Series

Health in Southeast Asia 6

Health-nancing reforms in southeast Asia: challenges in
achieving universal coverage
Viroj Tangcharoensathien, Walaiporn Patcharanarumol, Por Ir, Syed Mohamed Aljunid, Ali Ghufron Mukti, Kongsap Akkhavong, Eduardo Banzon,
Dang Boi Huong, Hasbullah Thabrany, Anne Mills

In this sixth paper of the Series, we review health-nancing reforms in seven countries in southeast Asia that have Lancet 2011; 377: 86373
sought to reduce dependence on out-of-pocket payments, increase pooled health nance, and expand service use as Published Online
steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor- January 25, 2011
DOI:10.1016/S0140-
supported health equity funds to reach the poor, and reliable funding and appropriate identication of the eligible
6736(10)61890-9
poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam,
See Comment page 792
social health insurance nanced by payroll tax is commonly used for formal sector employees (excluding Malaysia),
See Comment Lancet 2011;
with varying outcomes in terms of nancial protection. Alternative payment methods have dierent implications for 377: 355, 534, 619, and 700
provider behaviour and nancial protection. Two alternative approaches for nancial protection of the non-poor See Online/Comment
outside the formal sector have emergedcontributory arrangements and tax-nanced schemeswith dierent DOI:10.1016/S0140-
abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both 6736(10)62140-X
important in accelerating nancial protection. Expanding coverage of good-quality services and ensuring adequate This is the sixth in a Series of
human resources are also important to achieve universal coverage. As health-nancing reform is complex, institutional six papers about health in
southeast Asia
capacity to generate evidence and inform policy is essential and should be strengthened.
International Health Policy
Program, Ministry of Public
Introduction particularly for countries whose government scal Health, Nonthaburi, Thailand
The large amount of household out-of-pocket payments capacity is low and whose social health insurance for the (V Tangcharoensathien PhD,
for medical bills, resulting in household nancial employed sector is absent or very small, thus restricting W Patcharanarumol PhD);
Siem Reap Provincial Health
disruption and impoverishment, was a key motive for the mobilisation of additional resources from payroll
Department, Ministry of
the adoption of a World Health Assembly Resolution contributions. Financing health care in most developing Health, Siem Reap, Cambodia
in 2005 on nancial protection.1 Countries in southeast countries greatly relies on out-of-pocket payments,5 with (P Ir MPH); United Nations
Asia, home to 87% of the worlds population and that most donors and global health initiatives such as the University, Kuala Lumpur,
Malaysia (Prof S M Aljunid PhD);
have a fast economic growth and a moderate poverty Global Fund focusing on specic diseases or interventions
Gadjah Mada University,
level of 146%,2 have a high potential to accelerate rather than the broader health system.
protection from nancial risks and achieve universal
coverage of health care.
Universal coverage is dened as securing access by all Key messages
citizens to appropriate promotive, preventive, curative, The development of a universal health coverage policy is guided by explicit consideration
and rehabilitative services at an aordable cost.3 of how best to cover and nance specic population groups: those in formal employment,
Prospects of progress towards this aspiration seem poor,4 the poor and vulnerable, and the informal sector and the rest of the population.
Those in formal employment can be given nancial protection through
Search strategy and selection criteria payroll-nanced social health insurance or tax-funded arrangements.
A common protocol was developed by VT and WP and agreed The poor and vulnerable are accepted to need highly subsidised arrangements by general
upon by country authors. The protocol included country budget, and there is good evidence from Laos and Cambodia that demand-side targeted
health nancing background, analysis of the government approaches such as health equity funds work better than a simple fee exemptions policy.
eorts in coverage extension to the poor, those in formal The informal sector and the rest of the population remain a challenge, with countries
employment, and the informal sector. The analysis covered such as the Philippines and Vietnam seeking to expand coverage through contributory
source of revenue, pooling, service coverage, level of nancial arrangements, and others such as Thailand using tax funding.
risk protection, and the government policy towards universal In addition to extension of population coverage, eorts should be given to provide
coverage. In producing each country report, authors adequate nancial risk protection and to design an appropriate mix of provider
reviewed and synthesised the published literatures and other payment methods that can aect physicians clinical practices towards rational use of
government unpublished documents, such as the Philippine medical technologies, eciency, and long-term aordability.
health insurance corporation annual reports, the government Expanding coverage of good-quality services and ensuring adequate human resources
statistics year book in Vietnam, International Labour Oce are equally important elements of achieving universal health coverage.
statistics, and Laos Health Financing Strategies 201115. Comparative analysis such as that presented in this paper is helpful in bringing diverse
VT and WP then compiled and synthesised the nal experiences from the southeast Asia region together to learn lessons and develop a
references on the reports from the country authors. culture of evidence in decision making.

