UHC in Thailand

Walaiporn Patcharanarumol
International Health Policy Program (IHPP)

Disclaimer: The views expressed in this paper/presentation are the views of the author and do
not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its
Board of Governors, or the governments they represent. ADB does not guarantee the
accuracy of the data included in this paper and accepts no responsibility for any consequence
of their use. Terminology used may not necessarily be consistent with ADB official terms.

Thailand at a glance
Population
67.7 million
GNI per capita
US$ 5,410 (UMIC)
Health status
Life expectancy 77 (F)/ 71(M)
U5MR
12.6/1,000 LB
MMR
26/100,000 LB
Skilled birth attendance 99.6% (2012)
Total Health Expenditure (THE) 4.6% GDP
US$ 264 per capita
Public sources
56% THE, 3.3% GDP (2001) prior UHC
80% THE, 4.6% GDP (2014) post UHC
General Govt Health Exp, 17 % of Govt Exp
Out of pocket 11.3% of THE
Source: World Development Indicators, World Bank

I. Health systems development

towards UHC

I. Health System Development since 1970

Under-five mortality per 1,000 live births
100

1975 Low income card scheme

80

Expansion of health
financial risk protection

1980 Civil Servant Medical Benefit Scheme

MD mandatory
rural service

60

1983 Voluntary health card

MOPH nursing
colleges

1990 Social security scheme

Scaling up of district
hospitals

40

Village health
volunteers

National EPI

20

2002 UHC
Technical nurse

Supply sides expansion

Source: U5MR was analysed from IHME data

10th

2005

9th

2000

8th

1995

1990

1985

1980

1970

1975

National Economic and Social Development Plans

3th
4th
5th
6th
7th

UHC: started and achieved at low to middle income level

GNI/capita

29%

42%

53%

71%

99%

Population
coverage

1983: Community
based health insurance
1980: Civil
Servant Scheme
1975: Low
income scheme

Pragmatism: Thailand introduced and expanded financial health protection to different

groups of population: the poor and vulnerable, the formal sector and the informal sector

UHC cube snapshot: status in 2016

Thailand achievements in three dimensions
X axis: population coverage
99% pop overage by 3 schemes
[UCS 75%, SHI 15%, CSMBS 10%]

Y axis: financial protection

Free at point of services, very
minimum OOP,
Low incidence of catastrophic
health expenditure and medical
impoverishment
Z axis: service coverage
Extensive and comprehensive
benefit package, very small
exclusion list
Most high cost interventions were
covered: dialysis, chemotherapy
6

Thai UHC (Universal Health Coverage)

99% of 67 million population
Civil Servant
UC Scheme
Scheme

Social health
insurance

Act 2002

Royal Decree 1980

Act 1990

75% of pop, 50 mln pop

(reside in rural areas; Q1-2;
children, elderly, informal wker)

7 mln pop
(urban; Q4-5; children,
elderly, public sector)

10 mln pop
(city; Q4-5; only adult
wker in private)

Tax funded
Close ended budget

Tax funded
Open ended budget

Tripartite contribution
Close ended budget

Capitation, DRG, fee schedule

Fee-for-service, DRG

Capitation, DRG

National Health Security Office

(public independent body)
governed by the Board chaired
by Minister of Health, Civil
Society 5 seats (out of 32)

Comptroller General
Department, MOF

Social Security Office,

MOL

Public (75%) and private (25%) health facilities

II. Policy process of UC Scheme

II. Situations that lead to reform

1997 Constitution
Politics

2001 general
election

(Window of
opportunity)

HSRI
1992

1993,
1996,1997 HCF
workshops

Evidences
& capacity

Experienc
es SSS &
HCS

HCRP (EU)
1998-2000

IHPP

Triangle
that moves
the mountain
UC working
group 2000

SIP (WB)
1999-2001

HITAP

Social
mobilization
A civil proposal
on UC

HISRO
9

UC Schemes goals
Efficiency
Equity
Maintain quality
note that quality improvement by other key
players and other mechanisms e.g.

