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Evaluating ten years of universal health coverage in Thailand. Viroj Tangcharoensathien, MD. Ph.D. Phusit Prakongsai, MD. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health of Thailand Presentation to the 13th Annual Scientific Conference (ASCON XIII)

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Evaluating ten years of universal health coverage in thailand

Evaluating ten years of universal health coverage in Thailand

Viroj Tangcharoensathien, MD. Ph.D.

Phusit Prakongsai, MD. Ph.D.

International Health Policy Program (IHPP)

Ministry of Public Health of Thailand

Presentation to the 13th Annual Scientific Conference (ASCON XIII)

ICDDR,B, Dhaka, Bangladesh

15 March 2011

Objectives Thailand

  • Review achievements of universal coverage

  • Propose a conceptual framework for 10 years UC assessment [2001-10] to generate evidence and stimulate international debates

Background 1
Background 1 Thailand

  • Thailand,

    • LMIC, GNI/capita 3,760, THE: US$136/capita, 3.4% of GNI, OOP<18% of THE (2008)

  • A long march: 27 years of gradual coverage extension

    • Application of piecemeal targeting approaches

      • The poor, children, elderly, vulnerable: tax financed social welfare schemes

      • Formal sector

        • Civil servants and family: tax financed medical welfare

        • Private employee: payroll tax financed SHI

      • Informal non-poor sector : CBHI, transform to public subsidized voluntary insurance

      • The 30% uninsured was “last pushed” by general tax financed scheme

  • By 2002 Thailand achieved full population coverage, by 3 public insurance schemes

    • Formal sector

      • Private employee by SHI

      • Civil servants and dependants, tax financed scheme.

    • The rest of population by tax financed scheme, free at point of service

Background 2
Background 2 Thailand

  • Strong institutional capacities

    • Generate evidence and evidence informed policies

      • Policy relevance researches

      • Maintaining normative works

        • NHA, BOD, National Drug Account, National AIDS Spending Account, national household datasets for routine equity monitoring

    • Health technology assessment capacities:

      • HITAP institutional relation with UK NICE

    • Key platforms for evidence informed decision

      • National Essential Drug List sub-committee

      • Benefit package sub-committee

        • ICER, budget impact assessment are pre-requisites for inclusion of new interventions into drug list or UC benefit packages

Evidence on outcome before and after uhc
Evidence on outcome: Thailandbefore and after UHC

Equity in financial contribution kakwani indexes 2000 2006
Equity in financial contribution: ThailandKakwani indexes, 2000-2006

Financial risk protection 1 household oop as household income 1992 2008
Financial risk protection 1: ThailandHousehold OOP as % household income, 1992-2008

Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

Financial risk protection 2 incidence of catastrophic health expenditure 2000 2006
Financial risk protection 2: ThailandIncidence of catastrophic health expenditure 2000-2006

Source: Analysis from NSO SES 2000-2006

Financial risk protection 3 trend of health impoverishment 1996 2008
Financial risk protection 3: ThailandTrend of health impoverishment 1996-2008

Equity in utilization op and ip concentration index by levels 2001 2007
Equity in utilization OP and IP ThailandConcentration index by levels 2001-2007

Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).



Equity in budget subsidies benefit incidence analysis 2001 2007
Equity in budget subsidies: ThailandBenefit Incidence Analysis, 2001-2007

Summary achievements
Summary: achievements Thailand

  • Evidence on achievements

    • Financing sources

      • Public sources of finance [general tax and SHI contribution], the dominant source [67.6% THE], is the most progressive source of financing healthcare and positive Kakwani index,

      • OOP reduced to 18% of THE (2008), minimum rich-poor gap of OOP

    • Financial risk protection

      • Very low level of catastrophic health spending and impoverishment

    • Service utilization and public subsidies

      • Pro-poor utilization both OP and IP

      • Pro-poor public subsidies

Summary contributing factors
Summary: contributing factors Thailand

  • Contributing factors

    • Systems design: most important for equity and efficiency outcomes

      • Prakongsai et al, the equity impact of the universal coverage policy: lessons from Thailand, in Chernichovsky and Hanson (eds), Innovations in health system finance in developing and transitional economies 2009.

  • Supply side capacity to deliver services

    • Extensive geographical coverage of functioning primary health care and district health systems

  • Sustainable institutional capacities

    • Generate evidence

    • Maintain normative works as foundations for monitoring evaluation

    • Platforms for evidence informed decisions

  • Evaluating ten years of universal health coverage in thailand

    Scope of assessment of Thai UCS: 2001-10 Thailand




    1. UC Policies process & system design

    2. Contextual environment

    - MOPH structural reform

    -downsizing public sector


    -Medical hub

    -Compulsory Licensing

    -health information & IT

    -Governance of overall health system


    4. governance



    Governance NHSO




    Purchaser-provider split

    Strategic purchasing


    5. Impact




    Health system

    • Primary care development

    • Medical service delivery

    • Public health functions

    • Information system

    • Human resources

    • Resilience of system

    • Service pressure

    • Financial

    • Efficiency

    • Perception

    • Utilization

    • Financial protection

    • Perception

    • Before UCS

    • After UCS

    Assessment of 10 years ucs
    Assessment of 10 years UCS Thailand

    • Teams

      • International experts

        • Tim Evans (BRAC chair), Armin Fidler WB, Magnus (WB), Mushtaque (RF), Anne (LSHTM), Xenia (ILO), David (WHO)

      • Thai experts

        • Five team leads

    • Deliverables

      • Prelim report Oct 2011,

      • Final report launched in Prince Mahidol Award Conference, Jan 2012 on UHC

      • Scientific publications