www.thelancet.com Vol 377 March 5, 2011 863

 Series
Yogyakarta, Indonesia
(Prof A G Mukti PhD); National
Institute of Public Health,
Ministry of Health, Vientiane,
Laos (K Akkhavong MPH); World
Bank, Manila, Philippines
(E Banzon MD); Vietnam Health
Economic Association, Hanoi,
Vietnam (D B Huong MSc);
University of Indonesia,
West Java, Indonesia
(Prof H Thabrany PhD); and
London School of Hygiene and
Tropical Medicine, London, UK
(Prof A Mills PhD)
Correspondence to:
Dr Viroj Tangcharoensathien,
International Health Policy
Program, Ministry of Public
Health, Tiwanon Road,
Nonthaburi 11000, Thailand
viroj@ihpp.thaigov.net
See Online for webappendix
Gross national income per GDP yearly growth (%)*
capita in 2008 (PPP$)*
Malaysia 13 740
Thailand 5990
Philippines 3900
Indonesia 3830
Vietnam 2700
Laos 2040
Cambodia 1820
As data on poverty from national estimates in some countries are scarce and irregularly reported, some countries only have reports of poverty indicators from one year. GDP=gross domestic product.
PPP=purchasing power parity. NA=not available. *World Development Indicators database, April 2009.11 Fiscal space of Vietnam was analysed by the country author (DBH) on the basis of data from the General
Statistical Oce, Vietnam. Ocial country sources. World Development Indicators database (Aug 31, 2010).11 Percentage of population living at or below PPP US$125 per day.12
Table 1: Economic and poverty backgrounds of seven countries in southeast Asia
864
Countries with a high share of out-of-pocket payments
are more likely to have a high proportion of households
facing catastrophic health expendituredened as
spending more than 40% of household consumption
expenditure, excluding food, on health, more than
25% of non-food consumption expenditure of
households on health, or more than 10% of total
household consumption expenditure on health.6 A
1% increase in the proportion of out-of-pocket payments
in total health expenditure is associated with a
22% increase in the proportion of households facing
catastrophic health payments. The larger the share of
prepayment in health-care nancing, the smaller the
proportion of households that face catastrophic health
spending.7 However, there is no strong evidence that
countries with social health insurance oer better or
worse protection than do countries that rely on general
taxation.8 Nevertheless, the existence of prepayment
does not guarantee nancial protectioninadequate
nancial protection has been reported from some
prepayment schemes. For example, 15% of individuals
enrolled in the insurance scheme of the Self-Employed
Womens Association in India faced a nancially
catastrophic level of payment even after reimburse-
ment for hospital admission,9 and the Chinese Rural
Cooperative Medical System covers only 30% of in-
patient expenditure.10
For universal coverage, progress on three general areas
is needed: extension of population coverage of health
insurance schemes or other forms of prepayment,
specication of which types of services should be
provided and ensuring their availability and quality, and
improving nancial risk protection (webappendix p 1).
The breadth is population coverage by insurance
schemes, the depth means service coverage such as
outpatient, inpatient, and other high-cost services, and
the height is the level of nancial protection such as
co-payment. The smaller the co-payment by users and
2000 2005 2008
89 53 46
48 46 26
60 50 38
49 57 61
68 84 61
58 71 75
88 133 52
the more comprehensive the service coverage, the higher
the protection against nancial risk.
We focus discussion on these three areas. The key
dilemma in resource-poor settings is the choice between
providing a high level of service and nancial protection
for a small group of the population versus extending a
high level of population coverage but with restricted
services and nancial protection.
In this paper, we assess approaches to nancing health-
care reform and progress towards universal coverage in
seven low-income and middle-income countries in the
southeast Asia region. Brunei and Singapore, two high-
income countries, were excluded from this analysis, as
was Myanmar, for which there is little information on
health nancing. On the basis of documentary analysis,
we review achievements of the health-nancing reforms
of these countries and identify challenges with regards
to population coverage, service coverage, and nancial
protection to share lessons and to inform the nancing-
reform eorts of countries outside this region.
Country background
Seven countries in southeast Asia with dierent levels of
economic development and pace of expansion of health-
service coverage and nancial protection were selected as
case studies: two low-income countries with low coverage
(Laos and Cambodia), and ve middle-income countries,
three of which have more than 50% coverage and clear
policies towards universal coverage (Indonesia, the
Philippines, and Vietnam), and two of which have
achieved universal coverage (Malaysia and Thailand).
Table 1 shows the wide variation in economic and
poverty indicators among these countries. Fiscal space,
the governments ability to collect tax and to spend funds
for desired purposes, measured as a share of the gross
domestic product, ranges from 82% in Cambodia to
168% in Thailand (by contrast with an average of
225% in high-income countries in 2007).11
Fiscal space: government Poverty incidence (% below Poverty headcount (%)
tax (% of GDP)* national poverty line)
166 (2003) 87 (2004) NA
168 (2007) 210 (2000) NA
85 (2007)
143 (2006) 329 (2006) 226 (2006)
123 (2004) 202 (2009) 294 (2007)
130 (2007) 182 (2006) 215 (2006)
135 (2008)
101 (2007) 320 (2002) NA
270 (2008)
82 (2006) 347 (2004) 258 (2007)
www.thelancet.com Vol 377 March 5, 2011
 Series

The poverty incidence is not only suggestive of the
number of people who cannot aord to pay medical
costs when they are sick, but also indicates the magnitude
of the health budget needed if governments decide to
subsidise the poor. This subsidy puts pressure on the
scal space, and, in resource-poor countries such as Laos
and Cambodia, funding from donors is inevitable to
support access for the poor to health services, especially
services linked to the Millennium Development Goals.
Health-nancing challenges
Level and prole of health expenditure
Private health expenditure has a dominant role in nancing
health care in ve of the seven countries, contributing
more than 70% of total spending on health in Laos and
Cambodia (table 2),13,14 although the level of catastrophic
health expenditure diers between these countries,
consisting of 5% of households in Cambodia and 105% in
Vietnam.15 Less than 9% of the government budget is
allocated to health in ve of these seven countries
exceptions being Cambodia (because government funding
includes donor support channelled through government)
and Thailand (because loans from development banks and
bilateral sources were combined with the government
budget, which need to be repaid). The high amount of
external resources from donors in Cambodia (164% of
total health expenditure) and Laos (145%) not only raises
questions about long-term sustainability but also about the
extent to which donor-funded programmes are in
accordance with national priorities.16
Social health insurance nanced by payroll tax ranges
from none in Cambodia to 127% of total health expenditure
in Vietnam (table 2). Malaysia, an upper middle-income
country with a high level of formal sector employment, has
yet to establish a social health insurance schemesuch
spending is only 04% of total health expenditure. Despite
the well established schemes in Thailand, the Philippines,
and Vietnam, their spending was still below the lower
middle-income country group average of 158% of total
health expenditure, indicative of a smaller population size
in the employed sector and a lower benet package than
for other lower middle-income countries. Total health
expenditure per capita in three of the countries, Indonesia,
Laos, and Cambodia, is below the minimum US$4954
per capita17 estimated to be necessary to provide the
interventions and health-system platform necessary to
meet the Millennium Development Goals.
Population coverage by nancial protection schemes
The best estimates of insurance coverage for the country
populations are categorised in webappendix p 2 into four
relevant groups for 2009, on the basis of survey or admin-
istrative data. Because of the dierent pace of population
coverage expansion, the total number of the insured
population varies greatly, with low coverage in Laos and
Cambodia, medium coverage in Indonesia and Vietnam,
and high coverage in Thailand and the Philippines.
Malaysia is reported to have 100% coverage because of its
tax-funded system (although high out-of-pocket payments
suggest eective coverage is less than this level).
The high percentage of the uninsured population
(webappendix p 2), combined with the high level of out-
of-pocket payments, put the uninsured people at risk of
nancial impoverishment or forfeiting necessary health
care, resulting in disability or deaths at home. Social
health insurance coverage is low because of the small
size of the formal sector.
Coverage and extension of nancial
risk protection
The two most commonly used formal nancing
approaches are social health insurance for formal sector

THE GGHE Private health expenditure GGHE (% government External SHI (% THE) Out-of-pocket THE (per THE (per capita
(% GDP) (% THE)* (% of THE)* expenditure) (% of THE) (% THE) capita US$) PPP int$)
Malaysia 44 444 556 69 00 04 407 3072 6044
Thailand 37 732 268 131 03 71 192 1365 2857
Philippines 39 347 653 67 13 77 547 626 1302
Indonesia 22 545 455 62 17 87 301 418 810
Vietnam 71 393 607 87 16 127 548 583 1827
Laos 40 189 811 37 145 23 617 269 839
Cambodia 59 290 710 112 164 00 601 368 1081
Low income 53 419 581 87 175 46 483 268 670
Lower middle income 43 424 576 79 10 158 521 802 1810
Upper middle income 64 552 448 94 02 210 309 4879 7570
High income 112 613 387 172 00 256 140 44052 41450
Global 97 596 404 154 02 246 177 8023 8625

Data from the World Health Statistics, 2010. In accordance with National Health Accounts conventions, external nance is included within government and private shares (which sum to 100%). Private health
13

expenditure includes out-of-pocket payments, private social insurance, and other private insurance. International dollars are used when comparing across countries. US dollars are used when looking specically
in one country. THE=total health expenditure. GGHE=general government health expenditure. SHI=social health insurance. PPP=purchasing power parity. int$=international dollar. NA=not available.

