1 Thailand Health Financing Review 2010 Thai working group on Observatory of Health Systems and Policy Final version 31 May 2010 Thai Working Group on Observatory consists of Viroj Tangcharoensathien, IHPP Walaiporn Patcharanarumol, IHPP Chitpranee Vasavid, IHPP Phusit Prakongsai, IHPP Pongpisut Jongudomsuk, Health Systems Research Institute Samrit Srithamrongswat, Health Insurance Systems Development Office Jadej Thammathataree, National Health Security Office Acknowledgments This synthesis is supported by WHO SEARO in 2009
Thai working group on Observatory of Health Systems and Policy Final version 31 May 2010 Thai Working Group on Observatory consists of Viroj Tangcharoensathien, IHPP Walaiporn Patcharanarumol, IHPP Chitpranee Vasavid, IHPP Phusit Prakongsai, IHPP Pongpisut Jongudomsuk, Health Systems Research Institute Samrit Srithamrongswat, Health Insurance Systems Development Office Jadej Thammathataree, National Health Security Office Acknowledgments This synthesis is supported by WHO SEARO in 2009
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Table of contents Introduction........................................................................................................................3 1. Health expenditure: how much is spent and on what? ........................................................4 2. Population coverage and entitlement: who is covered and what are the benefits? ...............12
2.2 Benefit package .......................................................................................................15 3. Revenue collection and sources of funds: where does money come from?..........................17
3.1 Compulsory sources of financing ...............................................................................18 3.1.1 General Government Health Expenditure (GGHE)..................................................18 3.1.2 Compulsory pay-roll tax......................................................................................20
3.2 Voluntary health insurance (VHI)...............................................................................21 3.3 Out-of-pocket payments ...........................................................................................22 3.4 External sources of funds..........................................................................................23 3.5 Equity in health financial contributions .......................................................................23
4. How money is pooled, allocated and purchased?..............................................................25 4.1 pooling agencies and allocation .................................................................................25 4.2 Mechanisms for allocating funds among pooling/purchasing agencies ...........................26
5. Who spends the money? Purchasing and purchaser-provider relations ..............................29 6. How different services and personnel were paid for: various payment methods ..................32
6.1 Paying for health services .........................................................................................32 6.2 Paying for healthcare personnel ................................................................................32
Introduction Evidence on health care financing is vital for policy decision and monitoring progresses towards achieving health financing goals of efficiency and equity in a country. However, such evidence is limited and not available in a timely manner in most developing countries especially in South-East Asia Region. The WHO Health Financing Strategy for the Asia Pacific Region for 2010-2015 urges WHO member states to improve evidence on health financing through promoting research and studies on macroeconomics and health, and improving health financing information by expanding national and sub-national health accounts [1]. National Health Accounts (NHA) in Thailand was initiated in 1994 and sustained to date, in 2009 a 15 year series of 1994 to 2008 NHA was available in line with the recommendation by the Systems of Health Account. Based on Health in Transition (HIT) Template [2], this study describes the configurations, assesses health financing in Thailand in order to respond the following six major questions.
1. How much is spent on health of Thai population and on what services? 2. Who are covered and what are their benefits or entitlements? 3. Where does the health system’s money come from? 4. How is money pooling, allocated and purchased? 5. Who spends the money? 6. How different services and health personnel are paid for, based on various models of
payment? Each of the questions was addressed in the following sections 1-6 where Section 7 provides a conclusion from such analysis. This paper has gone through a peer reviewed process by partners involved health financing in Thailand.
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1. Health expenditure: how much is spent and on what? The Thai health care system has been financed by a mixture of health financing sources, namely general taxes, social insurance contributions, private insurance premiums and direct out-of-pocket payments. Health expenditure is income elastic; during the 1997 Asian economic crisis, health spending reduced both by the government and households. The introduction of the universal coverage (UC) policy fully implemented by 2002 significantly increased public share of total health spending, while household out-of-pocket payments significantly reduced. This is because the UC scheme is financed by general tax with a huge coverage of more than 75% of total population. After achieving universal coverage in 2002, there have been three major public insurance schemes providing health insurance coverage for the entire population: • The Civil Servant Medical Benefit Scheme (CSMBS) which covers around 5.2 million, as
of early 2010, government employees and their dependants (parents, spouse and children) as well as pensioners;
• The Social Health Insurance (SHI) scheme which covers approximately 9.5 million employees, as of early 2010, in the formal sector from non-work related health care expenditures;
• The UC scheme which covers the rest of the population and replaces all previous government-subsidized health insurance schemes, namely the Voluntary Health Card (VHC), the Low Income Card (LIC) scheme for the poor, the disabled, the elderly, and children aged less than 12 years and include all the uninsured into this scheme.
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Figure 1 Health care finance and service provision of Thailand after achieving UC in 2002
Health care finance and service provision of Thailand after achieving universal coverage (UC)
General tax
General tax Standard Benefitpackage
Tripartite contributionsPayroll taxes
Risk relatedcontributions
CapitationCapitation & global
Co-payment budget with DRG for IP
Services
Fee for servicesFee for services - OP
Population Patients
Ministry of Finance - CSMBS(6 million beneficiaries)
National Health Insurance Office The UC scheme (47 millions of pop.)
Social Security Office - SSS(9 millions of formal employees)
Voluntary private insurance
Public & Private Contractor networks
Figure 1 conceptualizes the relationship among three stakeholders: a) the population who are responsible to pay personal income tax or corporate tax or indirect tax through consumption items such as 7% Value Added Tax or contribute to SHI Fund if they are private sector employees or employers. At the same time these beneficiaries may fall ill and become patients; b) the public insurance purchasers consisting of Comptroller's General Department (CGD) of the Ministry of Finance who is responsible for CSMBS, Social Security Office (SSO) under the Ministry of Labour who is responsible for SHI and National Health Security Office (NHSO), an independent public agency, responsible for the UC Scheme. In addition to these three purchasers for the whole population, voluntary private insurances also provide insurance coverage on a competitive basis mostly to the high income earners.; and c) the public and private healthcare providers throughout the country. International Health Policy Programme of the Ministry of Public Health (IHPP) and its partners have developed and regularly updated National Health Accounts (NHA) of Thailand since 1994, a complete series of 1994 to 2008 is now available [3]. By 2002, a full application of OECD system of health accounts (SHA) using three dimensional matrix of health financing agencies, healthcare functions and healthcare providers were applied to the Thai NHA. Evidence from the NHA indicates that total health expenditure (THE) of Thailand increased significantly in nominal term from 127.6 billion Baht (approximately $5,106 million) in 1994 to 363.8 billion Baht (approximately $11,023 million) in 2008, an average annual nominal growth rate of 5.2%; see Table 1.
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The share of public financing increased from 45% in 1994 to 75% in 2008, particularly after the introduction of the universal coverage scheme in 2002. It is worth noting that health expenditure per capita between 2002-2006 after implementation of the UC policy ranged from $74-122 per capita which was slightly different from the situation prior to achieving UC, $61 per capita in 2001. The significant increase in THE per capita in 2008 which reaches $171 per capita was affected by consistent increase in the utilization rate, unit cost of services, salary adjustment in the government sectors. Table 1: Total health expenditure and selected indicators on health spending, 1994-2007, current prices
Indicator 1994 1997 2001 2002 2005 2006 2007 2008 THE, Total health expenditure (million Baht)
THE from public financing agencies (%) 45% 54% 56% 63% 64% 68% 73% 75%
THE from private financing agencies (%) 55% 46% 44% 37% 36% 32% 27% 25%
THE per capita (Baht per capita per year) 2,160 3,110 2,732 3,211 4,032 4,636 5,005 5,739
THE per capita (USD) 86 99 61 74 100 122 144 171 Exchange rate (Baht per 1 USD) 25 31 45 43 40 38 35 33
Source: NHA Working Group 2009 [4] Total health expenditure (THE), as percent of Gross Domestic Product (GDP), has not been much changed in 1994 to 2008. The ratio of THE to GDP ranged from 3.1 percent in 1994 to 3.8 percent in 1997 prior to Asian financial crisis. The ratio decreased in the subsequent years to be 3.0 percent in 2001 as health expenditure grew less than the overall economy. However, after the UC scheme, the ratios increased again and reached 3.4 percent in 2002 and increased to 3.7 and 4.2 percent in 2007 and 2008, respectively (Figure 2).
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Figure 2 Total health expenditure of Thailand as percent of GDP, 1994 to 2008, at 2008 constant price
Source: NHA Working Group 2009 [4] The real growth rate of operating health expenditure from 1995 to 2008 was not associated with that of GDP. Prior to the 1997 financial crisis, the real growth rate of GDP ranged from 5% to 10%, while that of operating health expenditure ranged from 11% to 17%. However, GDP fell significantly to -3% and -10% in 1997 and 1998, respectively as a result of Asian economic crisis, but the government health budget was safeguarded from cut. The growth rate of GDP slightly increased after the year 2001 showing a sign of recovery from crisis. Furthermore, the growth rate of operating health expenditure was significantly increased from 0-1 % during 1999-2001 to 18% in 2002, when the UC policy was first implemented. After that period, the average growth rate of operating health expenditure was approximately 8% per year (Figure 3).
