Challenges to universal health coverage in Thailand

1. Challenges to universal health coverage in Thailand Phusit Prakongsai, M.D. Ph.D. Viroj Tangcharoensathien, M.D. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to the 13th Annual Scientific Conference (ASCON XIII) ICDDR,B, Dhaka, Bangladesh 15 March 2011

2. Health financing arrangements and three public health insurance schemes in Thailand after achieving UC 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. Historical development of the Thai health system: Infrastructure development + expansion of financial risk protection Establishment of prepayment schemes User fees Informal user fee exemption 1945 Expansion consolidation of prepayment schemes 1970 1975 LIC 1980 CSMBS 1-3rd NHP 1962-76 Provincial hospitals 1990 SSS 1980 1983 CBHI SSS CSMBS LIC  MWS Universal Coverage 1990 4th -5th NHP (1977-86) District hospitals Health centers 1994 Pub VHI SSS 2000 2002 full achieve Universal Coverage CSMBS Health Infrastructure extension--wide geographical coverage 2002

4. Significant reduction in catastrophic health expenditure and gaps of household out-of-pocket payments for health between rich and poor Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO - Thailand

5. Inequity in geographical distribution of doctors and nurses in 2007 Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 Nurses 280 - 652 653 - 904 905 - 1,156 1,157 – 1,408

6. Use of expensive procedures Variations across 3 public insurance schemes Cesarean section Laparoscopic cholecystectomy Source: Limwattananon et al. (2009)

7. Use of expensive OP medicines Variations across 3 public insurance schemes Source: Limwattananon et al. (2009)

8. Double-digit cost escalationCSMBS’ 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) 8 Source: Comptroller General Department, Ministry of Finance

9. Medium- and long-term HCF modeling by ILO experts in 2008

10. Mismatch between increasing burden of disease from NCD and pattern of health expenditure DALYs attributable to risk factors

11. Structure of Health Information System Development in Thailand MOPH Thai Health Promotion Foundation Health System Research Institute (HSRI) NHSO NESDB Health Information System Development Plan and Networking NSO Civil societies Academics Steering committee NGOs Management office Data owners Professionals

12. Key challenges of the Thai health care system Need strong political commitment and support New health technologies and expensive services  long-term sustainability of health care finance for the UC scheme and primary care, An increasing disease burden from chronic NCD and the situation of aging society  reallocate more resources to HP and disease prevention, Inefficiency and inequitable access to quality health services among beneficiaries of different health insurance schemes  harmonization, The pandemic of new emerging infectious disease and unsuccessful control of tuberculosis and HIV/AIDS  need revitalization, Poor governance of the Thai health systems, Mal-distribution and internal brain drain of human resources for health, The impact of economic crisis and international trade/agreement on health of the Thai population, Adequate investment in health information system  M&E, Long-term capacity building of health system and policy research. 12

13. Conclusion 13

14. 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