Table 2: Key indicators of health nancing in seven countries in southeast Asia in 2007

www.thelancet.com Vol 377 March 5, 2011 865

 Series
employees and general tax nance for the poor and
vulnerable because these groups are generally accepted
to be the responsibility of the government. Given these
approaches, the coverage of the informal sector is a major
challenge, described as squeezing the middle at a
conference in 2006,18 the middle layer referring to the
non-poor or to the not-so-poor informal sector, whereas
the top layer consists of formal sector employees and the
bottom layer comprises the poor.
By social health insurance, we mean a payroll tax-
nanced scheme for employees in the public or private
sectors, in which a specic portion of an employees salary
is mandatorily deducted, with the employer also
contributing an equal or higher portion. In some countries,
the government also contributes. By contrast, tax-nanced
schemes draw on general tax revenues and do not need
pre-paid individual or household contributions.
The population groups are re-categorised in
webappendix p 3 to distinguish the economically active
(formal and informal sectors) from the poor and the
rest of the population, and indicates their size. The rest
of the population consists of non-poor children and
elderly dependants and other economically inactive
groups. The poor include children, elderly dependants,
and the poor in the informal sector. Despite the
complexity of potential overlapping populations across
these four broad groups, these categories are useful to
inform policy on how health-nancial protection for
each group should be nanced and progress in coverage
extension monitored.
Protecting the poor and vulnerable
Cambodia introduced a user-fee policy in 1996 with the
aim of improving the capacity of the health-care delivery
system, as revenues were used to pay incentives to health
workers, supplement the inadequate government budget,
and resolve irregularities of budget disbursement.19
However, user fees created a barrier for the poor in the
absence of an eective exemption system.19,20 Since the
rst pilot trial in 2000, the health equity fund, which is
mostly nanced by donors to compensate health facilities
for medical expenditures of the poor and to pay some
travelling costs, has been gradually expanded, covering
about 68% of the poor population, or 23% of Cambodias
total population, by 2008.21 Evidence suggests that this
fund has improved access of medical services for the
poor and potentially provided nancial protection.
Although there has not been a methodologically rigorous
study assessing the eect of the health equity fund on
health-care access and nancial protection, several case
studies have indicated a substantial increase in hospital
use by poor members of the fund, without a decrease in
use by self-paying patients. In most cases, the number of
beneciaries of the fund accounted for more than a third
of total hospital inpatients.2224 However, the nancial
sustainability and government capacity to expand using
its own resources have been questioned.25
866
The 1995 user charge policy in Laos26 made provision
for exempting the poor from payments, but this approach
did not work well as village leaders veried the poor on
an ad-hoc basis. Free care for the poor was a mandate
with inadequate fundingapart from routine allocations
for medicines and sta salary, there was no additional
budget line for this purpose.27 Health centres and
hospitals were reluctant to subsidise the poor using their
own revenue from user fees. A donor-funded health
equity fund piloted in 2003 has been expanded after an
assessment reported an increased use of services by the
poor, and recent government policy dialogues have
favoured increasing funding for the poor.28
In response to the 1997 Asian economic crisis, which
heavily aected the poor,29 Indonesia introduced a tax-
nanced targeted scheme for the poor and the near poor,
including homeless people and orphans. Finance is from
central and district governments, and providers are paid
on a case mix-adjusted basis for both outpatient and
inpatient services. Nationwide expansion of the scheme
reached 334% of the total population by 2008, so almost
all the poor and the near poor are covered. From hospital
administrative records, use has increased for ambulatory
and inpatient care,30 and the gap in the use of services has
reduced between the rich and the poor. Because of scal
constraints, the per capita government subsidy is only
US$6 per year for a package of outpatient and inpatient
services (relative to a total health expenditure of $418 per
capita), and so might result in a low level of service
provision and nancial protection. Out-of-pocket payment
also remains high.
Since October, 1997, the Philippine Health Insurance
Corporation (PhilHealth) has introduced a sponsored
programme for poor households that are identied and
registered by the local government. The premium for
this programme is subsidised by central (mean
contribution 80%, range 5090%) and local (mean
contribution 20%, range 1050%) governments. Yearly
enrolment has depended on local government political
will and scal capacity; for example, peaking during
election years.
Between 1975 and 2002, Thailand operated a scheme
designed to reach the poor when universal coverage was
introduced. Initially, partial to full exemption was left to
the discretion of health workers and, subsequently, a
means test (to verify whether an individual or family was
eligible for government help) was used to identify the poor;
this step was initially applied by health workers and later
by a local committee. Despite the community involvement,
nepotism resulted in under-coverage of the poor, and the
non-poor linked to local politicians commonly beneted.31
A common trend has emerged across the countries
that health services for the poor are subsidised by tax
through budget allocations to public providers, with
additional support in Laos and Cambodia from donors to
health equity funds. Historically, means testing to iden-
tify the poor has not been very accurate,32,33 and this
www.thelancet.com Vol 377 March 5, 2011