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Figure 3 Real growth rate of GDP and operating health expenditure, 1994 to 2008
Source: NHA Working Group 2009 [4] The proportion between government and private (non-government) financing sources significantly changed twice in 1997 after the Asian financial crisis and in 2002 after the introduction of UC scheme. Prior to 1997, the share of public health financing sources ranged from 45% to 47%. After the economic crisis, despite budget cut, government health budget was protected, the share of public financing sources increased to approximately 54-56% from 1997 to 2001. As a result of UC policy introduced in 2002, the proportion of public financing sources has been considerably increased from 63% in 2002 to 75% in 2008 (Figure 4) and vice versa, household out of pocket reduced significantly.
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Figure 4 Share of government and non-government health financing sources from 1994 to 2008
Source: NHA Working Group 2009 [4] When the annual growth rate of THE and GDP is grouped into two sets between the period of 1995-2000 and 2000-2007, the geometric mean of annual growth rate of THE during 2000-2007 is equivalent to 10.84% which is higher than that of GDP (8.75%). The Asian financial crisis in 1997 reduced the annual growth rate of GDP during 1995-2000 to be only 3.29%, and the crisis also led to the greater reduction in THE to only 2.49 %. It is noteworthy that in the normal situation, annual THE growth rate is higher than that of GDP, but during the financial crisis, households significantly reduced their health expenditure, also government reduced spending on capital investment due to prior heavy investment on this item during the economic boom. The government health spending (inclusive of all public financing agencies, MOPH, other ministries including local government, government spending on CSMBS, SHI and UC) as percent of total government spending increased from 18% during the period of 1995-2000 to 20.26% during 2000-2007. Table 2 indicates that the Thai government invested more on health during 2000-2007 as reflected by the proportion of government health spending as a percentage of GDP increased from 1.92% during the period prior to 2000 to 2.32% in the period from 2000 to 2007. As a result of more investment in health by the government; the proportion of household out-of-pocket payments to THE significantly decreased from 37.6% during the period prior to 2000 to 26% during the period after 2000, see Table 2. There are positive effects on the incidence of catastrophic health expenditure and impoverishment in particular the government health spending directly benefited the poor, through district health systems development, functioning primary healthcare [5].
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Table 2: Selected parameters of health care financing between the period of 1995-2000 and 2001-2007 1995-2000 2001-2007 Mean nominal annual growth rate in THE, geometric mean % 2.49% 10.84% Mean nominal annual growth rate in GDP, geometric mean % 3.29% 8.75% Mean total government spending, percent of GDP 10.67% 11.46% Mean government health spending, percent of total government spending*
17.99% 20.26%
Mean government health spending, percent of GDP 1.92% 2.32% Mean out-of-pocket payments, percent of total expenditure on health
37.59% 26.04%
Note * inclusive of all public financing agencies: MOPH, other ministries including local government administrations, spending on CSMBS, SHI and UC. Table 3 demonstrates a consistent pattern that expenditure on curative services dominates total health spending, increased from 38.4% in 1997 to 43.5% in 2006; expenditure for inpatient services increased from 26.2% in 1994 to 38.7% in 2007. The medical goods dispensed to out-patient had gradually decreased from 6.5% in 1994 to approximately 4% in 2007 (Table 3). At the same time, spending on capital formation had substantial reduction, from 13.7% in 1994 to 5% in 2001. Even after UC, capital investment stayed around 3% to 5%. The prevention and the public health services accounted 7% to 8% of total spending during 1994-2001. It increased sharply to 12.4% in 2002 when UC was launched, but declined to 6.6% and 4.5% in 2007 and 2008, respectively. Table 3: Healthcare spending profile, % of Total Health Expenditure, 1994 to 2008 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 In-patient care*
THE 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Note * including long term care and rehabilitation services ** Expenditure on medicines and medical devices paid by households only. Note that spending on outpatient and inpatient are inclusive of medicines and medical devices Source: NHA Working Group 2009 [4] In 2008, spending on ambulatory services and in-patient care was the lion share, public health and disease prevention activities shared only 4.5%. The proportion of health administration and capital investment was 6.8% and 5.6% respectively. The ancillary service was a tiny amount, 0.2 percent. Based on hospital database; most expenditure on
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ancillary services was included in outpatient care. Also expenditure on long-term nursing care was included in inpatient and rehabilitation services and did not present in a separate item. In the light of scientific advancement, new technologies such as pharmaco-genomics, surgical procedures and diagnostic imaging are expensive and unaffordable. OECD experiences have shown that technology advancement is one of the very important cost drivers [6] for which appropriate mechanisms should be introduced to generate evidence on cost effectiveness and other information to guide decisions on technology adoptions. As a result of these concerns, a long term, twenty-year financial projection was done, based on analyses of data from various sources including health and welfare survey, national health account 1994-2005, hospital input-output report and administrative inpatient database, and the use of social budgeting models of International Labour Organization. By 2020, total health expenditure will be within the capacity of the government to afford, less than 4.5% of GDP, whereby the general tax will be the highest share of financing sources for universal coverage followed by CSMBS expenditure. Private household spending will be equivalent to that of Social Health Insurance Scheme [7]. Historically, donors’ resources have played insignificant role in financing health in Thailand, less than 0.05% of total health spending since 1994, see Figure 5. Figure 5 Long term health financing projection, 2006-2020 base year 1994-2005
Long term financing projection 2006-2020, base year 1994-2005,
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
MOPH Other ministries LGU CSMBS State EnterprisesUC SHI WCF Private ins Traffic insEmployer benefit Household NGO ROW
Source [7]
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2. Population coverage and entitlement: who is covered and what are the benefits?
2.1 Population coverage
2.1.1 Thai populations After the UC scheme was launched in 2002, Thailand had three public health insurance schemes covered the whole population. The CSMBS provides health care free at point of service for 5.2 million government employees and their dependants [including parents, spouse and not more than two children less than 20 years old, and the pensioners]. The SHI protects 9 million private sector employees in any firm having more than one employee, for non-work related conditions, while Workmen’s Compensation Fund covers work related injuries, illnesses or deaths. Note that SHI covers individual worker, excluding their dependants except maternity benefit which covers spouse of male beneficiaries. Finally, the UC scheme covers the residual population who are neither CSMBS nor SHI beneficiaries. UC replaces all previous government subsidized health insurance schemes prior to 2001, namely the Low Income Card (LIC) scheme for the poor, the Voluntary Health Card (VHC), the disabled, the elderly, and children aged less than 12 years. However, private health insurance covers the affluent groups, 2.2% of total population. Table 4 describes key characteristics of these schemes. Table 4 Characteristics of three public and private health insurance schemes Insurance scheme
Population coverage Financing source
Mode of provider payment
Access to service
Civil Servant Medical Benefit Scheme
Government employees plus dependants (parents, spouse and up to two children age <20)
9% General tax, non-contributory scheme
Fee for service, direct disbursement to mostly public providers and DRG for inpatient care
Free choice of public providers, no registration required
Social Health Insurance
Private sector employees, excluding dependants
16% Tri-partite contribution, equally shared by employer, employee and the government
Inclusive capitation for outpatient and inpatient services plus additional adjusted payments for accident and emergency and high cost care, utilization percentile and high risk adjustment
Registered public and private competing contractors
Universal coverage
The rest of the population not covered by SHI and CSMBS
75% General tax Capitation for outpatients and global budget plus DRG for inpatients
Registered contractor provider, notably district health system
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Insurance scheme
Population coverage Financing source
Mode of provider payment
Access to service
plus additional payments for accident and emergency and high cost care
Private health insurance
Additional health insurance scheme for those who can afford premiums
2.2% (additional insurance)
Health insurance premiums paid by individuals or households
Retrospective reimbursement
Free choice of health care providers, either public or private providers
Source: Modify from Prakongsai et al [8]
The CSMBS is a fringe benefit to government employees and dependents to compensate relatively lower salary (compared to market rates) in the public sector. This is a tax-financed non-contributory scheme. Government employees and pensioners and their dependents including parents, spouses and not more than three children (less than 20 years old) are generously provided with a wide range of medical services. The Royal Decree on CSMBS was enacted in 1980, and designated the Comptroller’s General Department (CGD) of Finance Ministry to manage the CSMBS. The SHI is a mandatory tripartite payroll-tax financed scheme equally contributed by employers, employees, and the government for non-work-related illness and injuries, maternity and cash allowances for disability, old age pension and death compensation. The Social Security Act 1990 granted the statutory status to the Social Security Office (SSO) though legally it is a Department under the jurisdiction of Ministry of Labour, but governed by a tripartite governing board and guided by Medical Committee. The scheme started with coverage of employees in enterprises with more than 20 workers in 1991 which it launched. Then, it gradually extended to cover more than 10, more than five and finally more than one worker in April 2003 after UC scheme was fully launched. As of the end of 2003, the scheme covered around 7.76 million insured persons, although this was expected to be over 10 million insured persons (Table 5). The 2006 SSO Annual Report shows the number of SSS beneficiaries in 2006 was 9.1 million [9]. Note that SHI requires hospital with more than 100 beds and other speciality requirement as a contractor provider, therefore not many district hospitals with smaller size than 100 bed cannot serve as SHI contractors. Table 5 SHI members by type of registered contractors, 2001 to 2006 Type of contractor hospitals 2001 2002 2003 2004 2005 2006 MOPH Regional hospitals 16 16 16 16 17 17 MOPH Provincial hospitals 14 13 14 14 14 14 MOPH District hospitals 1 1 1 2 2 2 Other public hospitals 5 5 5 5 5 5 University hospitals 5 5 5 5 4 3 Private hospitals 58 59 60 60 59 58 Total, % 100 100 100 100 100 100 Total, million SHI members 5.9 6.7 7.8 8.2 8.6 9.1 Source: Analysis from database of Technical and Planning Division, Social Security Office of Thailand, 2001-2006 The Workmen’s Compensation Scheme (WCS), an employer liability scheme, covers work-related injuries, illnesses and funeral grants. The WCS was enacted by the 1994 Workmen’s
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Compensation Act replacing the Revolution Party’s Decree No. 103 which gave birth to the Scheme. The contribution was assessed as percentage, based on different types of establishment and related risks of occupational injuries, of the total wages of employees. The contribution rate varies from 0.2-1.0% of payroll based on risk rating of establishment categorized by industrial classification. The rate is used for the first four years of contribution. In the fifth year, this basic rate of contribution may increase or decrease depending upon the accidents and deaths record of the establishment. This is called ‘experience rating’. Higher accident records and higher claims from the Fund result in a higher experience rate and thus the basic rate in the fifth year would be adjusted in line with the increasing trend of compensation from the Fund. Details about the experience rates are:
• Firms whose loss ratio is less than 10% are granted a 70% reduction in the basic rate; • Firms whose loss ratio is 60-70% are not granted a reduction rate or are penalized by
an increase in the basic rate; • Firms whose loss ratio is 150% are penalized with an increase in the rate, to 200% of
the basic rate. It is important to note that WCS and SHI covers the same population, though coverage by WCS is reported to be lower. The UC scheme covers the residual population who are neither CSMBS nor SSS beneficiaries. The share of UC beneficiaries is approximately 75% of the entire population. In addition to these three public insurance schemes, around five million populations or 8% of total population was covered by voluntary private health insurance in 2004 [10]. However, the 2006 Health and Welfare Survey indicated a lower coverage of 1.4 million or 2.2% of population [11]. Estimates from Surasiengsang [10] tend to be more reliable due to the accuracy and completeness of data sources. There is a trend towards increasing coverage by private commercial insurance, especially during favourable economic growth. After the recovery from the 1997 economic crisis, a significant increase in premium collection was observed in the NHA [4]
2.1.2 Migrant populations Thailand is a recipient country having more than two millions irregular migrants including their dependants, spread throughout the country. Health services for the registered migrants, a small fraction of total migrants were covered by their employers with full access to health service. Employers pay some 2,000 Baht to cover one employee for a year, the scheme is managed by the MOPH provincial health office. For the large proportion of non-registered migrants, health services were partly or fully covered, on a humanitarian basis, by the Thai MOPH. Patients who could not afford to pay were exempted on a sliding scale. Budget subsidies for the huge amount of non-registered migrants and their dependants are increasingly placing financial burden to the government. A recent policy endorsed the universal coverage for half million stateless people in Thailand financed by general tax revenue.
