Financial Risk Protection development: Thailand case study

1. Financial Risk Protection development: Thailand case study Viroj Tangcharoensathien, MD PhD. Walaiporn Patcharanarumol, MSc. PhD. Socio-economic policies for child rights with equity Royal Orchid Sheraton Bangkok, 13 June 2011

2. Thailand at a glance1 • Lower middle income country • Gross National Income: US$ 3,760 per capita (2009) • Gini index 42.5 (2004) • Fiscal space: tax revenue 15.5% GDP (2003)16.5% (2008), [World 16.0%, OECD average 37.4%] • Slow increase, 1% GDP in 5 years • Yet to expand to meet increased demand for social expenditure • Poverty headcount ratio, PPP$1.25 a day, 2% of population

3. Thailand at a glance2 • Financing health systems (2009 National Health Account) • Total health expenditure (THE): • US$ 178 per capita in 2009 • Public sources: 73.2% of THE, • Out of pocket: 19.2% of THE, on par with OECD average • Very low level of catastrophic health expenditure

4. Objectives • Review experiences on the development of social health protection • Processes from targeting to universalism • Universal Health Coverage • Universal ART • Universal renal replacement therapy • Outcomes of UHC • Lessons on why social health protection is feasible and successful

5. I. Experiences on the development of social health protection

6. Milestone: social health protection1 • Long march towards universal coverage • 1975-2001: targeting different population groups • The low income households, expanded to the elderly, children <12, the disable and other vulnerable population • Civil Servant and dependants, Civil Servant Medical Benefit Scheme • Private sector employees, social health insurance scheme • The informal sector: CBHI health card scheme evolved to voluntary public subsidized scheme • 2001: still 29% of population were uninsured

7. Milestone: social health protection2 • Long march towards universal coverage • 2002: Universal health coverage achieved for the entire 62 million population, • Though not 100%, but 98% of population covered • At the UC inception, ART and renal replacement therapy were excluded from benefit package • 2003: Universal ART • 2006: Termination of Baht 30 copayment by UC members • 2007: Universal renal replacement therapy [HD, PD, KT] • Though not cost-effective but catastrophic to households, • Approved by Cabinet resolution in 2007

8. Long march towards universal coverageGNI per capita, 1970-2009

9. District hospitals 4 decade health infrastructure development 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)

10. U5MR per 1,000 live births 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 Asian economic crisis 1997 National Economic and Social Development Plans: 3-th 4-th 5-th 6-th 7-th 8-th 9-th 10-th U5MR and Health Systems Development: 1970-2010 Ref: Patcharanarumol et al 2011 Good Health at Low Cost

11. Universal ART • Introduced in 2003 • When HIV prevention programs were well established, • Long after the observed decline in HIV prevalence in 1996 • Eligibility • CD4 <200 cells, free at point of services for medicines, all Lab test • Mix funding source: Tax financed + Payroll tax financed • Rapid scaled up >250,000 PHA in 2011 • 77.8% coverage of PHA eligible CD4<200 • Adult: 75.4%, paediatric: 85.5% [UNGASS2010] • ART is cost-effective, affordable • Cost per life year saved: US$ 736 for 1st line and US$ 2,145 for 1st + 2nd regimens [Revenga et al 2006] • Note: national benchmark for cost effective interventions using public resources • 1 GNI per capita for one Quality Adjusted Life Year gain, (US$ 3,760)

12. Universal RRT • Not covered by UC members at 2002 inception • But CSMBS and SHI fully covered • Introduced for UHC in 2007 • Despite not cost effective, >3 GNI per QALY gained, but • Catastrophic and impoverishing households • Inequity compared to other two schemes • Eligibility and policy strategies • All ESRD, “Peritoneal Dialysis first” policies • Home base care PD ensures equitable access by all patients • Minimum travelling cost, compared to Haemodialysis, PD has high potential for cost reduction • Financing • General tax financed managed by NHSO, free at point of services, • Scaling up supply side capacity • Reaching high coverage • Though poor performance of Kidney Transplantation due to organ shortages

13. Outcome • Published evidence demonstrates • Increased health equity • Minimum level of catastrophic spending, impoverishment • Pro-poor equity outcome: higher use rate by the poor, budget subsidies in favour of the poor • Universal ART • Life saving, reduced mortality, improved QOL • Burden of diseases from AIDS moved down from Rank 1st in 1999, 2004 to 5th in 2009 • Universal RRT • Live saving, zero copayment free at point of services for PD first, 1/3 copayment is enforced for HD.

14. Where is Thailand? 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

15. Source: Analysis of Socio-Economic Surveys (SES, various years)

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

17. II. Lessons: why financial risk protection feasible and successful? Ref: Patcharanarumol et al 2011Good Health at Low Cost

18. Enabling factors 1 1. Health Infrastructure • District Health Systems: District hospitals and sub-district health centres • Major hub of integrated service provision • Geographically accessible by the rural poor. • Critical to the successful expansion of district health systems. • Long-standing policy on government bonding and rural deployment of all graduates of the health-related professions • Financial incentives + social recognitions

19. Enabling factors 2 2. Financial risk protection, • Introduced initially to protect the poor and vulnerable, • Subsequently extended to achieve universal coverage of the entire population by 2002. 3. Nine successive five-year national health plans • Ensured continuity over four decades of health system development.

20. Enabling factors 3 4. Generations of charismatic MOPH and other leaders • Highly influential technocrats and medical leaders inside and outside of the MOPH • Share common vision of pro-poor, pro-rural ideologies 5. Other contributing factors • Economic growth and poverty reduction, • Fiscal space, free from donor’s influences • High level of female literacy, a fall in the gender literacy gap. 6. Evidence platform: • Institutional capacity to generate evidence to inform policy

21. Conclusions • A long winding rough road to build up a “resilience health system” and “financial self-reliance” on social health protection • Pro-poor pro-rural ideology were key guiding principles in last 4 decades • Important enabling factors • Political and financial commitment: investment in health systems capacities at district level: “close-to-client services” for all rural people key cutting edge of success: • Mandatory rural services by health professional • Financial/non-financial incentive for rural retention • Increasing strengths and vital role of civil society • Institutional capacities to generate evidence and support informed policy decisions.

24. Thank you for your kind attention