imprecision remains a challenge in the countries that
rely on it. Panel 1 compares the targeting experiences in
the Philippines, Laos, and Cambodia where lessons can
be drawn from the dierent approaches in identifying
the poor in these three countries.
Protecting the formal employment sector
Thailand, the Philippines, Indonesia, Vietnam, and
Laos use mandatory social health insurance for the
formal sector. This insurance is commonly managed by
a non-prot independent body with a clear governing
structure, and services are purchased on behalf of
members. A percentage of the payroll is deducted from
employees and an equal or higher contribution made
by employers, and some governments also contribute
as in Thailand.
A social health insurance scheme can have a major
strategic purchasing role in regulating public and
private provider behaviour and in achieving goals of
eciency, quality, and nancial protection. Dierent
provider payment arrangements can have dierent
eects on doctors clinical decisions and behaviour on
resource use.34 International experience indicates that a
fee for service payment stimulates unnecessary
diagnosis, prescription, and treatment, resulting in cost
escalation; closed-end payment such as capitation and
case-based payment have lower costs. The eects of
capitation and case-based payment are an increased use
of generic medicines and an increased use of
proper diagnosis and treatment, resulting in cost
containment.
The design of PhilHealth does not provide adequate
nancial protection for its members. Outpatient services
are not covered; inpatient care is reimbursed up to a
maximum amount, leading to balance billing, when
patients pay additional bills beyond the level of
reimbursement. The share of social health insurance in
total health expenditure was 11% in 200535 and has
declined to 85% in 2007,3638 indicative of increasingly
restricted nancial protection to members. PhilHealth
found that reimbursement was only slightly more than a
third of the total medical bill paid by patients in 2008,39
and aims to improve nancial protection of members.
An increased incidence of catastrophic health spending
(dened as >25% of non-food consumption expenditure
of households) has been observed, from 211% of the
total population in 2000 to 221% in 2003 and
297 in 2006.40
Whereas the PhilHealth fee-for-service model ensures
free choice of the patient for their provider, the Thai
social health insurance scheme introduced in 1991 limits
such choice through a capitation contract model.
Members register yearly with preferred public or private
contractors and, in return, contractors are paid a
capitation fee, currently 1900 Baht (US$57) per member,
to provide all outpatient and inpatient services. Balance
billing is illegal. The scheme covers private employees
www.thelancet.com Vol 377 March 5, 2011
Series
Panel 1: Challenges in targeting the poorlessons from Cambodia, Laos, and
the Philippines
In Cambodia, beneciaries of the health equity fund are identied on the basis of
eligibility criteria either at the community level (pre-identication) or at health facilities
through questionnaire interviews using proxy means tests (such as durable assets,
housing, land ownership, and number of working members, dependants, and disabled
members) and estimates of household income, expenditure, and debt. Identication at
point of service picks up those missed at the community level.
In Laos, poor households eligible for the health equity fund are identied by a village
committee, using certain means-testing criteria. In areas not covered by the fund, the
village head issues a letter at the request of a patient, certifying the individual as poor on
a case-by-case basis. Unlike beneciaries of the fund who get the cost of their free care
reimbursed to hospitals, poor individuals in non-fund areas have to negotiate for
exemption with providers as there is no budget line to subsidise free care for the poor.
In practice, some patients are allowed to delay payment.27
In the Philippines, those who are indigent for a certain period are assessed by local
government units, using a family income test, and are enrolled into a programme that
has budget subsidies to cover outpatient and inpatient care. The recently elected
government in 2010 has now mandated the central Department of Social Welfare and
Development to manage this assessment, because income tests are inconsistently applied
by local government units.
Potential leak of benets to the non-poor is likely in all three countries, although further
study is needed, especially in Laos and Cambodia. In these two countries, supporting
transport costs for fund beneciaries, in addition to medical costs, has been essential to
facilitate access to care by the poor.
Lessons
Ad-hoc certication in non-fund areas, and limited funding, are major factors in Laos
for under-coverage of the poor.
The health equity funds in Laos and Cambodia, with clear identication procedures
and reliable funding, have improved rates of use of services and tend to provide better
nancial protection. Similarly, the sponsored programme of PhilHealth, with clear
targeted funding, has improved access and use.
In addition to the provision of basic quality health care, support of transport and food
for poor patients during their admission to hospital seems to be essential.
Although challenging, objective criteria and transparent and participatory
engagement by local communities in identifying the poor, as experienced in all three
countries, are essential to prevent favouritism and leakage to the non-poor.
onlytheir dependants fall under the universal coverage
scheme, and public employees and dependants fall under
a separate, non-contributory scheme nanced by general
tax. Panel 2 describes the experiences of resistance to
reform in Malaysia.
The Thai capitation model ensures containment of cost
and transfers nancial risk to providers, whereas fee-for-
service transfers nancial risk to PhilHealth members
through balance billing. The risk under capitation is
inadequate services, so unit costs and rates of use are
monitored and members can change contractor yearly if
they are not satised. Results from studies have suggested
that service use of this model in Thailand is adequate in
terms of rate of use (more than two visits per person per
year) and good quality of care provided to social health
insurance members.4446
867
 Series
Vietnam, having experienced the drawbacks of fee-for-
service schemes such as excessive diagnosis and treatment
and levels of co-payment up to 30% of total bills,
introduced a law in 2008 on health insurance that provides
for capitation for primary care services and case-based
payment to be used for inpatient care. This programme is
expected to be fully implemented by 2014.
Strategic purchasing, in particular design of benet
package and provider payment method, establishes
system eciency, and level of out-of-pocket and
catastrophic spending. Once a payment system is
entrenched, particularly in cases for which private-for-
prot providers dominate the health-care market, radical
reform from fee-for-service to capitation or case-based
payment will face united resistance from the medical
profession, as experienced in South Korea.47 Introducing
the right purchasing strategies at an early stage is a key
foundation for the successful performance of social
health insurance. Panel 2 indicates some of the
complexities of agreeing the introduction and design of
social health insurance in Malaysia.
Panel 2: Complexities of introducing social health insurance in Malaysia
In Malaysia, an upper middle-income country, health services are free for all citizens at
primary, secondary, and tertiary levels with minimum co-payment, ranging from 100 RM
(US$031) for outpatients to 300 RM ($094) per admission day. The country spent
$3072 per capita on health in 2007, using supply-side nancing through yearly budget
allocations to public-sector providers. Despite this relatively high expenditure, various
problems are apparent: high levels of out-of-pocket payment making up 407% of total
health expenditure (mostly spent on secondary and tertiary private services); long waiting
times for procedures in public hospitals (eg, 23 weeks for orthopaedic surgery41); rising
health care costs because of the epidemiological transition in the face of limited public
funds; and poorly regulated private fees.
Between 1985 and 1996, the Government commissioned ve reviews on health
nancing; recommendations were made that the Government should establish a National
Health Financing Scheme to pool resources from both public and private sources and to
provide universal nancial risk protection based on social health insurance principles.
Discussions on health-nancing reform were restarted in 2000. From 2000 to 2006,
multi-stakeholder meetings were convened to discuss the National Health Financing
Mechanism. However, no decision was made and various barriers can be identied in
addition to absence of political will:
Loser versus gainer dierences: the proposed introduction of social health insurance
necessitates mandatory contributions by the formal sector such as civil servants and
private sector employees who have reservations about having to pay on top of
personal income tax. The voices of the informal sector and the poor who are potential
gainers from the new scheme are not heard. Social solidarity mechanisms seem
insucient to overcome opposition.
Private interests: there is strong lobbying by private health insurance operators who
fear the scheme will dilute their prots.
Institutional conict of interest: the proposed National Health Financing Authority,
which will administer the national scheme, threatens the Ministry of Health, which
might lose all its nancing power to the Authority.
Technical barriers: collection of premiums from the informal sector is dicult.
Information from Yon and colleagues.42,43 RM= Ringgit Malaysia.
868
Protecting the informal sector and the rest of
the population
The informal sector and the rest of the population make
up a large proportion of these countries; for example,
49% in Cambodia, 64% in Indonesia, and 73% in Vietnam.
Because of the large numbers, their restricted capacity to
pay premiums, and the feasibility of enforcing payment,
extension of coverage to this group is especially challenging.
These seven countries have faced a key choicebetween a
contributory scheme and a general tax-nanced scheme.
Both PhilHealth and the Vietnam social insurance
scheme use a contributory approach to extend coverage to
the informal sector, with premiums collected from groups
such as taxi drivers and street vendors. PhilHealth seeks
to collect a xed yearly premium of 1200 Peso (US$258)
from individual members, but enforcement is not
eective despite huge eort and various innovations.
Furthermore, the administrative cost of premium
collection is high and collection complex because of high
mobility and interruption and seasonality of cash income.
There is adverse selection because members enrolling
individually are mostly chronically ill and have high rates
of use. This element of PhilHealth needs subsidies from
the payroll tax-nanced component.
In Vietnam, tax funding is used to subsidise the premium
for the informal sector by 50%. There is a risk that coverage
might stall once the easy-to-reach population has been
enrolled, and the administrative cost of premium collection
will be high in hard-to-reach remote areas. Moreover,
information from impact assessment studies suggests that
the fund has not reduced average out-of-pocket spending
and has had negligible eects on use among the poorest
population, although it has substantially increased overall
service use and reduced the risk of catastrophic spending.48
In Thailand, despite community-based49 and then
publicly subsidised voluntary health insurance,50 30% of
the total population remained uninsured in 2001, mostly
in the informal sector. In addition to problems of adverse
selection and nancial viability,51 enforcement of premium
payment in the informal sector is not technically feasible.
When an opportunity arose with a political demand to
reach universal coverage in a year, as promised in the
January 2001 general election campaign, a contributory
scheme was ruled out on reasons of speed and because it
was politically inadvisable because of its implications for
voters supporting the new government. The political
context at that time provided no option but to adopt general
tax funding for universal coverage, although nancial
assessment indicated its feasibility for both short term
(ie, 1 year) and medium term (ie, 5 years) at the time.52 The
caveat is the question of nancial feasibility in the long
term as the population of Thailand age and their demands
increase. Thailand has extended tax nancing from the
poor to the informal sector and the rest of the population
(ie, squeezed bottomup), whereas the Philippines and
Vietnam have extended the contributory scheme from the
formal to the informal sector (ie, squeezed topdown).
www.thelancet.com Vol 377 March 5, 2011
 Series