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2.2 Benefit package Though there is a slightly difference in the benefit package in terms of coverage of disease, conditions and medical interventions, CSMBS significantly differs from other two public insurance schemes in terms of access to private room and board and some new technology, as a result of fee for service provider payment. Historically CSMBS and SHI did not cover prevention and health promotion, the UC scheme provide prevention and health promotion for the whole population not only UC members by extension of health promotion and disease prevention to CSMBS and SHI members. The CSMBS benefit package includes out-patient services and hospitalization, medical and surgical services, emergency services, operation, expensive health services and medicines. However, the benefit package excludes some services such as cosmetic surgery and preventive services, except for annual health check-up. In fact the benefit package of the three public health insurance schemes was quite comparable. The exception is CSMBS members were entitled to stay in private ward while the major difference from two other schemes (UC scheme and SHI) is the provider payment method. With the application of fee for service payment, CSMBS granted free choice to public providers (though access to private sector admission service was limited to life threatening accident and emergency); beneficiaries could go to any public hospitals for receiving health services, but recently in 2007 the Scheme encouraged the beneficiaries to register with a preferred public hospital in order to receive outpatient services without paying upfront and reimburse later. These public hospitals were direct disbursed by the Comptroller’s General Department (CGD) on a monthly basis for outpatient services they provided to CSMBS members. The cashless services have resulted in exponential growth of outpatient expenditure by the scheme see figure 7. The 1990 Social Security Act article 62 defines the SHI benefit package to include diagnostic and medical treatments, hospitalization including room, nutrition, and other treatments, pharmacy and medical supplies for which quality is not lower than those included by the National Drug list[12]. These benefits apply to all diseases except self-inflicted illness or injuries. Health services must be provided until the patients have completely recovered. Conditions are not a medical necessity (e.g. cosmetic purposes) and those that are too expensive to provide are excluded from the benefit package. The Scheme applies a very minimum number of negative lists. In the design of the benefit package for the UC scheme, having harmonization in mind among the reformists, the benefit package for UC scheme is very similar to that covered by the SHI. It provides a comprehensive benefit package which includes ambulatory care, hospitalization, laboratory investigation, dental care, disease prevention, health promotion and many expensive medical services such as radiotherapy and chemotherapy for cancer treatments, surgical operations, and healthcare for accidents and emergency illnesses. Prescription drugs are also free of charge. It should be noted that dental care differs between the UC scheme and SHI. The UC scheme limits dental condition to be covered such as all basic such as extraction, filling, scaling and acrylic partial and full dentures. SHI limits the maximum reimbursement level per annum. As the UC scheme applies the capitation contract model, beneficiaries are required to register with a preferred primary care network, though in fact there is no choice for UC members. They are required to register to their local district health provider networks, for which they resided. Due to geographical monopoly in rural areas; NHSO required
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beneficiaries to register with provider network in their domicile districts, which is the MOPH district provider network (consists of district hospitals and some 10-15 health centres). However, UC members residing in urban city, there are choices of different public and private network for which they are free to choose the network nearby their home. As per NHSO rule, UC member can change their contractor provider network proximal to their residence twice a year. This is to facilitate the internal temporary migration. To achieve this, applicants need to prove that they reside in that area either through the following proofs, (a) certification letter by house owner they reside, (b) by the village head or other community leader, (c) by electricity or pipe water bills. Beneficiaries are entitled to free services in the registered provider network only with referral. Self referral by patients is liable to full payment. If the registered hospital cannot provide appropriate treatment, patients are transferred to a higher level health facility such as a provincial or regional hospital, and sometimes a university hospital without any cost sharing; transferring provider is responsible to pay for services rendered by higher level of outpatient care except admission services. This design is called “fund holder” primary care network. Although the UC benefit package is quite comprehensive, some expensive medical care, for example, renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients was, in the inception phase, excluded from the benefit package due to the high costs of certain procedures and the limited government health resources. However, RRT was now included in the benefit package since early 2008 through cabinet resolution* Health Intervention and Technology Assessment Program (HITAP) a spin-off program from IHPP, initiated in 2007 with multi-sources of funding support, was mandated to conduct technology assessment of health interventions. Increasingly HITAP plays a significant role in assessing and providing recommendations to the National Subcommittee on Essential Drug List and the Benefit Package Subcommittee of the National Health Security Board on which benefit package should be included by the UC scheme. Recently recommendations by IHPP to NHSB benefit package sub-committee were approved on the introduction of seasonal influenza vaccination to elderly more than 65 years with certain chronic conditions.
*Renal replacement therapy (renal and peritoneal dialysis, and kidney transplantation) has been included in the UC benefit package since end of 2007.
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3. Revenue collection and sources of funds: where does money come from? Refer to Thai National Health Account [4], there are five main funds of finance: general government health expenditures (GGHE), social health insurance (SHI), private health insurance, out-of-pocket (OOP) and the rest of world (ROW). In 1994, the share of health care spending by GGHE was less than the private spending (private health insurance and OOP). However, the proportion of GGHE gradually increased and overtook the private spending, and became the dominant financing source after the 1997 Asian economic crisis and the emergence of the UC scheme in 2002 (Table 6). SHI was not a major contributor in health expenditure. SHI accounts for 2.9% of THE in 1994 and gradually increased to about 7% in 2007. Household OOP had a lion share in 1994, 44.5% of THE, until the 1997 Asian economic crisis and then slowly and steadily dropped to 19.2% in 2007. Funding size from the rest of the world is negligible. Table 6 Percent distribution of five sources of finance, 1994-2007
Year GGHE excluding SHI
SHI Private Health
Insurances
Out-of-Pocket
Rest of the
World
THE THE (Million
Thai Baht)
1994 41.7% 2.9% 10.9% 44.5% 0.1% 100% 127,655
1995 43.6% 3.3% 10.4% 42.6% 0.1% 100% 147,837
1996 43.8% 3.4% 10.3% 42.5% 0.0% 100% 177,103
1997 50.5% 3.4% 9.2% 36.9% 0.1% 100% 189,143
1998 49.8% 5.0% 9.8% 35.4% 0.0% 100% 172,811
1999 50.0% 4.9% 10.6% 34.5% 0.0% 100% 162,124
2000 50.8% 5.3% 10.1% 33.7% 0.0% 100% 167,147
2001 49.6% 6.6% 10.5% 33.1% 0.1% 100% 170,203
2002 57.7% 5.6% 9.3% 27.2% 0.3% 100% 201,679
2003 57.4% 6.2% 9.4% 26.8% 0.3% 100% 211,957
2004 58.1% 6.5% 9.0% 26.1% 0.2% 100% 228,041
2005 56.2% 7.9% 8.4% 27.2% 0.3% 100% 251,693
2006 60.3% 7.5% 9.3% 22.6% 0.3% 100% 291,294
2007 65.8% 7.1% 7.6% 19.2% 0.3% 100% 315,531 Source: NHA Working Group 2009 [3] Note: 1 General Government Health Expenditures (GGHE) comprised of health expenditure spent by the ministry of public health and other ministries, local government agencies, CSMBS, state enterprise and universal coverage scheme since 2002. 2 Social Health Insurance (SHI) comprised of health expenditures through social health insurance fund and workmen compensation fund. 3 Majority of private health insurances were voluntary basis (about 57% of all private insurances) while the rest (43%) were compulsory traffic accident protection fund managed by private insurance companies. 4 Out-of-Pocket (OOP) were paid by household at point of services. 5 Rest of the World (ROW) means grants from bilateral and multilateral donors.