Work ethics nurtured since before graduated

Clinical practice guideline
Hospital accreditation risk management, patient safety
Hospitality of health staff
Watchdog NGO, media, consumer protection group, patient groups

10

III. Achievements
1. Improved utilization, minimum unmet needs

Increased access to care by beneficiaries;

Journal of Public Economics 2015;121:79-94

Pro-poor utilization and benefit incidence;

BMC Public Health 2012; 12(suppl 1): S6

2. Financial risk protection

Preventing non-poor households become poor from medical bills;

Bulletin of the World Health Organization 2007; 85: 6006

3. Health system efficiency

Improved equity in financing healthcare;

Health Research Policy and Systems 2013;11:25

Gaining efficiency and cost containment;

Economic & Political Weekly 2012; 47: 53-7

11

1.1 Increased utilization, low unmet needs

Prevalence of unmet need

OP

IP

National average

1.44%

0.4%

CSMBS

0.8%

0.26%

SSS

0.98%

0.2%

UCS

1.61%

0.45%

Source: NSO 2009 Panel SES, application of OECD unmet need definitions

12

1.2 Access to caner treatment FY 2005 - 2010

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010

total cancer patients who were
treated

74,626

78,647

83,285

89,315

Source: National Health Security Office, UC Scheme members

96,160

110,599
13

1.3 Pro-poor outpatient and inpatient utilization

Health utilization by the poorest (Q1) and richest (Q5) beneficiaries
2003-2009
UCS beneficiaries

Total OP visits

Total IP admissions

29.2

30

28.6

28.9

28.4

27.9

27.8

27.6

27.0

27.4

26.4

25.8

24.2

23.9

23.4

23.2

25.5

23.5

23.2

20

12.6

12.5

12.3

12.2

12.3

12.1

11.4
9.4

10

10.6

10.0

8.5

8.3

9.6

8.9
7.5 7.7

9.2

6.9

0
Q1

Q5

2003

Q1

Q5

2004

Q1

Q5

2005

Source: Analysis of Health and Welfare Survey

Q1

Q5

2006

Q1

Q5

2007

Q1

Q5

2009

14

2.1 Protect households from medical impoverishment

UCS versus counterfactual 2000 onwards

Source: analysis from Socio-Economic Survey conducted by National Statistical Office,

Supon Limwattananon
15

2.2 Reduced of health impoverishment

Per 100 households

Per 100 households

Per 100 households

Per 100 households

0 0.5

0 0.5

0 0.5

0.6 1.0

0.6 1.0

0.6 1.0

1.1 2.0

1.1 2.0

1.1 2.0

2.1 3.0

2.1 3.0

2.1 3.0

3.1+

3.1+

3.1+

0 0.5
0.6 1.0
1.1 2.0
2.1 3.0
3.1+

1996

1998

2000

2002

Per 100 households

Per 100 households

Per 100 households

Per 100 households

0 0.5

0 0.5

0 0.5

0 0.5

0.6 1.0

0.6 1.0

0.6 1.0

0.6 1.0

1.1 2.0

1.1 2.0

1.1 2.0

1.1 2.0

2.1 3.0

2.1 3.0

2.1 3.0

2.1 3.0

3.1+

3.1+

3.1+

3.1+

2004

2006

2007

Source: Analyzed by Dr Supon Limwattananon using household data from

Socio-Economic Survey various years conducted by National Health Statistical Office

2008
16

3.1 Cost containment:

the merits of close end provider payment
Close ended budget with mixed of provider payment methods
(capitation, DRG with global budget, fee schedule for high cost, medical devices)

Send strong signal towards efficiency e.g. use generic

medicines, prevent supply induced demand
Risk of under-service provision,
counteracted by
Complaint management
through 1330 call centre,
Quality assurance, accreditation,
medical audit