Thailand Philippines
100% 98% 100%
100 Population
Insurance coverage
80 76%
64% 64%
60
45%
40 35% 33%
27% 25%
22% 23%
18%
20
9% 9%
0

Indonesia Vietnam
100% 100%
100

80 73%
64%
60 55%
48%
40
28%
16% 15% 20% 20%
20 13% 13% 13% 14% 14%

Laos Cambodia
100% 100%
100

80
59%
60
48%
40 35%
27% 24%
23%
20 14% 17%
4% 8%
2% 2% 0% 1%
0
Formal sector The poor Informal sector Total Formal sector The poor Informal sector Total
and ROP and ROP

Figure 1: Insurance coverage for three population groups in 2009

Malaysia is not included because it has 100% coverage. In the Philippines, the formal sector covered by PhilHealth (35%) includes public and private employees and
their spouse and dependants, whereas the target population (22%) from the International Labour Oce statistics covers only the public and private sector employees.
Data from webappendix pp 23. ROP=rest of population.

Figure 1 summarises the achievements in insurance
coverage extension by 2009 for three population groups
(including the informal sector and rest of population
groups together) in six countries. Laos faces challenges
in coverage extension to all groups, whereas Vietnam
has fully covered the formal sector and the poor but has
a major challenge covering the informal sector and the
rest of the population through a contributory scheme.
Cambodia has made good progress in using health
equity funds to cover the poor, although this achievement
needs to be sustainedintroducing social health
insurance for the formal sector and devising
arrangements to cover the large informal sector is a
huge challenge both for scal capacity and programme
management. The Philippines face two major
challenges, to extend coverage to the poor by encouraging
increased local government nancial commitments,
and to enrol the hard-to-reach informal sector into the
individual contributory scheme. Huge challenges in
Indonesia are also coverage extension to the informal
sector and the rest of the population with a clear policy
on sources of nancing, while sustaining coverage of
the poor and near-poor in a fully decentralised system.
By contrast, Thailand and Malaysia have reached a
coverage for the whole population.
This region of southeast Asia still has a huge gap of
insurance coverage, which is a daunting challenge in the
next wave of reform eorts.
Discussion and recommendations
Table 3 summarises achievements in the three areas of
population coverage, service coverage, and nancial
protection. Population coverage has been established by
willingness and capacity to subsidise the poor, enforce
formal sector enrolment into social health insurance,
and protect the rest of the population through
prepayment, whether through tax or contributions.
Service coverage is indicative of previous and current
investments in the health-service infrastructure, and
decisions on benet packages for the various schemes.
The level of nancial protection is established by
willingness and scal capacity to purchase a large or
small benet package, and by co-payment policy.
The 76% estimate of insurance coverage for the
Philippines is from PhilHealth; however, a recent house-
hold survey from the National Statistics Oce53 estimates

www.thelancet.com Vol 377 March 5, 2011 869

 Series

Population coverage Health service coverage by nancial protection schemes Financial protection for the total
by nancial population (measured by out-of-
protection schemes pocket costs as % of THE, 2007)
Malaysia 100% Primary care services focus on maternal and child health; curative services are free for all. Services are rationed 407%
by waiting time and number of family physicians in health centres; patients opt to pay for private services;
survey reports 62% of ambulatory care was provided by private clinics.
Thailand 98% Comprehensive benet package, free at point of service for all three public insurance schemes. 192%
Philippines 76% Benet package covers admission only except for the sponsored programme, which also covers outpatient 547%
services; high level of co-payment for all PhilHealth components: average reimbursement is 54% of the total
medical bill, the balance being paid out-of-pocket.
Indonesia 48% Although the policy intention is to provide comprehensive services, the low per capita government subsidy for 301%
the poor of US$6 per year for a package of outpatient and inpatient services might result in inadequate service
provision, high levels of self-payment, and low levels of nancial protection.
Vietnam 548% Benet package is comprehensive but has a substantial level of co-payment: 520% of medical bills. 548%
Laos 77% In principle, there is a comprehensive coverage for social health insurance and government employee 617%
schemes, but low level of funding results in a small service package.
Cambodia 24% The poor covered by the health equity fund are entitled to a comprehensive package, including transport cost 601%
and food allowance, but the scope and quality of care provided at government health facilities are restricted.

Information is from synthesis of the authors research. THE=total health expenditure.

Table 3: Summary population, service coverage, and nancial protection in seven countries in southeast Asia in 2009

the high level of out-of-pocket payments for private sector

Malaysia care, which is a major source of public concern.5860
(166%) Thailand
100 Figure 2 depicts the association between insurance
(168%)
Philippines coverage and general government health expenditure as a
(143%) percentage of total health expenditure, and the size of
% Insurance coverage

80
60
Vietnam Indonesia
(130%) (123%)
40
Cambodia
20 (82%)
Laos
(101%)
0 given its large benet package. For Malaysia, public sector
0 20 40 60 80
GGHE as % THE
Figure 2: Fiscal space in the context of insurance coverage and general government expenditure
The size of the spheres indicate the size of the scal space as measured by tax revenues as percentage of gross
domestic product. GGHE=general government health expenditure. THE=total health expenditure.
a national coverage of 38%, suggesting the need to improve
PhilHealths electronic membership database. All three
insurance schemes in Thailand (covering the formal
private sector, civil servants, and the rest of the population)
provide a comprehensive benet package with almost no
co-payment. Out-of-pocket payments have decreased from
33% of total health expenditure in 2001 before universal
coverage, to 177% in 2008,54 and the reduced incidence
and intensity of catastrophic payment has especially
beneted the poor population.55,56 With universal coverage,
Thailand implemented a purchaser-provider split and
mandated that people choose a local primary care unit at
which to register, with their costs covered through
capitation and case-based payment. There is evidence that
health-care providers are improving their responsiveness
to patients.57 Malaysia has retained the traditional Ministry
of Health power of nancing and provision. The perceived
absence of responsiveness of public providers has led to
each sphere indicates the scal space for each country.
Three country groups are apparent: a tax eort of more
than 15% of the gross domestic product (Malaysia and
Thailand), 10%15% (the Philippines, Indonesia,
Vietnam, and Laos), and less than 10% (Cambodia). Long-
term scal capacity to sustain the universal coverage in
the Thailand scheme is a major policy challenge, especially
100
responsiveness needs to improve and a much greater
proportion of funding needs to be channelled through
prepayment arrangements.61,62 As an upper middle-income
country, Malaysia has a high potential either to increase
the general government health expenditure from 444%
of total health spending (table 2) or to introduce payroll
tax-nanced social health insurance, given the large
proportion of the formal employed sector.
In reducing out-of-pocket spending by households, it is
dicult for the national government in a decentralised
system, such as that in the Philippines and Indonesia, to
mobilise political will and improve nancial commitment
to the poor and vulnerable. The US$6 per year for a
package of outpatient and inpatient services for poor
individuals in Indonesia can cover only a very limited set
of services, resulting in high levels of out-of-pocket
expenditure, and the contributory premium of US$258 for
the informal sector in the Philippines also provides only a
small package and thus co-exists with high levels of out-of-
pocket payment. General tax could be used to nance
individual members in PhilHealth, although this approach
is a major political decision as it departs from the current
law. The government needs to broaden the tax base and