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3.1 Compulsory sources of financing
3.1.1 General Government Health Expenditure (GGHE) Between the year 1994 and 2007; GGHE was fluctuated within a range from 14.5% to 20.0% of General Government Expenditure (GGE); while GGE steadily increased from 9.8% of GDP in 1994 to 12.2% in 2007 (Table 7). Table 7 Key NHA parameters, 1994-2007
Gross Domestic Product, GDP (Million Baht)
General Government Consumption Expenditure, GGE (Million
Baht)
GGE as % GDP
GGHE, excluding
SHI (Million Baht)
GGHE, excluding SHI, as %
GGE
1994 3,629,341 354,387 9.8% 53,182 15.0%
1995 4,186,212 414,403 9.9% 64,468 15.6%
1996 4,611,041 469,516 10.2% 77,537 16.5%
1997 4,732,610 476,705 10.1% 95,478 20.0%
1998 4,626,447 511,691 11.1% 86,055 16.8%
1999 4,637,079 533,041 11.5% 81,034 15.2%
2000 4,922,731 557,807 11.3% 84,924 15.2%
2001 5,133,502 581,117 11.3% 84,505 14.5%
2002 5,450,643 603,891 11.1% 116,325 19.3%
2003 5,917,369 636,002 10.7% 121,627 19.1%
2004 6,489,476 720,595 11.1% 132,575 18.4%
2005 7,092,893 843,649 11.9% 141,506 16.8%
2006 7,841,297 927,575 11.8% 175,587 18.9%
2007 8,493,311 1,037,571 12.2% 207,564 20.0% Source: NHA Working Group 2009 [3] Taxation is the main source of Thai government's revenue. A large part of tax collection is responsible by three Department of the Ministry of Finance—The Revenue Department, the Excise Department, and Customs Department - which collectively account for about 85-90% of the government's revenue collected (Table 8). The Revenue Department responsible for personal and corporate income tax collection, contributes more than half of the total tax collected. Liability of tax payers are prescribed by rules and regulations stipulated in the Revenue Code. In the tax revenue structure, the direct tax (personal income and corporate tax) is the largest portion, follows by consumption tax (including value added tax—VAT and a very small role of business tax for small enterprises), excise tax and import and export duties respectively. However, indirect tax combining all items has a large share than direct tax. This tax profile has not changed between 1994 and 2007, except in the year 1998 and 1999, two years after the 1997 Asian economic crisis; the consumption tax was larger than direct tax (Table 8). The main source of direct tax is from personal income tax which applies very progressive tax rates (Table 9). Revenue Department had demonstrated an improved effectiveness of tax collection, now totally in electronic submissions by March every year for personal income tax. However the tax base is still narrow. There is no political will to introduce property and inheritance tax though this was discussed by the Parliament in 2009.
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There is only one earmark tax to healthcare, 2% levies on tobacco and alcohol consumption was transferred by the Excise Department on a daily basis to the Thai Health Fund. The Fund is governed by a Board chaired by the Prime Minister, aiming to campaign against tobacco, alcohol and active health promotion activities by funding NGO and civil society and government agencies to strengthen healthy enabling environment [13]. Table 8 Structure of government revenue, 1994 and 2007
A A1 A2 A2.1 A2.2 A2.3 B C=A+B
Year Tax Direct tax
Indirect tax
Consumption tax, including
VAT
Excise tax
Import-export duties
Non-tax revenue
Total Total (Million Baht)
1994 88% 29% 59% 23% 20% 16% 12% 100% 707,546
1995 89% 30% 59% 24% 19% 16% 11% 100% 815,143
1996 90% 32% 58% 25% 19% 14% 10% 100% 895,291
1997 88% 31% 57% 26% 20% 11% 12% 100% 909,049
1998 88% 28% 61% 33% 19% 8% 12% 100% 815,681
1999 86% 28% 58% 29% 21% 8% 14% 100% 793,346
2000 87% 30% 57% 26% 20% 10% 13% 100% 817,595
2001 88% 31% 57% 26% 20% 10% 12% 100% 874,766
2002 89% 31% 57% 26% 22% 10% 11% 100% 958,373
2003 89% 31% 58% 25% 22% 10% 11% 100% 1,104,627
2004 91% 34% 57% 27% 22% 8% 9% 100% 1,258,805
2005 90% 35% 55% 28% 19% 7% 10% 100% 1,472,935
2006 90% 38% 52% 29% 17% 6% 10% 100% 1,581,524
2007 90% 39% 51% 29% 17% 5% 10% 100% 1,666,824 Source: Fiscal Policy Office, Ministry of Finance http://www.fpo.go.th/fiscaldata/Revweb.xls, access 20 December 2009 Table 9 Progressive Tax Rates of Thai personal income tax Taxable Income (baht per annum) Tax Rate (%) 0 - 150,000 Exempt 150,001 - 500,000 10 500,001 - 1,000,000 20 1,000,001 - 4,000,000 30 4,000,001 and over 37 Source: Revenue Department, Ministry of Finance: website http://www.rd.go.th/publish/6045.0.html access 20 December 2009 Note: This rate is applicable in 2008 onwards Through annual budget allocation, general government health expenditure covers expenditures by CSMBS, UC and operating cost of public health facilities (mainly salary for the health staffs), capital investment of public health facilities and contributions to the SHI, as part of the tripartite contributions.
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3.1.2 Compulsory pay-roll tax A. Social Health Insurance (SHI) SHI including other social security benefits (e.g. death compensation, sickness allowance, disability) was successfully enacted in late 1990 and implemented in April 1991 covering employees who worked in formal private sector. The scheme is a mandatory tripartite contribution scheme, which is financed by an equal payroll tax paid by the employee, the employer and the government. The scheme has been managed by the Social Security Office (SSO) under the jurisdiction of Ministry of Labour. Since the launch of SHI in 1991, the maximum salary for assessed contribution was fixed at 15,000 Baht per month and had never indexed since then. In 1991, the minimum wage was 3,000 Baht per month. The rich poor gap for contributory wage was 5 folds. Note that the minimum wage was adjusted annual to catch up with inflation and announced by the Ministry of Labour. Unfortunately, there is no revision of the maximum ceiling of contributory wage, while the minimum wage slowly increased every year. As a result the five folds rich poor gap gradually became narrower, and less progressive. This challenges the notion of solidarity of social health insurance. However, the Social Security Office demonstrates no political will to reverse the less progressive trend. For four short-term benefits (medical, maternity, invalidity and death) requires 1.5% payroll tax contribution by each party, the employee, employer and the government. Wage of each employee is liable to reported and registered to SSO, so that by the end of each month, employers are liable to deduct 1.5% from employee payrolls and contribute equally from employer and wire transfer to the Social Security Fund. Failure to comply with, employers are liable to financial fine and imprisonment. Government contribution to the Fund is through annual budget allocation to SSO. In some financial crunch years, when the Government cannot pay its contribution on time, the dues were retrospectively paid in subsequent years. In addition to a statutory insurance coverage for the employee, SHI also offer insurance coverage to the voluntary members; according to article 39, e.g. the retirees. Contribution for these members was solely by themselves; neither employer nor the government provides matching contribution. B. Workmen’s Compensation Fund (WCF) The WCS was formally established on 16 March 1972. After more than two decades of implementation, the 1994 Workmen’s Compensation Act replaced this outdated regulation. The WCS office is one of the Divisions in the Social Security Office. The purpose of the new Act was to replace individual employer liability and to provide a prompt and equitable protection against injury, disease, disability or death resulting from employment through the pooled risk of all private sector employers. The employees are entitled to benefits consisting of medical and rehabilitation services and cash benefits including compensation and monthly indemnity. In case of death due to work-related injuries and illness, a funeral grant is paid to survivors. Contributions to the WCF are mandatory and solely paid by employers on an annual basis. The contributions are assessed on total wages of employees multiplied by the contribution rate, according to the type of business. The contribution rate varies from 0.2-1.0% of wages based on risk rating of establishment type classified by industrial classification. The
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rate is used for the first four years of contribution. In the fifth year, this basic rate of contribution may increase or decrease depending upon the accident record of the enterprise. This is called experience rating. Higher accident records and higher claims from the fund result in a higher experience rate and thus the basic rate in the fifth year may be adjusted in line with the increasing trend of compensation from the Fund. Similar to SHI, employer’s failure to comply with the contribution are liable to financial fine and imprisonment.
