Ekachai Piensriwatchara, MD.

Walaiporn Patcharanarumol, PhD.

17 July 2017

Yokohama, Japan

Universal Health Coverage:

Thailand experience

2

ASEAN-Japan 15 July 2017

Statement of the Minister of Public Health, Thailand

1. With strong political commitment, UHC can be started and

achieved at low level of income

2. Peace and sustained economic growth mobilized ‘more

money for health’

3. Universal access to good quality essential health services is

the real goal

4. Strong capacity on health system and policy research

5. Participatory governance systems ensures real ownership

3

1. UHC can be started and achieved

at low to middle income level

29% 42% 53% 70% 100%Population coverage

4

2. Peace and sustained economic growth

mobilized ‘more money for health’

5

13.5

*Security

22.6

16.1

13.113.7

13.2

24.7

*Debt serv.

8.2

5.0 5.3

9.112.5

24.4

17.9

*Education

16.9

25.8

23.5

21.8

8.1

4.34.14.25.1

4.43.23.4

2.9

*Health

4.4

7.6 7.87.1

0

5

10

15

20

25

30

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

From security and debt service budget to healthP

erce

nta

ge

Year

Source: Bureau of Budget; Dr.Suwit’s presentation 30 Sept 2011

6

More budget to health

1972

1990

2004

Government budget Budget for health

29,000 mil. ฿

986.6 mil. ฿(3.4%)

16,225.1 mil. ฿(4.8%)

335,000 mil ฿

77,720.7 mil. ฿ (78x) (8.1%)

1,028,000 mil ฿

(35x)

2011 Budget

for health rose

to 13% of

government

budget

7

1,659

1,899

2,1002,202

2,4012,546

3,0283,109

1,3961,308

1,202 1,202

2,7552,895

-

500

1,000

1,500

2,000

2,500

3,000

3,500

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Continued political commitment to UC Scheme:

Budget, Baht per capita, by Regime 2002-20178 governments, 13 Health Ministers, 11 Permanent Secretaries

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

G 1 G 2 G 3 G 4, 5 G 6 G 6, 7 G 7 G 7, 8 G 8

M 1 M 2 M 3 M 4 M 5-7 M 8 M 9 M 9 M 10 M 11 M 12 M 12 M 13 M 13

8

3. Universal access to good quality essential

health services is the real goal

• Free but inaccessible health services and/or poor

quality is not UHC.

• Thai’s UHC focuses on Primary Health Care.

• Evolution of rural health systems since before UHC

– 780 district hospitals: one district hospital per district

– 9,777 health centers: one health center per rural commune

• Rapid increase in HRH training, i.e., doctors, nurses,

voluntary health volunteers, etc, through “rural

recruitment, local training and hometown placement”

and compulsory public work for graduates with

adequate motivation and incentives;

9

District health system: hub for pro-poor outcomesThe Lancet 2013;381:2118-33.

community

temple

school

Local authority

private sector

Rural

Health facilities

Rural health centers with 3-6 nurses and

paramedics cover 2,000-5,000 population

Rural community hospitals with 2-8

doctors cover 30-80,000 population

1. Health promotion

2. Disease control

3. Health care

4. Rehabilitation

5. Consumer protection Pri

ma

ry h

ea

lth

ca

re

10

Huge increase in access to primary care

46%(5.5)

29%(3.5)

24%(2.9)1977

Regional / General Hospital

Rural Health Centres

District Hospital

27%(11.0)

35%(14.6)

38%(15.7)

1987

200046.1%(51.8)

35.7%(40.2)

18.2%(20.4)

201054.0%(78.0)

33.4%(33.4)

12.6%(18.1)

Regional / General Hospital

Rural Health Centres

District Hospital

Regional / General Hospital

Rural Health Centres

District Hospital

Regional / General Hospital

Rural Health Centres

District Hospital

Note: (number of OP visits in million)