870 www.thelancet.com Vol 377 March 5, 2011


diversify the sources of government non-tax revenue.
However, improving the current low contribution to
people in the informal sector is consistent with the policy
direction of PhilHealth.
A clear message emerges from the analysis of Vietnam;
the government needs to increase scal space for health
subsequent to consistent favourable economic perform-
ance to full its commitment towards universal coverage
by 2014. With a contributory scheme for the informal
sector, government subsidies might increase enrolment
but those people hard to reach will not be covered, and at
some point there will need to be consideration of a tax-
nanced scheme that pays the premiums of the poor
and enrols them in the Vietnam social security scheme.
This scheme would demand strong political leadership
supported by scal capacity.
Because scal space constraints limit coverage extension
to the poor in Laos and Cambodia, resources from donors
are inevitable. There are opportunities to harmonise and
reorient funding from global health initiatives to
strengthen health systems, in compliance with the Paris
Declaration on aid eectiveness,63 in particular to
strengthen primary health care. The Declaration calls for
synergies of donor programmes in line with national
priority and furnishes an opportunity to improve primary
health care that is accessible to the rural poor population.
Better access to quality care is one aspect of universal
health coverage, and good-quality and accessible primary
care services can contribute to improved service use by the
poor.46 Improvement of the eectiveness of means testing
is possible through active engagement by community
members in identifying the poor, using approaches such
as quantitative assessment of consumption levels and
qualitative assessment to rank households by wealth.64
The experience in Cambodia exemplies the advantage of
demand-side nancing by a health equity fund in
improving the accountability of providers to the poor.
Removing user charges without additional funding to
subsidise health care for the poor might be harmful.65
Newly established social health insurance schemes
should learn from the experiences of dierent provider
payments regarding strengths and weaknesses of various
payment models. PhilHealth not only provides limited
nancial protection to its members, but also loses its
potential monopsonistic purchasing power to steer health-
care providers to improve eciency. As the largest or only
purchaser of medical services in the country, PhilHealth
has an opportunity to exert its purchasing power to achieve
eciency, such as introducing capitation and case-base
payment system. The PhilHealth 2008 annual report
stated that: PhilHealth must move away from fee for
service towards provider payment schemes where it can
easily leverage its purchasing power of more than
185 billion Pesos of health care purchases in 2008.66
Social health insurance in Laos, although mandatory,
does not cover the full eligible population and eorts
should be made to expand coverage. Cambodia has yet to
www.thelancet.com Vol 377 March 5, 2011
Series
establish social health insurance to encompass the
rapidly increasing formally employed sector. Although
expanding the community-based health insurance can
lead to adverse selection, this approach can be a temporary
means for coverage extension to the informal sector, as
indicated in Thailand. In general, coverage extension to
the informal sector and the population outside formal
schemes is divided, with contributory schemes leading
one way and tax nancing another. The choice depends
on political and health-system contexts. Well functioning
contributory arrangements need an eective government
and administrative capacities. When scal space is more
favourable, the case in Thailand indicates that tax-
nanced arrangements are feasible.
Although decisions on extending coverage to the
various population groups can be made on pragmatic
grounds, governments need to move towards
harmonisation of benet packages, levels, and methods
of provider payment across these schemes as members
move from one scheme to another. Dierences between
schemes within a country is also a major source of
inequity. In a decentralised context, particularly in
Indonesia and the Philippines, evidence is needed on the
proper balance between national and local government
nancing and roles in coverage extension.
Financing reform is complex and necessitates context-
specic evidence; national institutional capacity to
generate evidence and eective translation into policy
decisions are vital.67,68 Regular assessment of cost drivers,
long-term nancial projections, and capacity to generate
and act on evidence about cost-eective interventions are
needed. However, there is scope for countries to learn
from each other. Partnership and collaborative work
among co-authors in southeast Asia are strong foundations
for further regional collaboration in the eorts towards
better nancial risk protection and universal coverage in
this region. As we have experienced and discussed, there
are great opportunities to share experiences among
countries in this region in the movement towards
universal coverage for improved health care. Moreover,
the challenges the governments face, including how to
improve the responsiveness of public services, expand
social health insurance, and identify and protect the poor,
and whether coverage of the informal sector is better
implemented through contributory arrangements or tax
nance, are ones faced across the developing world.
This paper is a timely contribution to the current global
debates on how to provide nancial risk protection to the
poor and vulnerable, how to extend coverage to the formal
and informal sectors, and how to reach universal coverage,
drawing on experiences and lessons from seven countries
in southeast Asia with dierent paces of development. We
have discussed the strengths and weaknesses of dierent
designs of strategic purchasing and debated nancing
sources for the informal sector. The experiences of each
country indicate the diversity of country choices, related to
political decisions, historical precedence, and social value.
871
 Series
However, our focus on nancing reforms should not be
interpreted to imply that additional supply factors, notably
quality of care and human resources, are not also important
elements of achieving universal coverage.
In conclusion, governments hold responsibility to
protect their citizens from catastrophic health expenditure
and impoverishment, or welfare loss from inability to use
health services when needed. Key messages emerge for
resource-poor settingsrst, the extension of functioning
and aordable primary health-care services is an initial
priority for governments as geographical access to services
is still a major problem. This extension needs to be