3.2 Voluntary health insurance (VHI) Since 2001, a voluntary public subsidized health insurance scheme (so called the Heath Card project) was terminated and replaced by UC scheme. Today, only private VHI is available. Private commercial insurance has been operating in the Thai market since 1929 for mostly the better-off population. There are two major types of private health insurance companies: the majority schemes are providing health insurance as part of life insurance policies, and very small market of providing health insurance alone. Both types also provide individual and group insurance policies. [14, 15] Private insurance companies are regulated by an independent commission established by the 2007 Insurance Business Regulation and Support Act. The agency called Office of Insurance Commission [16]. This is a major reform; as formerly regulation of insurance business is done by the Department of Insurance belong to Ministry of Commerce. Membership is voluntary, prior physical examination and exclusion of existing conditions are general practices. The elderly beyond 60 years old were usually not accepted by VHI. The membership of health insurance policy is renewed annually. The population coverage by voluntary private insurance was low about only 2.2% of total population. Personal income tax relief was applied for the premium paid for VHI (including life insurance). The premium was deducted as annual expenditure, in order to provide incentives for voluntary insurance coverage. There is no “complementary voluntary health insurance” to offer additional services with a reduced premium, as the benefit packages are comprehensive by the three public insurance schemes. There has never been policy discussion to introduce such complementary packages. As of today, benefit package offered by all private health insurance are “supplementary”, it offers faster access to private hospitals and increased consumer choice with a full premium. The society tends to tolerate with the supplementary package; often VHI is annual renewal where premium are adjusted based on previous year risk and reimbursement, and often exclude members reaching 60 years old, and certain pre conditions were excluded from being membership. Unlike some countries in the European Region, when the SHI emerged in 1990, the decision was made explicitly that SHI members cannot opt out from paying contribution to SHI, and that no “substitutive voluntary health insurance” is allowed, SSO is the sole purchaser for services on behalf of all SHI members. A mandatory third party Traffic Victim Protection Act 1992 was carried by private for profit insurance companies. All vehicle owners are liable to mandatory pay a premium to the Scheme which covers treatment for traffic injuries and funeral grants for the victims. The loss ratio of this scheme was low, approximately 40%, with huge administrative expenditure and profit.
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3.3 Out-of-pocket payments When universal coverage was achieved and benefit packages were comprehensive, there was a rapid and significant reduction in the proportion of out-of-pocket payments, see NHA tables. Households are liable to pay out of pocket for services provided by public or private health care facilities not covered by the benefit package of the three public health insurance scheme e.g. private pharmacies, private clinic and private hospital or public provider network without referral from registered network (the self referrals); or for services in the negative lists announced by SHI and UC Scheme. Services provided by the contractor providers were free without copayment by UC and SHI members. There is no deductibles, no maximum ceiling of coverage, no extra-billing allowed by healthcare providers. However, some services such as dental care covered by SHI, 250 Baht reimbursable per service not more than two services per annum. Service beyond 250 Baht has implicit copayment. In 2010, SHI lump sum payment of 12,000 Baht per pregnancy for all related services such as anti-natal care, delivery, post natal care; there is a implicit copayment when the actual payment by members beyond the lump sum. Fee schedule for hemodialysis is 1,500 Baht per session, not more than 3,000 Baht per week; there is implicit copayment if the services fee paid by members beyond the schedule. These are SHI services covered outside the capitation for OP and IP services. Unofficial or under-table payment is not common and socially unacceptable. Services are literally free in all three schemes. There are still some practices of gratitude payment put in an “envelop” for the special private attendance by obstetrician during birth delivery particularly commonly practised by CSMBS members and the high income groups. Other envelop payment is very uncommon. Historically for the last fifty years since user charges were adopted in 1945, revenue generated by public hospitals from OOP was allowed by the Finance Ministry to be kept in these public hospitals. Revenue is not liable to transfer to the Treasury, but use of these revenues is regulated by MOPH or other ministries’ rule and subject to external audit by the Auditor Generals. Since the UC launch in 2002, UC members were liable to copay a flat fee of 30 Baht (US$0.7) per visit or admission; until a new government in November 2008 abolished this copayment not only for political reasons, some poor UC members who were supposed to be exempted from copayment but still had to pay due to poor exemption mechanisms. There are some attempts to introduce copayment for medical care for UC members chose to stay in private room, but the Council of State ruled unlawful as it is against the National Health Security Act. Hospital can only charge for the private room and board, but not medical care. Also there is current effort to introduce additional pay for medicines outside the national essential drug list (which is referred as the drug package for UC, CSMBS and SHI) or “brand products”. This was discouraged by the Government for fear of undermining the national essential drug policy and the lower cost generic products and may result in two tier systems, and non-confidence by patients in the non-copay systems. Argument in favour of cost sharing to discourage moral hazard by beneficiaries is counteracted by the fact that providers under close end provider payment methods, e.g. capitation for outpatient and global budget plus Diagnostic Related Group for admissions send strong signal over cost containment, and the fact of information asymmetry, it is very unlikely to see moral hazard by the patients.
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Other parallel systems are very small and mostly historical. For example, the State Railways runs a small hospital in Bangkok in its headquarter at Makasan, mainly providing services to their employees who are state enterprises; also the Tobacco Monopoly of Thailand also runs a small hospital in Khlong Toey. Employees and dependants of state enterprises applied the CSMBS rules and regulation. Voluntary charitable funds play an insignificant role in financing health in Thailand, mostly are small scale and has limited funding role, such as subsidized the poor who cannot afford to pay hospital bills in the old days prior to 2002 universal coverage. A Chinese Poh Tek Tung also mobilize charitable fund to maintain pre-hospital emergency services for traffic accidents. However, the emergency medical services system was formalized by the 2008 Emergency Medical Services Act. These services were fully funded by NHSO for the whole population. There is no specific financing for mental healthcare. All covered by the three insurance schemes, in particular acute psychotic patients who were admitted less than 15 days. Beyond this benchmark, funding is through national mental health programme, whereby the MOPH Mental Health Department is responsible for some 15 psychiatric hospitals throughout the country. However, the maximum 15 days acute psychotic admission for UC members were removed, for which it will take full effects in November 2010. Long term care is not well developed, there is no specific funding for long term care, and mostly not covered by public fund, households are responsible to support themselves either through home care givers. There are a very limited number of long term care hospitals.
3.4 External sources of funds External sources of fund is a tiny portion in Thai health financing system, only 0.1-0.3% of THE between 1994 and 2007 (Table 6). Usually, mostly funding from the Global Funds to fight with HIV/AIDS for fight HIV/AIDS epidemic, but still small scale compared to government budget on ART.
3.5 Equity in health financial contributions An EU funded EQUITAP study and subsequent studies conducted [17] [5], estimates a Concentration Index of various sources of healthcare finance in Thailand, using NSO SES data and National Health Account in its estimates, see Table 10.
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Table 10 Financing Sources for healthcare and their progressivity 2002 2004 2006 Financing sources
CI* Fraction** CI* Fraction** CI* Fraction** Direct tax 0.8221 0.20 0.8162 0.21 0.7687 0.23 Indirect tax 0.5594 0.38 0.5958 0.37 0.5512 0.33 Social insurance contribution 0.4975 0.06 0.4561 0.07 0.4492 0.08 Private insurance 0.3785 0.09 0.4221 0.09 0.4188 0.08 Direct payment 0.4883 0.27 0.4626 0.26 0.4705 0.28 Total 0.5719 1.00 0.5822 1.00 0.5593 1.00 Source [5] Note: * Concentration Index (CI) based on Socio-Economic Survey (SES: 2002, 2004 and 2006). CI ranges from – 1 to + 1, the closer to 1 the more progressive of financial contribution. ** Fraction of health expenditures by source was derived from Thailand National Health Account (figures in 2006 were estimated from 2005 data) CI, an index of the distribution of payments, ranges (-1 to 1), a positive (negative) value indicates the rich (poor) contributes a larger share than the poor (rich), a value of zero is everyone pays the same irrespective of ability to pay. Between 2002 and 2006, the proportion of total expenditure made up from direct tax payments increased from 20% to 23% while the share from indirect tax payments fell from 38% to 33%. The proportion from household direct payments remained unchanged, at 27-28%. Direct tax was the most progressive funding source, where the rich paid proportionally more than the poor, followed by indirect tax, and SHI contribution. Private insurance premiums and household OOP payment were both regressive. General tax finance (direct, indirect tax and other government revenues) was therefore progressive. As indicated in Table 10, the dominant share of general tax as a source of total health expenditure in Thailand resulted in an overall progressive system. The overall CI remained virtually unchanged over the three observations: 0.5719 in 2002, 0.5822 in 2004 and 0.5593 in 2006. The main reason why the SHI contribution was less progressive was the 15,000 Baht (approximately US$428) per month ceiling placed for the assessed contribution. This ceiling has never indexed or revised since the 1990 SHI inception, resulting in consistent movements towards less progressivity as workers’ wages have increased.
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4. How money is pooled, allocated and purchased?
4.1 pooling agencies and allocation There are four major insurers, Comptroller General Department for CSMBS, SSO for SHI, NHSO for UC scheme, and private insurance firms for voluntary health insurance schemes. These agencies play two roles, pooling funds and also purchase services on behalf of their respective members. Figure 6 Flows of funds to pooling agencies are described below.
In Figure 6, SSO play double roles, collective revenue and pooling, through mandatory electronic transfer by employers of the payroll tax contributions on a monthly basis by themselves and the equal portion deducted from the employee wages. Also SSO received on an annual basis the government contribution as part of the tripartite financed scheme, also annual operating budget for SSO, as it is one of the Departments under the jurisdiction of the Ministry of Labour. However, CGD responsible for CSMBS and NHSO for UC schemes did not have collection role, but got annual budget allocation from the government through annual Budget Act. Private insurance companies also play double roles, collecting premiums from their member on an annual basis, pool them and purchase services for their members.
