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Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP)

Challenges and recent experience of countries leveraging provider payments in support of universal health coverage in Thailand. Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand

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Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP)

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  1. Challenges and recent experience of countries leveraging provider payments in support of universal health coverage in Thailand Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to expert group meeting on provider payments WHO Barcelona Office, Spain 27 February 2011

  2. Health financing arrangements and three public health insurance schemes in Thailand after achieving UHC in 2002 Full capitation Capitation for OP DRG with global budget FFSuntil 2006, DRG for IP Direct billing FFS(2006+) for OP Traditional FFS for OP Source: Tangcharoensathien et al. (2010)

  3. Characteristics of three main public health insurance schemes • 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 3

  4. GNI per capita, US$ on a road towards UHC, 1970-2009

  5. Historical development: provider payments

  6. UHC scheme payments Basic health care Capitation in OP, DRG with global budget in IP Population/patient ARV drug Fee schedule & development plan UC fund Provider RRT Fee schedule & development plan Chronic (DM/HT) Point by no of pt Mental health (Medicine) Medicine supply & development plan

  7. Basic health care

  8. Coverage of health insurance: 1991-2003 Source: HWS 1991, 1996, 2001, 2003

  9. Achievements after implementation: key financing functions

  10. Decreasing regressive (OOPs) and increasing progressive sources of finance (direct tax) over time

  11. Increasing share of public financing sources in Thailand after achieving universal coverage Achieving UC Total health expenditure during 2003-2008 ranged from 3.49 to 4.0% of GDP, THE per capita in 2008 = 171 USD Capitation payment for UC beneficiary in 2010 = 80 USD per capita

  12. Financial risk protection 1: Household OOP as % household income, 1992-2008 Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

  13. Financial risk protection 2: Incidence of catastrophic health expenditure 2000-2006 Source: Analysis from NSO SES 2000-2006

  14. Trend of health impoverishment 1996-2008

  15. Distribution of budget subsidies for health: BIA, 2001 and 2007

  16. Profile of government health subsidies 2004

  17. Fee-for-service CSMBS experienceCSMBS’ OP-IP health expenditures (1988-2010) 2006 implementation: - IP DRG system - OP direct billing 1997 Asian economic crisis and conservative reform (Expenditures in nominal term) Source: Comptroller General Department, Ministry of Finance 18

  18. Summary: achievements • Financing sources • General tax and SHI contributions constituting 2/3rd THE - are very “progressive” or pro-poor. • Marked decline in out-of-pocket expenditure to 18% of THE with elimination of rich-poor gap of OOP • Financial risk protection • Very low level of catastrophic health spending and impoverishment • Public subsidies of health facilities • Pro-poor subsidies of out patient and in patient • Utilization of health facilities • Pro-poor utilization of publicly financed out/in patient facilities • Pro-rich utilization of privately financed out/in patient facilities

  19. Contributing Factors to Effective Implementation • Systems design for equity and efficiency • Prakongsai et al, the equity impact of the universal coverage policy: lessons from Thailand, in Chernichovsky and Hanson (eds), Innovations in health system finance in developing and transitional economies 2009. • Supply side capacity to deliver services • Extensive geographical coverage of functioning primary health care and district health systems • Long-standing policy on government bonding of rural services by doctor, nurse, pharmacist and dentist new graduates • Availability of quality private services for which rich either covered by private insurance or OOP, can opt out • Adequate funding • Continued political commitment despite changing political party • UC budget was estimated by actual utilization X actual unit costs projected for that year • Financial access is determined by • Comprehensive service package • Zero co-payment at registered provider network

  20. The increasing health budget 77,720.7 mil. ฿ (8.1%) 16,225.1 mil. ฿ (4.8%) 986.6 mil. ฿ (3.4%) In 2011, Public health budget rose to 13% of National budget 29,000 mil. ฿ 1972 335,000 mil ฿ 1,028,000 mil ฿ 1990 National budget 2004 Public health budget

  21. Long-term financial projection, 2006-2026 based on 1994-2005 NHA, by ILO and Thai experts in 2008

  22. Contributing Factors to Effective Implementation • Strong institutional capacities • Information systems • Burden of Disease, National Health Accounts, National Drug Account, National AIDS Spending Account, national household datasets for routine equity monitoring • Health technology assessment • HITAP institutional relation with UK NICE • Key platforms for evidence informed decision • National Essential Drug List sub-committee • Benefit package sub-committee • Mandatory economic evaluation and budget impact assessment for new drugs/interventions

  23. Conclusions Health systems in Thailand equitable and responsive Full geographic coverage, well staffed and funded PHC capacity to absorb rapid increase in utilization translation and implementation capacity translate policy into real actions, M&E and feedback loops for fine-tuning policies strong leadership with continuity, Not only political but financial commitment Capable technocrats Active civil society long term investment in institutional capacity strengthening in health policy and systems research, Evidence generation, Effective mechanisms for evidence informed policy decisions

  24. Key challenges of UHC in Thailand • Data from National Health Accounts (NHA) indicate the majority of health finance was spent on curative care, and low investment in health promotion and disease prevention - only 5% of THE in 2009, • Inequitable distribution of human resources for health especially medical doctors and nurses is the key challenge in equitable access to MCH care, • Harmonization of three public health insurance schemes, • Double burden of disease (BOD) from communicable and chronic non-communicable diseases, • Aging society and increasing demand for health care, • Advance in expensive medical technologies including medicines.

  25. 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, • World Health Organization (WHO) • London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom

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