matched with nancial risk protection for the poor,
including eective identication of the poor, user fee
exemption, and adequate levels of subsidy. Second, even
though the formal sector might be small, social health
insurance can make an important contribution to
insurance coveragealthough general tax funding might
be preferable in the long run.69 Finally, when the poor are
adequately protected by tax-funded schemes, and in cases
in which scal capacity allows, introducing partial subsidy
for the informal sector can be an appropriate choice.
These practical steps of reform should maintain a long-
term objective of harmonising all prepayment or health
insurance schemes with a universal and equal coverage.
Contributors
VT was the lead author and was responsible for setting the conceptual
framework of the paper, undertaking the literature search, verifying data,
data interpretation, writing the manuscript, and ensuring full
participation and contributions by country authors. WP helped to set the
conceptual framework of the paper, and provided country data
(Thailand), compiled data and data analysis for seven counties, produced
tables and gures, and gave comments on the content of the draft.
PI (Cambodia), SMA (Malaysia), AGM (Indonesia), KA (Laos),
EB (Philippines), and DBH (Vietnam) provided and veried country
data. HT (Indonesia) provided country data. PI, SMA, and AGM gave
comments on the framework and on the general content of the draft. PI,
SMA, KA, and EB helped to rewrite the text relevant to the country they
provided data on. DBH gave comments relevant to Vietnam. AM was the
scientic guarantor, responsible for setting the conceptual framework of
the paper with VT, giving comments on the draft, redrafting the whole
paper until reaching the nal version.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
This paper is part of a Series funded by the China Medical Board,
Rockefeller Foundation, and Atlantic Philanthropies. We thank the China
Medical Board and the Regional Steering Committee in convening
various workshops.
References
1 WHO. WHA58.33: Sustainable health nancing, universal coverage
and social health insurance. http://apps.who.int/gb/ebwha/pdf_les/
WHA58/WHA58_33-en.pdf (accessed Feb 14, 2010).
2 Chongsuvivatwong V, Phua KH, Yap MT et al. Health and
health-care systems in southeast Asia: diversity and transitions.
Lancet 2011; published online Jan 25. DOI:10.1016/S0140-
6736(10)61507-3.
3 Carrin G, Mathauer I, Xu K, Evans D. Universal coverage of health
services: tailoring its implementation. Bull World Health Organ 2008;
86: 85763.
4 Garrett L, Chowdhury M, Pablos Mendez A. All for universal health
coverage. Lancet 2009; 374: 129499.
5 ODonnell O, van Doorslaer E, Rannan-Eliya RP, et al. Who pays
for health care in Asia? J Health Econ 2008; 27: 46075.
872
6 Xu K, Evans D, Kawabata K, Zeramdini R, Klavus J, Murray CJL.
Household catastrophic health expenditure: a multicountry analysis.
Lancet 2003; 362: 11117.
7 Kawabata K, Xu K, Carrin G. Preventing impoverishment through
protection against catastrophic health expenditure.
Bull World Health Organ 2002; 80: 612.
8 Xu K, Evans D, Carrin G, Aguilar A, Musgrove P, Evans T. Protecting
households from catastrophic health spending. Health Aairs 2007;
26: 97283.
9 Ranson MK. Reduction of catastrophic health care expenditures by a
community-based health insurance scheme in Gujarat, India: current
experiences and challenges. Bull World Health Organ 2002; 80: 61321.
10 Yip W, Hsiao WC. Market Watch: the Chinese health system
at a crossroads. Health Aairs 2008; 27: 46068.
11 World Bank. World Development Indicators. http://data.worldbank.
org/indicator (accessed Nov 18, 2010).
12 World Bank. Poverty indicators. http://data.worldbank.org/indicator/
SI.POV.DDAY (accessed Nov 15, 2010).
13 WHO. World Health Statistics 2010. Geneva: World Health
Organization, 2010. http://www.who.int/whosis/whostat/
EN_WHS10_Full.pdf (accessed Nov 15, 2010).
14 WHO. World Health Statistics 2008. Geneva: World Health
Organization, 2008. http://www.who.int/whosis/whostat/
EN_WHS08_Full.pdf (accessed Nov 15, 2010).
15 Van Doorslaer E, ODonnell O, Rannan-Eliya RP, et al. Catastrophic
payment for health care in Asia. Health Economics 2007; 16: 115984.
16 Lane C. Scaling up for better health in Cambodia. A case study for
World Health Organization in follow-up to the High-Level Forum on
the Health Millennium Development Goals. Geneva: World Health
Organization, 2007. http://www.who.int/hdp/publications/
subhcambodia.pdf (accessed Nov 15, 2010).
17 Taskforce on Innovative International Financing for Health Systems.
Constraints to scaling up and costs. Working Group 1 Report. Geneva:
World Health Organization, 2009. http://www.
internationalhealthpartnership.net/pdf/IHP%20Update%2013/
Taskforce/Johansbourg/Working%20Group%201%20Report%20%20
Final.pdf (accessed Nov 15, 2010).
18 PhilHealth. Conference on extending social health insurance to
informal economy workers, 1820 October 2006, synthesis report
January 2007. Manila, Philippines. PhilHealth, GTZ, ILO, WHO, and
World Bank, 2007. http://www2.gtz.de/dokumente/bib/07-0986.pdf
(accessed Nov 15, 2010).
19 Jacobs B, Price N. The impact of the introduction of user fees at a
district hospital in Cambodia. Health Policy Plan 2004; 19: 31021.
20 Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a
public hospital in Cambodia: eects on hospital performance and
provider attitudes. Soc Sci Med 2004; 58: 55364.
21 Bureau of Health Economics and Financing. Annual Health
Financing Report 2008. Phnom Penh, Cambodia: Ministry of Health,
2009.
22 Hardeman W, Van Damme W, Van Pelt M, Por I, Kimvan H,
Meessen B. Access to health care for all? User fees plus a Health
Equity Fund in Sotnikum, Cambodia. Health Policy Plan 2004;
19: 2232.
23 Jacobs B, Price N. Improving access for the poorest to public sector
health services: insights from Kirivong Operational Health District in
Cambodia. Health Policy Plan 2006; 21: 2739.
24 Noirhomme M, Meessen B, Griths F, et al. Improving access to
hospital care for the poor: comparative analysis of four health equity
funds in Cambodia. Health Policy Plan 2007; 22: 24662.
25 Ir P, Bigdeli M, Meessen B, Van Damme W. Translating knowledge
into policy and action to promote health equity: the health equity fund
policy process in Cambodia 20002008. Health Policy 2010; 96: 20009.
26 WHO. Essential Medicine Monitor 2010. http://apps.who.int/
medicinedocs/documents/s16784e/s16784e.pdf (accessed Nov 14,
2010).
27 Patcharanarumol W, Mills A, Tangcharoensathien V. Dealing with the
cost of illness: the experience of four villages in Lao PDR. J Int Dev
2009; 21: 21230.
28 WHO. Health-nancing strategy for the Asia Pacic Region
(20102015). Manila, WHO Western Pacic Region 2009.
http://www.wpro.who.int/internet/resources.ashx/HCF/
HCF+strategy+2010-2015.pdf (accessed Nov, 14, 2010).
www.thelancet.com Vol 377 March 5, 2011

