Reducing impoverishment from health payments:

impact of universal health care coverage in Thailand

Phusit Prakongsai1

Supon Limwattananon1,2

Viroj Tangcharoensathien1

1 International Health Policy Program (IHPP)

2 Faculty of Pharmacy, Khon Kaen University

The First Annual Conference of HTAsiaLink

Grand Pacific Sovereign Hotel, Petchaburi,Thailand

May 14‐16, 2012

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• Background information

• Methodology

• Research findings

• Discussion

• Policy recommendations

2

Outline of presentation

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Background

4

Universal Health Coverage – system changes

- Removal of financial barriers to access health services,

- Shift of the main source of health care finance from out-of-pocket payments to general taxation,

- Promoting the use of primary care by contracting a primary care unit (PCU) as the main contractor and gatekeeper,

- Changing provider payment mechanisms from historical allocations to close-ended payments,

- Increased access to, availability of and utilisation of quality health services, with a strong health infrastructure staffed by committed health professionals,

- Hospital Accreditation for all hospitals.

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ObjectivesObjectives

• To assess impact of the universal health care

coverage (UHC) on

household impoverishment due to direct health

payments,

households facing catastrophic health spending

(when household health expenditure exceeds 10%

of total household consumption or income)

Health impoverishment of households refers to

Total consumption expenditure – Health payments < Poverty lines

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MethodologyMethodology

• Comparing pre-UC (1996-2000) vs. post-UC (2002-2009)

- Descriptive analyses of health service use and household

health spending,

• Health impoverishment and catastrophic health spending

– Expenditure-based poverty lines as reported annually by NESDB

• Specific to urban-rural areas in 4 regions + Bangkok

– Consumption expenditures based on nationally representative

household Socio-economic Survey (SES) by National Statistical

Office (NSO)

– Health payment including

• Medicines/medical supplies

• OP + IP services

• Household is the unit of analysis

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Research findings

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Increased access to and utilization of health services with very 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

Distribution of government subsidies for health:

BIA from 2001 to 2007

28%

31%

28%

29%

20%

22%

26%

24%

17%

15%

20%

20%

17%

16%

14%

14%

18%

15%

11%

12%

0% 20% 40% 60% 80% 100%

OP&IP

OP&IP

OP&IP

OP&IP

2544

2546

2549

2550

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

More pro-poor health care system and distribution of government subsidies for health after achieving UHC in 2002

24%

1%9%

26%

1% 3%

24%

4%

6%

24%

7% 6%

18%

34% 21%

16%

38%

23%

11%

48% 55%

12%

35%

57%

0%

20%

40%

60%

80%

100%

UC SS CS UC SS CS

2003 2007

20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest

10

Incidence of catastrophic health spending

OOP>10% total consumption expenditure

Source: Analysis of Socio-economic Survey (SES)

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UHC achieved

Protection against health impoverishment

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13.7

4.2

5.0

4.4

17.3

5.0

5.9

5.1

16.0

4.8

4.9

4.6

19.7

5.4

5.5

4.9

18.1

5.3

5.1

4.9

22.3

6.6

6.2

5.3

13.5

4.4

4.3

4.4

16.1

5.3

5.0

5.1

10.1

3.9

4.2

4.0

12.9

4.8

5.1

4.5

8.7

3.4

3.7

3.7

11.5

4.5

4.8

4.6

8.0

3.1

3.4

3.9

10.9

4.0

4.3

4.7

8.4

3.4

3.9

3.9

11.2

4.4

4.8

4.8

7.1

3.2

3.6

3.7

9.9

4.0

4.3

4.4

0

10

20

30

40

1996 1998 2000 2002 2004 2006 2007 2008 2009

All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf

PL: Poverty lines; Inf: Informal employment sector

All vs. Informal sector, 1996-2009

Poor and near-poor households

Consumption expenditure: < PL < 110% PL < 120% PL < 130% PL

15.5

13.1

18.3

9.2

7.8

5.4

3.6

5.0

3.8

19.7

18.2

27.1

12.512.0

7.6

5.5

6.8

4.9

2.5

1.00.2 0.1 0.0 0.2 0.0 0.1 0.0

10.2

5.3

9.3

3.8 3.4

1.50.8

1.70.8

13.6

11.0

12.0

8.5

5.44.6

2.4

4.74.0

All employment sectors

Informal sectors -all

Public employees -all

Private employees -all

Mixed groups

0

5

10

15

20

25

Imp

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ed

ho

use

ho

lds p

er

1,0

00

no

n-p

oo

r h

ou

se

ho

lds

1996 1998 2000 2002 2004 2006 2007 2008 2009

Health impoverishment by employment status of household adult members

Reduction in health-impoverishment*Reduction in health-impoverishment*(A difference-in-difference approach)