Private insurance
NHSO
SSO
CGD
Bureau of Budget
Revenue departments
Private insurance members
Pooling / purchasing agencies
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The characteristic of the market structure of pooling and purchasing is “multiple non-competing insurers/purchasers”. Multiple natures as there are four purchaser agencies. Non-competing as each of the three insurers cover three distinct populations, namely the private sector employees are mandatory covered by SHI, public sector employee by CSMBS, and the rest of the population by UC scheme. There three public insurance schemes are not competing for members. Unless when the SHI members become unemployed, they would be automatically transferred to UC Scheme, or child dependants of CSMBS when reaching beyond 20 years would be automatically transferred and covered by the UC scheme. However, when UC members are employed by private sector, they would be covered by SHI and removed from the UC scheme. Members of these three public insurance schemes are not allowed to opt out from the schemes; though they can free to enrol in the voluntary private health insurance schemes. The size of budget for UC scheme was negotiated annually between the NHSO and Budget Bureau, decision is made by the National Health Security Board, chaired by the Minister of Health. The budget is proposed on the estimate total expenditure per UC member in the year concerned, based on the last year utilization rate of outpatient, inpatient and projection to the concern budget year, and the unit cost of outpatient and inpatient, also other components such as prevention and health promotion services. In the past years, budget increased as a result of significant increase in service utilization and labour cost as a result of annual six percent government salary adjustments and inflation of other medical products. The size of budget for CSMBS was proposed by the CGD based on historical total expenditure trend and projection to the budget year of concern. However, as a result of fee for service for OP, although IP is paid on conventional DRG, there were significant cost escalations for outpatient services. CGD over spent the approved budget, but cross subsidized by the Central Fund earmarked for contingencies such as flood, drought. Recently, cross subsidy is not permitted by the Constitution, and legal approval for overspending is required by the Parliament. The per capita expenditure for SHI is fixed by SSO and adjusted every few years. Similar to UC scheme, the SHI estimate per capita total expenditure for the next year based on service utilization rate and unit cost of services, including some other service components covered outside the capitation. Other parallel government health systems such as Ministry of Public Health for public health programs, Ministry of Defence for arm force medical services and Ministry of Justice for prison medical services are based on annual budget allocation, based on historical budget with slight adjustment.
4.2 Mechanisms for allocating funds among pooling/purchasing agencies Three public insurance purchasers have distinct purchasing mechanisms. UC scheme estimated age adjusted capitation for outpatient services to a contractual unit, typically a district health provider network (including district hospital, and 10-12 sub-district health centres) based on number of total registered members with the network. NHSO also set a national global budget ceiling for admission services, and based on electronic submission of every inpatient discharged from hospitals the information on DRG and its respective relative weight, that NHSO on a monthly basis, reimburses the total fund for admission services incurred to individual hospital throughout the country. There are also some other additional
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pay such as high cost services, e.g. bone marrow transplantation, for which a fee schedule is applied to certified providers. Annual budget allocated to providers by NHSO is a “hard budget”, it is not possible to pay beyond what is negotiated and approved, by the end of the year, budget for medical services were fully disbursed and cannot be carried forward to next fiscal year. Table 11 shows the approved budget per capita UC members, slowly increased from US$ 35.4 in 2003 to US$ 73.5 in 2010, the annual growth rate ranged from 5.2% in 2009 to 18.8% in 2006. Table 11 Different components of approved budget per capita UC member, 2003-2010, nominal price. 2003 2004 2005 2006 2007 2008 2009 2010 OP 47.7 37.3 38.2 35.1 33 29.6 29 30.2 IP 25.2 32 31.2 27.7 26.2 38.7 36.5 35.8 Prevention-Promotion 14.6 15.7 15 13.6 12.7 11.6 11.4 10.9 High cost 4.7 6.6 8.9 14.7 13.3 6.7 7.8 7.4 Other 7.8 8.4 6.7 8.9 14.8 13.4 15.3 15.7 Total 100% 100% 100% 100% 100% 100% 100% 100% Baht per capita* 1202.4 1308.5 1396.3 1659.2 1958.3 2184.7 2296.3 2497.3 US$ per capita 35.4 38.5 41.1 48.8 57.6 64.2 67.5 73.5 Annual growth,% 8.8 6.7 18.8 18 11.5 5.2 8.8 Source: NHSO various years Note: * include all items of special payment such as dialysis, ART and other additional pays. SHI allocates non-risk adjusted capitation inclusive for OP and IP services to contractor hospital based on the number of registered members with that contractor. Public and private hospitals are competing contractors for SHI members, though private contractors had higher share, 65% of total SHI members. Members have choices to change the registration with their preferred contractor provider once a year or when they change their employer, or domicile to facilitate better access to care. In return, contractors have to report the service output both OP and IP (including DRG information) to the SSO on a monthly basis. The number of registered members was monthly updated, both in and out from the contractor. Though the capitation budget allocated to contractor hospitals is a “hard budget” for services covered by capitation where there is no additional pay, SSO pays incentive to contractor providers for percentile of utilization rate, from 30 to 70 percentiles to provide incentives to high utilization contractors. SSO also compensates high risk beneficiaries registered to each contractor for some selected chronic conditions, See table 12. Additionally, there are pays to providers based on fee schedule such as dialysis and other high cost cases. These additional pays aim to mitigate the negative impact of capitation on under-provision of services.
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Table 12 SHI per capita budget for contractor: 2000 to 2009, Baht at current year price 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Capitation 1,100 1,100 1,100 1,100 1,100 1,250 1,250 1284 1,306 1,404, plus 77
Source: SSO various annual reports CSMBS has limited capacity to act as a pro-active purchaser, it reimburses directly to healthcare providers for outpatient bills on a monthly basis since 2007. Before 2007, it is a fee for service reimbursement to CSMBS members, when members have to pay for service upfront and reimburse later. For admission services, CGD did not set up a global budget ceiling, but fully applies a conventional DRG style, the reimbursement rate per Relative Weight varies hospital by hospital. Individual hospital has different compensation per DRG relative weight. As a result, expenditure both for OP and IP increased significantly in particular OP expenditure. CGD applies “soft budget” as in the past 15 years, it over spent than the total annual budget approved. VHI purchases services mostly from private providers. However, it introduces implicit copayment as there are ceiling for all items of services, e.g. room and board, medical and surgical interventions.
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5. Who spends the money? Purchasing and purchaser-provider relations The dominant form of organizational relationship between purchasers and providers in Thailand is contract model, except some government parallel systems apply integrated model such as the State Railway set its budget to purchase services from its own State Railway hospital in Makasan. The State Railway employs its own hospital staffs and provides annual budget to finance the operation. Also Department of Correction prisoner medical services owns a number of hospitals, employs staffs and fund directly. However, these parallel systems play a very small provision role. In the contract model, public and private health care providers are independent from and are contracted by the third-party payers--in this case: the CGD for CSMBS, SSO for SHI and NHSO for UC Scheme. There is a separation between purchaser and provider function in the contract model, as commonly referred to as “purchaser provider splits”. Table 13 Number of hospitals and health centres by different ministries, 2007 Bangkok Regional 75 Provinces 1. Hospitals • Bangkok Metropolis authority/ municipality 8 - - • Medical schools 5 6 • MOPH Specialized/Regional / provincial hospitals 18 72 70 • MOPH District hospitals 731 • Other Ministries 10 - 60 • State enterprise 4 - Total hospitals 45 78 861 2. Health centres • Bangkok metropolis admin./municipality 77 - 214 • MOPH health centres - - 9,762 • MOPH community health post - - 311 Total health centres 77 - 10,287 The MOPH owns a lion share of healthcare provision in Thailand, particular 731 district hospitals, 70 provincial hospitals, 72 regional and specialised hospitals located in 12 public health regions, as well as 18 national referral- and specialised hospitals in Bangkok. See table 13. These public healthcare providers earn their revenue from the three public health insurance schemes, also additional revenue from OOP paid by patients who opted out their entitlement. After the 2002 launch of UC scheme, there is no more supply side financing. SHI, CSMBS and UC scheme fully apply demand side financing.
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Table 14 Summary detail of contracting mechanism for UC scheme and SHI UC scheme SHI Contractor agency
National Health Security Office, national level
Social Security Office, national level
Service under contract
OP services and prevention and health promotion services
Inclusive OP and IP services
Catchment population
Typical: population reside in the district. For internal migrant workers to other provinces/ districts, they are registered in their preferred provider network.
No catchment areas, contractor providers compete for registered members through marketing and advertisement.
Contractor providers
Typical: District health provider network including district hospital and all 10-15 health centres in the district
Competitive public private contractor hospitals >100 beds with all other quality requirement posed by SSO
Type of contract
Block contracts, annual contract based on agreed capitation rate for outpatient services to a defined number of registered UC members, regardless of utilization
Block contract for inclusive outpatient and inpatient service for a year regardless of number of services rendered to a defined number of SHI member registered with the contractor. For outpatient, in addition to block contract, volume contract is given based on the percentile of OP utilization, for incentives not to under provision of service.
Term of contract
Annual contract renewal every year, members can choose to register
Usually annual,
Choices of members
Annual choice to register elsewhere Annual choice to register elsewhere
Monitoring contract
Monthly electronic reporting of throughput, number and profile of outpatient visits
Monthly electronic reporting of throughput, number and profile of outpatient visits
How contract is developed?