Special management to improve access e.g. cataract surgery, stroke

fast tract, DM & HT screening, rehabilitation
17

3.2 Managing benefit package:

gradual deepening financial protection
Negative list approach: comprehensive with
few exclusion list
Extend coverage to high cost interventions
e.g. Renal Replacement Therapy, ART

Inclusion of new interventions: using evidence

Health technology assessment
(ICER <1 GDP per capita per one QALY gain)

Long term budget impact assessment,

Ethical and equity consideration,
supply side capacities
18

3.2 Evidence based decision

Contribution by IHPP and HITAP
Interventions
(Indication)

Cost-effectiveness

Budget
impact

UHC
coverage

Lamivudine
(Chronic hepatitis B)

Cost-saving

Low

Yes

Cyclophosphamide + azathioprine
(Severe lupus nephritis)

Cost-saving

Low

Yes

Peg-interferon alpha 2a + ribavirin

(Chronic hepatitis C)

Cost-effective
(ICER=86,600*)

High

No

Adult diapers
(Urinary and fecal incontinence)

Cost-effective
(ICER=54,000* )

High

No

Anti IgE (Severe asthma)

Cost-ineffective

High

No

Implant dentures

Cost-effective
(ICER= 5,147*)

Low

No

Note: * THB per QALY; Threshold: ICER 1 GDP per capita/QALY; GDP per capita =130,000 THB

Source: UC Benefit package project

19

3.3 NHSO: prudent monopsonistic purchaser

Bargaining power of a purchaser (on behalf of 50 mln pop):
Central purchasing or constraint fee
Market unit Negotiated Cost savings,
price, $
price, $
US$ million
Medical supplies
Folding lens (2011-2012)
Unfolding lens (2011-2012)
Balloon stent (2009-2012)
Coronary stent (2009-2012)
Drug coated stent (2009-2012)
DES Alloy stent (2012)
Medicines
ARV (2010-2012)
High cost drug (2010-2012)
Influenza vaccine (2010-2012)
Erythropoietin (2009-2012)
CAPD solution (2010-2012)
Total cost saving to UCS

133
133
667
1,000
2,833
1,833

93
23
333
167
567
833

2.6
0.8
8.9
8.8
76.6
0.3

747
4,508
7
22
7

658
3,197
5
8
4

2.7
6.1
1.3
22.9
57.3
188. 3

Cost saving = cost difference X unit purchased

20

Summary: contributing factors

Leadership and continuity

Continued political support despite rapid turn over government
[10 Prime Ministers, 13 Ministers of Health during 2001-2015]
Capable technocrats and active civil society
UC Scheme is owned by members, 75% of pop - hold politic

accountable; less subject to political changes, though continued political

support is vital

Readiness of health service delivery system, esp primary

care level
Design of the UC Scheme
Close ended budget and proper mixed of provider payment methods
Primary health care focus District Health System

Evidence informed decision, strong institutional capacities

Health policy and system research
Health technology assessment capacities
Key platforms for evidence informed decisions
21

Remaining Challenges
1. Inequities among and within health insurance
schemes
Different in government subsidy, financial contribution,
benefit package, delivery systems and payment mechanisms
Need harmonization

2. Financial Sustainability
Looks good: less than 5% of GDP on health with only 11% Out
of Pocket payment ..but,
Limited fiscal space - Technology development, increasing
demand and expectation, as well as ageing population
22

National Health Financing for Sustainable UHC

S-A-F-E
Sustainability,
Adequacy,
Fairness,
Efficiency

11 Indictors and
targets by 2022
23

Conclusion 1
UHC does not mean only financial protection but more
on universal (equitable) access to comprehensive
essential quality health services
Achievements and sustainability of UHC depend more on
the committed spirits of the health workers, the
ownership by the people, and the good governance
systems than the money
UHC is context specific learn from others and adapt but
not copied
26

Conclusion 2
Reform champions
From generation to generation

Thank you for your attention

28