Source: Suwit’s presentation on 30 Sep 2011 and updated 2010 data

11

4. Strong capacity on health system and policy research

• Home grown technical capacities

– Designing and implementing UC scheme

• Provider payment methods: capitation, DRGs, fee schedule

• IT to support UHC

• Medical audit

– Priority setting using many tools, including health technology

assessment, budget impacts, supply side readiness,

– Monitoring progress of UHC

• Population coverage using citizen ID of CRVS; everyone is count

• Service coverage -> effective coverage of 6 conditions: HIV, TB,

cervical cancer, DM, Hypertension, cerebrovascular disease

• Financial risk protection: catastrophic and medical impoverishment

12

UC Scheme achievements

• Some key achievements

• Improved equity in financing healthcare;• Health Research Policy and Systems 2013;11:25

• Increased access to care by beneficiaries; • Journal of Public Economics 2015;121:79-94

• Pro-poor utilization and benefit incidence; • BMC Public Health 2012; 12(suppl 1): S6

• Preventing non-poor households become poor from medical bills; • Bulletin of the World Health Organization 2007; 85: 600–6

• Gaining efficiency and cost containment;• Economic & Political Weekly 2012; 47: 53-7

• UCS flourishes despite eight rival governments, six elections, two

coup d’etat, thirteen health ministers, between 2001-2015

• UCS gradually owned by the people, not political party who initiated it.

13

New interventions assessed for service coverage Contribution by IHPP and HITAP

Interventions (Indication)

Cost-effectiveness Budget impact

UC Scheme coverage

Lamivudine

(Chronic hepatitis B)

Cost-saving Low Yes

Cyclophosphamide + azathioprine

(Severe lupus nephritis)

Cost-saving Low Yes

Peg-interferon alpha 2a + ribavirin

(Chronic hepatitis C)

Cost-effective

(ICER=86,600*)

High No

Adult diapers

(Urinary and fecal incontinence)

Cost-effective

(ICER=54,000* )

High No

Anti IgE (Severe asthma) Cost-ineffective High No

Implant dentures Cost-effective

(ICER= 5,147*)

Low No

Note: * Threshold: ICER = 160,000 ThaiBaht per QALY

Source: UC Benefit package project

14

Incidence of catastrophic health spending >10% of household expenditure, before and after UC Scheme in 2002

Health Research Policy and Systems 2013;11:25

15

Sub-national health impoverishment 1996 to 2008

16

5. Participatory governance systems ensures real ownership

• Voices of people

– Board of UC scheme: 5 seats from civil society (out of 30),

chaired by the Minister of Health

– satisfaction survey of providers and patients

– Call Center 1330 of UC Scheme

– Annual public hearing at the national level, regional level and

now extend to provincial level

Call Center 1330 of UC Scheme Public hearing of UC Scheme

17

(%)

Satisfaction of UC beneficiaries & health care providers

Source: NHSO

83 83.483.284.083.188.389.389.8

92.890.895.596.62

45.639.3

47.750.9

56.550.7

60.3

78.8

66.968.567.6 64.4

0

10

20

30

40

50

60

70

80

90

1002003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

UC people

provider

18

• UHC is context specific – learn from others and adapt but not copied

• Political and financial commitment is the key factors – on both health systems development and financial protection

• Ensuring equitable access to and good quality of health care services is as important as the financial protection

• The success of UHC depends much on the spirit of committed health workers not only money

• National capacity for evidence based policy is really needed

Summary

19

Situations that lead to reform

Triangle that moves the mountain

1997 Constitution

Politics(Window of opportunity)

2001 general election

Social mobilization

A civil proposal on

UC

1993, 1996,1997

HCF workshops

Evidences& capacity

HSRI 1992

HCRP (EU)1998-2000

SIP (WB)1999-2001

UC working group 2000

Experiences SSS & HCS

IHPPHITAP

HISRO

20

Thank you for your attention