in health outcomes, service outputs, and resource inputs • This requires regular information from (demand-side) household surveys and (supply-side) facility-based administrative reports at the national and sub-national levels • Analysis of long time-series, multiple cross-sectional, and panel data would help increase validity in claiming health systems improvement as a result of health care reforms