29 Waters H, Saadah F, Pradhan M. The impact of the 199798
East Asian economic crisis on health and health care in Indonesia.
Health Policy Plan 2003; 18: 17281.
30 Rokx C, Scheiber G, Harimurti P, Tandon A, Somanathan A. Health
nancing in Indonesia: a reform road map. Washington DC, USA:
World Bank, 2009. http://siteresources.worldbank.org/intindonesia/
Resources/Publication/280016-1235115695188/5847179-
1243406029796/Full.Report.en.pdf (accessed Nov 15, 2010).
31 Nitayarumphong S, Pannarunothai S. Achieving universal coverage
of health care through health insurance: the Thai situation.
In: Nitayarumphong S, Mills A, eds. Achieving universal coverage of
health care. Bangkok: Oce of Health Care Reform, Thailand
Ministry of Public Health, 1998.
32 Gilson L, Russell S, Ruyajin O, Boonchote T, Pasandhanathorn V.
Exempting the poor: a review and evaluation of the low income card
scheme in Thailand. PHP Publication No 30. London: London School
of Hygiene and Tropical Medicine, 1998.
33 Pannarumothai S, Mills A. The poor pay more: health-related
inequality in Thailand. Soc Sci Med 1997; 44: 178190.
34 Langenbrunner JC, Cashin C, O Dougherty S. Designing
and implementing health care provider payment systems
how-to manuals (eds). Washington DC, USA: The International
Bank for Reconstruction and Development/The World Bank, 2009.
http://siteresources.worldbank.org/healthnutritionandpopulation/
resources/peer-reviewed-publications/providerpaymenthowto.pdf
(accessed Nov 15, 2010).
35 National Statistical Coordinating Board. Philippine National
Health Accounts, 2005. http://www.nscb.gov.ph/stats/pnha/2005/
sources.asp (accessed Nov 15, 2010).
36 National Statistical Coordinating Board. Philippine National Health
Accounts, 2007. http://www.nscb.gov.ph/stats/pnha/2007/
2007pnhatables.asp (accessed Nov 15, 2010).
37 National Statistical Coordinating Board. 2008 Philippine Statistical
Yearbook. Manila, Philippines: NSCB, 2008.
38 WHO. National Health Accounts, Estimates for the Philippines,
2009. http://www.who.int/nha/country/phl/en/ (accessed Jan 26,
2009).
39 Department of Health. Health sector reform agenda monograph no 9.
Bridging to future reforms. Manila, Philippines: Department of
Health, 2010.
40 World Bank. Philippines: fostering more inclusive growth.
Report No 49482-PH. Washington DC, USA: World Bank, 2010.
http://www.worldbank.org.ph/wbsite/external/countries/
eastasiapacicext/philippinesextn/0,,contentMDK:22673984~menu
PK:3968175~pagePK:64027988~piPK:64027986~theSitePK:332982,00.
html (accessed Nov 15, 2010).
41 Sharifa Ezzat WP, Azimatun NA, Jasmin NM, Aljunid S. Waiting
times for elective orthopaedic surgeries in a teaching hospital and
their inuencing factors. Medicine Health 2009; 4: 5360.
42 Yon R. Health care nancing in Malaysia: future trends. In:
Aljunid SM, Mohsein NAA, eds. Health economics issues in
Malaysia. University of Malaya Press: Kuala Lumpur, 2002: 87112.
43 Yon R, Hamidy MA, Lin CY. Evaluation of the seventh Malaysia plan:
a new approach. Asia Pac J Public Health 2001; 13: 5458.
44 Tangcharoensathien V, Supachutikul A, Lertiendumrong J. The social
security scheme in Thailand: what lessons can be drawn? Soc Sci Med
1999; 48: 91323.
45 Mills A, Bennett S, Siriwanarangsun P, Tangcharoensathien V.
The response of providers to capitation payment: a case-study from
Thailand. Health Policy 2000; 51: 16380.
46 Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity
impact of the universal coverage policy: lessons from Thailand. In:
Chernichovsky D, Hanson K, eds. Innovations in health system
nance in developing and transitional economies. London: The
Emerald Group Publishing Limited, 2009: 5781.
47 Kwon S. Payment system reform for health care providers in Korea.
Health Policy Plan 2003; 18: 8492.
48 Wagsta A. Health insurance for the poor: initial impacts of
Vietnams health care fund for the poor. Impact evaluation series No
11 policy; research working paper No WPS 4134. The World Bank,
2007.
49 Tangcharoensathien V. Community nancing: the urban health
card in Chiangmai, Thailand. PhD thesis, University of
London, London School of Hygiene and Tropical Medicine, 1990.
www.thelancet.com Vol 377 March 5, 2011
Series
50 Tangcharoensathien V, Teokul W, Chanwongpaisarn L. Challenges of
implementing universal health care in Thailand. In: Kwon HJ, ed.
Transforming the developmental welfare state in east Asia. United
Nations Research Institute for Social Development.
Palgrave Macmillan, 2005.
51 Pannarunothai S, Srithamrongsawat S, Kongpan M, Thumvanna P.
Financing reforms for the Thai health card scheme. Health Policy Plan
2000; 15: 30311.
52 Tangcharoensathien V, Prakongsai P, Limwattananon S,
Patcharanarumol W, Jongudomsuk P. From targeting to universality:
lessons from the health system in Thailand. In: Townsend P, ed.
Building decent societies: rethinking the role of social security in
development. Houndmills, Basingstoke, Hampshire: Palgrave
Macmillan, 2009: 31022.
53 National Statistics Oce. The 2008 National Demographic and
Health Survey results. Manila, Philippines: NSO, 2010. http://
philippines.usaid.gov/sites/default/les/resources/key_documents/
NDHS_2008.pdf (accessed Nov 15, 2010).
54 Thai working group on National Health Account. The report on
19942008 National Health Expenditure. Nonthaburi, International
Health Policy Program, Ministry of Public Health, 2010. http://www.
ihppthaigov.net/nha/thai_nha_1994-2008.xls (accessed Feb 20, 2010).
55 Somkotra T, Lagrada L. Payments for health care and its eect on
catastrophe and impoverishment: experience from the transition
to universal coverage in Thailand. Soc Sci Med 2008; 67: 202735.
56 Limwattananon S, Tangcharoensathien V, Prakongsai P. Catastrophic
and poverty impacts of health payments: results from national
household surveys in Thailand. Bull World Health Organ 2007;
85: 60006.
57 International Health Policy Program. Eectiveness of public health
insurance schemes on nancial risk protection: the assessments of
purchasers capacities, contractors responses and impact on patients.
Research report, Consortium on Research into Equitable Health
Systems. Nonthaburi, Thailand: Ministry of Public Health, 2010.
58 Yu CP, Whynes DK, Sach TH. Equity in healthcare nancing: the case
of Malaysia. Int J Equity Health 2008; 7: 114.
59 Yu CP, Whynes DK, Sach TH. Assessing progressivity
of out-of-pocket payment: with illustration to Malaysia.
Int J Health Plann Manage 2006; 21: 193210.
60 Chee HL. Ownership, control, and contention: challenge for the
future of healthcare in Malaysia. Soc Sci Med 2008; 66: 214556.
61 Nor Hayati I, Azimatun NA, Rozita H, Sharifa Ezat WP, Rizal AM.
In-patients satisfaction in the medical and surgical wards
a comparison between accredited and non accredited hospital
in the state of Selangor. J Community Health 2010; 16: 6068.
62 Sharifa Ezat WP, Jamsiah M, Aniza I, Suryati AA. Client satisfaction
and relationship with ISO certication status in Negeri Sembilans
health clinics. J Community Health 2008; 13: 1121.
63 Organisation for Economic Co-operation and Development. The Paris
Declaration and Accra Agenda for Action. http://www.oecd.org/docu
ment/18/0,3343,en_2649_3236398_35401554_1_1_1_1,00.html
(accessed Nov 14, 2010).
64 Patcharanarumol W. Health care nancing for the poor in Lao PDR.
PhD thesis, University of London, London School of Hygiene and
Tropical Medicine, 2008.
65 James CD, Hanson K, McPake B, et al. To retain or remove user fees?:
reections on the current debate in low- and middle-income
countries. Appl Health Econ Health Policy 2006; 5: 13753.
66 Philippines Health Insurance Corporation. PhilHealth Board
resolution 1,113 April 30, 2008 and 2008 PhilHealth Annual Report.
http://www.philhealth.gov.ph/about_us/annual_report/ar2008.pdf
(accessed Nov 15, 2010).
67 Tangcharoensathien V, Wibulpolprasert S, Nitayarampong S.
Knowledge-based changes to health systems: the Thai experience
in policy development. Bull World Health Organ 2004; 82: 75056.
68 Green A. Reforming the health sector in Thailand: the role of the
policy actors on the policy stage. Int J Health Plann Manage 2000;
15: 3959.
69 Wagsta A. Social health insurance reexamined. World Bank policy
research working paper 4111, January 2007. http://www-wds.
worldbank.org/servlet/WDSContentServer/WDSP/IB/2007/01/09/
000016406_20070109161148/Rendered/PDF/wps4111.pdf (accessed
Nov 15, 2010).
873