Employmen

t sector1998

200

0

200

2

200

4

200

62007 2008 2009

All-informal -0.09 9.65 -4.85 -5.23 -9.87-

11.73

-

10.56

-

12.32

Mixed -1.13 0.75 -2.68 -5.70 -6.73 -8.62 -6.50 -7.07

All-private -3.46 1.40 -4.07 -4.27 -6.47 -6.86 -6.12 -6.95

*Absolute difference from 1996, as compared with all-public employeeall-public employee households households

in number of health-impoverished households per 1,000 non-poor households

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ResultsResults

1. National level2. Sub-national level

• Regional level (urban / rural / Bangkok)• Provincial level

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Sub-national health impoverishment 1996 to 2008

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

1996 1998 2000 2002

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

Per 100 households

0 – 0.5

0.6 – 1.0

1.1 – 2.0

2.1 – 3.0

3.1+

2004 2006 2007 2008

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17

20

8

11

27

15

14

34

2

11

1

18

8

1011

20

10

32

5

9

5

27

15

2021

36

19

38

11

24

1

13

4

67

98

24

3

8

2

12

54

9

12

7

23

5 5

1

8

2

76

8

5

12

7

2

0

6

21

5

9

6

8

0 0

4

7

2

1

6

8

3

13

0

2

0

5

1 1

5

7

3

8

1

4

0

0

5

10

15

20

25

30

35

Imp

ove

rish

ed

ho

use

ho

lds

pe

r 1

,00

0 n

on

-po

or

ho

use

ho

lds

1996 1998 2000 2002 2004 2006 2007 2008 2009

' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S .

Region: C -Central; N -North; Ne -Northeast; S -South

Informal employment sector households

Health impoverishment by geographic region and area

Whole country

Urban area

Rural area

Bangkok

How health equity and efficiency were achieved?

1. Long term financial sustainability

2. Technical efficiency, rational use of services at primary health care

Functioning primary health care at district level, wide geographical coverage of services, referral back up to tertiary care where needed, close-to-client services with minimum traveling cost

In-feasible for informal sector (equally 25% belong to Q1 and Q2) to adopt contributory scheme

1. Equity in financial contribution Tax financed scheme,

adequate financing of primary healthcare

2. Minimum catastrophic health expenditure 3. Minimum level of impoverishment

Breadth and depth coverage, comprehensive benefit package, free at point of services

4. Equity in use of services 5. Equity in government subsidies

Provider payment method: capitation contract model and global budget + DRG

EQUITY GOALS

EFFICIENCY GOALS

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Conclusions (1)Conclusions (1)

• Reduction in health-impoverishment in the informal sector and

mixed groups was stronger than in the public sector.

• UCS-mitigated health impoverishment was also found at the

sub-national level

• Comprehensive benefit package and zero copayment at points

of services are key contributing factors of health financing

arrangement in reducing health impoverishment,

• In addition, the extensive geographical coverage of health

infrastructure, adequate finance and functioning primary

healthcare are other contributing factors.

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Conclusions (2)Effective implementation: enabling factors

• System design focusing on equity and efficiency• Strengthening supply side capacity to deliver services

– Extensive geographical coverage of functioning primary health care, and district health systems need strong PHC and health infrastructure and health workforce,

– Long-standing policy on government bonding of new graduates health workforce for rural services since 1972.

• Strong leadership with sustained commitment– Continued political support despite changes in governments, – Capable technocrats, – Active civil society,

• Strong institutional capacity– Long term investment in health information system,– Health technology assessment (HTA),– Health system and policy research, – Good collaboration among researchers, reformists, and

advocacy, – Key platform for evidence to inform policy making decisions.

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• Ministry of Public Health (MOPH) of Thailand,• National Health Security Office (NHSO),• National Statistical Office (NSO) of Thailand,• Health Systems Research Institute (HSRI)

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Acknowledgement