Capitation rate for OP is based on utilization rate and unit cost of services projected to the contract year
Capitation rate is a combination of utilization of OP and IP and unit cost of OP and IP
Enforcement of violation
Due to geographical monopoly, there is no choice by NHSO not to contract the only MOPH district provider network in that district. Application of positive engagement for quality and services improvement and responsiveness, social pressure and social accountability are often found useful
Competitive market, members are urban residents, where there are competing qualified public and private contractor hospitals. Termination of contract in subsequent year (never been implemented by SSO), or reduced number of registry quota (implemented sometimes).
Choices of contractor agency
Not much choices in rural areas, geographical monopolies is a problem, however, MOPH district health providers are non-profit, so far there is no much problems
Competitive market
Rules and standards
Same rule for all public and private contractor providers
Same rule for all public and private contractors
Table 14 summarizes the key characteristics of contracting mechanism for UC scheme and SHI. Despite SSO is the predecessor of NHSO in term of contract experiences; the NHSO outperformed in their design, implementation and enforcement of contracts, as there are no medical personnel in the SSO, while NHSO staffs, not only medical background, but having huge experiences in managing public health at provincial and MOPH levels.
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In the CSMBS fee for services systems, the CGD applies the MOPH national standard fee schedule for services update every 4-5 years (e.g. laboratory, surgical and medical interventions and percent mark up of medicines) for MOPH providers for OP services. Though there is no standard fee schedule produced by other non-MOPH public hospitals, CGD applies and endorses the MOPH fee schedule to all other non-MOPH public hospitals as a national fee schedule. Update by MOPH requires approval by the CGD. Enforcement of overcharging and increased volume of unnecessary services are difficult. Observation found supplier-induced demand, for example, excessive use of non-essential medicines, brand products (which is 5 to 10 times more costly than respective generic versions) and longer length of stay. Particular when hospitals directly reimburse OP expenditure directly to the CGD, there is no financial barrier by the users, one observes a rapid cost escalation in 2008 when direct disbursement was launched. Attempts to reform CSMBS provider payment failed since 1994 to date due to entrench benefit and interests by various stakeholders. Figure 7 provides a classic example of CSMBS cost escalation as a result of fee for services with no copayment or maximum ceiling of service benefit. Figure 7 CSMBS expenditure, 1990-2008, nominal price
CSMBS expenditure, 1990-2008, nominal price
0
10,000
20,000
30,000
40,000
50,000
60,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
mill
ion
Bah
t
OPIPTotal
Source: CGD various years Direct disbursement for OP service started in 2004 for some chronic diseases only, later in 2006, it extended to the pensioners and finally in 2007 direct disbursement was applied for all CSMBS members
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6. How different services and personnel were paid for: various payment methods
6.1 Paying for health services Table 15 describes how different health services were paid for by three public insurances schemes as well as the voluntary health insurance schemes. We observe that there are harmonization of payment for health services by NHSO and SSO as they applied the close ended provider payment contract mode while the CGD applied fee for service opened ended provider payment for outpatient services and conventional DRG for inpatient services.
6.2 Paying for healthcare personnel Table 16 describes how different health personnel who worked in different level and public and private health care services were paid no matter what sources of finance the providers generated. There is quite a large gap of discrepancies across different public sector and between public and private providers. This information leads towards how to harmonize paying personnel and keep them work productively in the organizations.
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Table 15 paying for health services Paying for services
Universal Coverage scheme Social Health Insurance CSMBS* Voluntary health insurances
1. Primary/ ambulatory care
Capitation to contractor provider network (mostly district health providers including the district hospital + all health centres or Primary care units in the district) based on number of registered beneficiaries. Capitation rate is based on utilization rate and unit cost of services in the previous year, annual negotiated between NHSO and Budget Bureau. Downstream allocation to contractor provider network is based on age adjusted capitation for OP services. Additional fee-for-service payments in case of specific services and medical equipments
Inclusive capitation for ambulatory care, admission based on number of registered beneficiary to competing public and private hospitals (having more than 100 beds and other facility and professional requirement). Additional risk-adjusted fix pay per beneficiary for effective managing chronics and high cost diseases, additional pay per beneficiary for utilization in the past year Additional fee-for-service payments in case of specific services and medical equipments
Fee for services, directly reimbursed to providers not beneficiaries. Note, only public providers are eligible.
Fee for services with varying conditions, more favourable benefit for higher premium
2. Inpatient care Annual global budget was set based on utilization and unit cost, within this budget, case base payment based on actual relative weight points earned by providers (mostly public) Additional fee-for-service payments in case of specific services and medical equipments
Inclusive capitation for ambulatory care, admission Additional fee-for-service payments in case of specific services and medical equipments
Prior to 2008, conventional fee for services for items of services, with combination of fee schedule for room and board, medical appliances, and other specialised services. Conventional DRG was applied recently 2008, Baht per relative weight was announced upfront.
Fee for services with ceiling of total reimbursement per admission
3. Prevention and health promotion [personal preventive and health promotion services]
Capitation for providers (mostly public) covers the whole Thai population (not only UC members) as a national scheme
Covered by NHSO Covered by NHSO Not covered
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Paying for services
Universal Coverage scheme Social Health Insurance CSMBS* Voluntary health insurances
4. Maternity and pregnancy including antenatal care and post-natal care
Covered in inpatient care Additional fix pay for antenatal services, delivery and post-natal care, per confinement to beneficiary, not more than 2 confinements
Covered in inpatient care Mostly covered in inpatient care
5. Renal replacement therapy
NHSO negotiate purchase of peritoneal dialysis solution through Government Pharmaceutical organization deliver to district hospitals. NHSO purchases hemodialysis from public private centres based on fix fee, copayment is fixed per hemodialysis session by NHSO
Additional pay, fix fee per session of dialysis, free choices by beneficiaries, no control of provider fee, implicit copayment when actual fee beyond the rate given by SSO
Similar arrangement to SHI, separate additional pay, fix fee per session of dialysis (but higher than SHI), free choices by beneficiaries, no control of provider fee schedule, implicit copayment when actual fee beyond the rate given by CGD.
Not covered
6. Antiretroviral services
NHSO purchases anti-retroviral medicines through Vendor Managed Inventory, additional pay to providers for VCT, viral load tests, registration of patients required
SSO purchases and distribute anti-retroviral medicines to providers, additional pay to providers for VCT, Viral Load tests, registration required
Fee for services methods, covered in ambulatory care
Not covered
7. Public health services
National program responsible by MOPH e.g. diseases surveillance, covered the whole population
By law, services not covered, it is covered by national program
By law, services not covered, it is covered by national program
Not covered
8. Pharmaceutical care
Pharmaceutical benefit referred to medicines in the national Essential Drug (ED) List is fully covered in capitation fee for ambulatory care and global budget + case base payment for inpatient services
Drug benefit referred to National ED lists. Drug payment is included in the inclusive capitation for ambulatory and inpatient services
Drug benefit referred to National ED lists. Fee for services for drugs in ambulatory care, and DRG for admissions
Covered in ambulatory and admission care
9. Rehabilitation covered in OP and IP budgets, fee schedule for community rehabilitation from a separated rehabilitation and disabled budget.
covered in the capitation budget fully covered in facilities
10. Long term care Not covered Not covered Not covered Not covered 11. Emergency
Medical Services [pre-hospital care]
NHSO proposes budget for pre-hospital care and referral to its beneficiaries, fee per three different types of services
Not covered Not covered
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Paying for services
Universal Coverage scheme Social Health Insurance CSMBS* Voluntary health insurances
12. Dental care Covered except costmetic procedures and integrated in the ambulatory care payment
Fee for services with ceiling, two services per annum
Not covered except a few basic dental services
Mostly not covered
13. Mental health care
Fully covered in ambulatory care. For admission, acute psychotic is covered not more than 15 days of admission [though this is abolish and will take effect in November 2010], beyond this limits, covered by national Psychiatric program based on annual budget allocation
Aute psychotic is covered not more than 15 days of admission
No limitation, fully covered by ambulatory and admission
Not covered
14. Healthcare for special population, e.g. prisoners, military personnel
Not covered, medical services for prisoners are covered by Department of Correction, routine budget allocation, the Department also manages some hospitals, or referral to MOPH hospitals for which payment is mostly fee for services
Civil servants, military personnel and their dependants are fully covered by CSMBS
* There are increasing numbers of local government officials and employees of independent public organizations. The provider payment mechanism often applies the CSMBS reimbursement model. Any reform in the CSMBS may have effects to these groups.
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Table 16 paying for health personnel Category of professionals
Primary health care centre
MOPH district hospitals
MOPH provincial/regional hospitals
University hospitals
Private sector: private clinics
Private sector: hospitals
1. Medical doctors in clinical services
No MD at this level of care
Mostly non-specialists, they are salary paid (salary scale is standard for all civil servants across sectors, based on grade when entry to service), additional pay includes non-private practice allowance, over time allowance, hardship allowance, lump sum allowance. Specialty allowance
Mostly specialists, salary paid, similar salary scale as a civil servant, grade are higher than district hospital doctors due to seniority and specialist training. Other allowances similar to that of district hospital though neither hardship nor lump sum allowance are eligible
Mostly specialists, recent reforms when most university hospitals become autonomous body, higher salary scale than civil servant (1.4 times higher), other allowances
Private clinics provide diagnosis and dispensing medicines. Charges for service include doctor fee and dispensing medicines,
Different modes, most common is fee for service with minimum monthly guarantee. Rate of pay varies by seniority and specialty, e.g. fee per consultation, surgical fees or anaesthesiologist fees. Other modes are payment per session of service, e.g. 4 hr. of OP consultation.
2. Professional nurses
They can be either civil servants or non-civil servants depending on availability of civil service posts. This means they will be introduced to the same payment mechanism as professional nurses in district hospitals.
Civil servants are salary paid plus other allowance such as hardship allowance, allowance for deficit health professions (พตส.), in addition with overtime payment. Non-civil servant e.g. contract staffs are salary paid but higher rate than civil servant as they are not entitle to medical and pension benefit.
Similar to that of MOPH district hospitals. Usually higher income from over time shifts (and private practices).
When university hospitals become autonomous, nursing staffs are contract staff (non-civil servant status), are salary paid (with higher scale than civil servants), plus other allowance and incentives
Not common Salary paid, plus other incentives such as nursing license, or specialisation such as nurses in Intensive Care Unit, Cardiac Care Unit, Dialysis unit; plus other allowances, annual bonus
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Category of professionals
Primary health care centre
MOPH district hospitals
MOPH provincial/regional hospitals
University hospitals
Private sector: private clinics
Private sector: hospitals
The rest of that they will get the same allowances and pay as those government officers.
3. Dentists Dental nurse, or dental assistants are usually civil servants, they are salary paid.
Similar to doctors in district hospitals, almost all are civil servants and salary paid, plus other incentives, e.g. overtime payment, hardship allowance, non-private practice incentives, and lump sum allowance,
Similar to those work in district hospitals
Status and payment are quite similar to that of doctors in university hospitals
Private dental clinics earn living from dental services, based on fee for services for different services rendered. The fees cover medical supplies, material and their wages
Almost all paid based on doctor fee for different services provided, annual bonus
4. Pharmacists Not applicable at this level.
Mostly they are civil servant, but increasing number of contract staffs, all are salary paid, with a lower level of incentives and allowance compared to doctors and dentists
Similar to those work in district hospitals
Similar to those work in provincial hospitals
Pharmacists in private pharmacy earn living from selling prescribed medicines and over the counter medicine based on fee for services for each item of medicine, for which the mark up covers their wage. The mark up varied greatly.
Salary paid, plus other incentives such over time payment, and annual bonus
5. Public health workers
Salary paid as most are government officials
Salary paid as most are government officials
Salary paid as most are government officials. However, not so many staffs in provincial hospitals
Not applicable Not applicable Not applicable
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Category of professionals
Primary health care centre
MOPH district hospitals
MOPH provincial/regional hospitals
University hospitals
Private sector: private clinics
Private sector: hospitals
6. Allied professionals: physiotherapists, therapists, medical technologists
Not applicable at this level of care
Salary paid as most are government officials
Salary paid as most are government officials
Salary paid, contract staffs in autonomous university has higher salary scale than civil servants
Not applicable Salary paid with over time payment
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7. Future challenges Despite success on coverage extension to the whole population in 2002 and equitable outcome of the reforms; three main challenges were identified for which they require policy attentions.
7.1 Managing Cost Drivers Despite positive cost containment outcomes for SHI and UC schemes due to strategic purchasing; three cost drivers challenge the long term financial sustainability as the majority of financing comes from general tax revenue. Demographic transition: the proportion of the elderly (more than 60 years) has increased from 5.4% in 1960 to 11.8% in 2010 [18]. Service utilization rate among elderly is 2.3 times that of general population. With an increased proportion of elderly, there has been thus a substantial increase in demand for health services. Epidemiological transition: The 2004 Burden of Diseases confirms the 1999 BOD studies that non-communicable diseases contribute to Disable Adjust Life Year (DALY) loss more than communicable, nutritional, childhood and maternal diseases and injuries (The Thai Working Group on Burden of Disease and Injuries, 2007). Proportion of DALY attributed to non-communicable diseases to overall DALY also increased from 58.9% in 1999 to 65.7% in 2004. It is not possible to halt demographic transitions; however maintaining a healthy ageing population through effective primary and secondary prevention of chronic NCD for the middle age groups can minimize the future demand for such expensive services [19]. Effective interventions are needed to tackle shared risk factors, namely: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol and, therefore, have to influence not only health policies but also feature prominently in public policies [20]. Despite the cost-ineffectiveness of renal replacement therapy for UC members who have end-stage renal diseases; inequity across insurance schemes, catastrophic health spending and impoverishment to households prompted the government to adopt dialysis into the benefit package of the UC scheme in 2008. Once adopted, it is not possible to withdraw from the benefit package except in the future where co-payments may be introduced.
7.2 Managing Benefit Package Even rich governments cannot afford to keep abreast with and adopt all of advance health technologies. There is a need for institutional capacity to generate evidence on effectiveness, cost effectiveness and long term budget impact of new health technologies to guide decisions on benefit package. The Health Intervention and Technology Assessment Program (HITAP), a budding unit of IHPP will, in the future, evolve as a national focal point in technology assessment of the country [21]. Two major decision platforms worth mentioning, first the National Subcommittee on Essential Drug (ED) List which reports its work to the National Committee on Drug Systems Development chaired by the Prime Minister is responsible to review and update which
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medicines are listed in the national ED list. The ED is referred to by all three insurance schemes as drug benefit package, requires evidence on cost effective comparison to be included or excluded from the List. Second, the Sub-committee on Benefit Package which reports to the National Health Security Board chaired by Minister of Health, is responsible to review and update, including and excluding health interventions into the benefit package. The assessment of interventions will involve a broad base stakeholder engagement on topics submission and selections, for example, policy makers, royal colleges, industries, civil society, patient groups and general lay public. The results of technology assessment would be submitted to the two sub-committees for their reviews and further decision by relevant bodies. The performance of the two sub-committees ensures that benefit package is updated based on hard evidence. The societal benchmark is adopted and an intervention is deemed cost effective and worth public investment if its cost does not go beyond one GNI per capita to gain one QALY from the said intervention [22]. 7.3 Managing health systems There is a need to actively manage health systems in response to demographic and epidemiological transitions. In the context of adequate and equitable distribution of health infrastructure, there is no significant need for new infrastructure except maintenance for effective operations. The current health systems performance has been hampered by limited human resource in comparison to other middle income countries, using the human resources for health to population ratio. The human resource shortage problem is aggravated by the inequitable distribution across geographical regions, though the gap gradually reduced. In the context of trade in health services and regional trade agreement in the ASEAN, there is a major trend of outflow of experienced professionals from public to private sectors within the country and through migration outside the country. The health systems are not very well equipped to provide high level of effective coverage of essential interventions for chronic NCD, in particular diabetic and hypertension. For example, the 3rd National Health Examination Survey in 2004 reported that only 36.7% of total patients with high blood pressure and 29.2% of total diabetic patients have adequate control of their conditions. Although the 4th National Health Examination Survey in 2009 reported a substantial improvement; 50.6% of patients with high blood pressure and 54.5% of diabetic patients, there is still room for improvement. There is also limited financial and systems investment as well as lack of effective interventions in keeping the pre-elderly population group stay healthy in order to move toward healthy elderly. Long term care and the effective referral to and from acute hospital care and community based care to accommodate increasing frail elderly who need health and social support require clear policy and significant investment. Intersectoral actions between health and social welfare departments are yet to be strengthened.
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Despite a clear policy of NHSO to strengthen primary health care, the quality of health services provided by primary care provider has still not satisfied or created public confidence. Devolution of health centres, which are the main public primary care providers in the rural area, to work under the direct supervision of local authorities, has started since 2007 but without any progress. However, according to the Thai Constitution of 2007, devolution of health service provision to local authority especially at primary health care level seems to be unavoidable and could affect health systems management.
8. Conclusions The 2010 health financing review provides a snap shot on the sources of financing in Thailand. After UC was successfully achieved by 2002, the whole population is covered by one of the three public insurance scheme, as well as voluntary private health insurance. The financing healthcare is dominated by general tax revenue, which is one of the most progressive sources of funding. The level of THE, as percent of GDP, is modest; this is within the fiscal capacity of the country to afford in long term, see long term projection of total health expenditure by 2020. One of the strengths of healthcare financing is strategic purchasing, with the application of capitation contracting model as major mode of provider payment for SHI and UC Schemes. Compared to fee for service reimbursement model, capitation contracting model has better prospect of long term cost containment [23] Benefit package provided by the three public insurance schemes is generous and comprehensive, almost all health service including high cost care are included; though a few items of negative exclusion list are excluded such as cosmetic surgery. Comprehensive coverage where services are provided free of charge results in extremely low prevalence of catastrophic health spending and impoverishment; the poor resided in rural areas had better access and use of health services from the district health provider network which serves as a “close to client service” results in pro-poor public budget subsidies. The administrative costs of the UC and SHI schemes are very low as NHSO relies on annual budget approval through the Budget Act processes, and SSO collects revenue from mandatory monthly wire transfer from the employers. The purchasing functions when apply the capitation contract model, the administrative cost is much less where there is no need to review and approve claims as is the case of CSMBS fee for service reimbursement model. Benefit package was harmonized across three public insurance schemes facilitate movement of members from one to another scheme, provider payment is better harmonized between SHI and UC scheme, while CSMBS is still outstanding when it applies fee for service direct disbursement for OP services, although CSMBS applies DRG systems for hospitalization similar to that of the UC Scheme.
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