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  1. Healthcare Financing in Thailand:an update in 2007 Updated by International Health Policy Program (IHPP) Ministry of Public Health, Thailand

  2. Outline presentation I. Background information on burden of disease and health care finance IA. Burden of Disease in 2004 & national health expenditure, 1994 – 2005 IB. Healthcare financing performance • Fairness in financial contribution – EQUITAP results • Incidence of catastrophic and impoverishment from OOPs • Equity in utilization & benefit incidence analysis (BIA) II. Ongoing major works IIA. Universal offer of VCT IIB. Major program review of cervical cancer control IIC. Review of DCP2 and its application in chronic diseases management IID. Annual hospital report III. Future challenges: Renal replacement therapy, financial sustainability, and potential moral hazards, etc.

  3. IA. Background information:BOD and financing healthcare

  4. Profile: top 10 mortality, Thailand 2004Total deaths 390,285 Top 10 deaths share 63% of total national deaths

  5. Profile: top 10 YLL, Thailand 2004Total YLL 6.07 million years Top 10 YLL shares 63 % of total national YLL

  6. Profile: top 10 YLD, Thailand 2004Total YLD 3.1 million years Top 10 YLD shares 71% of total national YLD

  7. Profile: top 10 DALY loss, Thailand 2004Total DALY loss 9.17 million years Top 10 DALY shares 52% of totalnational DALY loss

  8. DALY loss by age group and gender, Thailand 2004

  9. DALYs per 1,000 population, ranked 22 categories

  10. Top 15 risk factors, men Thailand 2004

  11. Top 15 risk factors, women,Thailand 2004

  12. Total Health Expenditure,NHA 1994 – 2005

  13. Real term growth GDP versus THE, 1994-2005 13

  14. THE, Baht per capita NHA 1994-2005 current and constant price (2003) 14

  15. Trend of financing sourcesNHA 1994-2005

  16. Trends of financing agents, NHA1994-2005

  17. Expenditure by financing agent NHA2005

  18. Expenditure by healthcare Function NHA2005 19

  19. CSMBS total expenditure and growth 1988-2006 million of employees/pensioners Source: Comptroller General Department, Ministry of Finance (various years) 20

  20. IB. performance of UC scheme

  21. Why general-tax-financed UC Scheme? • Contributory UC Scheme was not in the policy agenda during 2001 general election, • Feasible to apply general tax, additional budget requirement was in fiscal capacity • Not feasible to collect premium • Urgency to nation-wide scale up immediately, political obligations to the constituency • Subsequent studies indicate the Concentration Index of various sources of healthcare finance – Thailand 2002 (O’Donnell et al 2005) CI weight NHA • Direct tax 0.9057 0.1868 • Indirect tax 0.5776 0.3155 • Social insurance 0.57600.0582 • Private insurance 0.3995 0.0668 • Direct payments 0.4864 0.3728 • Total Health Financing 0.5929 • General Tax 0.6996 Note: 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

  22. Contribution of Social Health Insurance (SHI) to UC Scheme system design • SHI as a predecessor of UC • Contract model contractual arrangement with competitive public and private provider contractors • Contract is feasible in the context of comprehensive geographical coverage of MOPH healthcare infrastructure • Closed-ended provider payment method • Among a few developing countries, Thailand pioneers capitation payment method • Additional pay for A&E, high cost care, based on fee schedule • Purchaser Provide split • Social Security Office and National Health Security Office as purchasers – design packages and payment methods • MOPH, other public and private medical institutions as major providers • Comprehensive coverage • Comprehensive service package, OP, IP, Prevention, Promotion • Neither deductibles nor co payment at point of services, UC scheme has nominal pay of US$ 0.75 per visit or admission

  23. Advanced characteristics of the UC Scheme

  24. Capitation rate and componentsBaht per capita, approved fig. 2002-2007, plan fig. 2008

  25. IHPP calculates capitation rate based on actual utilization rate and unit cost. Due to fiscal constraint, it results in discrepancy Discrepancy: proposed & approved capitation rate FY2002-2006

  26. Household health expenditure as % of household income by income deciles prior to UC (1992-2000) and after UC 2002-2006 Source: NSO SES (various years)

  27. Distribution of households with health expenditures > 10% total consumptionby consumption expenditure quintiles Source: NSO’s SES (various years)

  28. Catastrophic health payments in Thailand, 1996-2002 Source: National Statistic Office, Household Socio-economic Survey, various years.

  29. Pre-post UC incidence of catastrophic expenditureHouseholds with health payment > 10% of total consumption expenditures Source: NSO’s SES (various years)

  30. Impact of UC: Catastrophic illnesses, impoverishment Limwattananonet al 2005 • Dataset: NSO SES 2000 (24,747 households), 2002 (34,785) and 2004 (34,843). • Finding • The incidence of catastrophic health expenditure (>10% of total HH consumption) reduced • From 5.4% in pre-UC 2000 • to 3.3-2.0% in post-UC 2002-2006 • An increase in the poverty headcounts due to OOP payments dropped • From 2.1% in pre-UC • to 0.8-0.5% in post-UC. • Conclusions • Reduction in the catastrophe and impoverishment due to OOP health payments is evident after the UC reform which provides comprehensive coverage of health care with a very small nominal fee.

  31. Healthcare Catastrophe vs. OOP Payments & Incomedata as of 2000 Source: van Doorslaer et al. (2005)

  32. Utilization by UC memberssource: NSO HWS2001, 2003, 2004, 2005 and 2006

  33. Total Ambulatory Visits (millions/yr)(HWS 2001, 03, 04, 05, 06) SSS LIC/VHC & UC-E/-P CSMBS

  34. Average Ambulatory Visits (per member/yr)(HWS 2003, 04, 05, 06) 1.13 1.09 1.12 0.91 1.86 2.18 2.07 1.53 SSS 1.80 1.98 1.93 1.67 UC-E/-P CSMBS

  35. Insurance Use for OP Visit (% compliance)(HWS 2003, 04, 05, 06) SSS UC-E/-P CSMBS

  36. Total Hospital Admissions (millions/yr)(HWS 2001, 03, 04, 05, 06) SSS LIC/VHC & UC-E/-P CSMBS

  37. Average Hospital Admissions (per member/yr)(HWS 2001, 03, 04, 05, 06) 0.06 0.06 0.07 0.06 0.07 0.09 0.08 0.09 0.08 0.08 SSS 0.10 0.09 0.12 0.11 0.08 LIC/VHS & UC-E/-P CSMBS

  38. Insurance Use for IP admission (% compliance)(HWS 2003, 04, 05, 06) SSS UC-E/-P CSMBS

  39. The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities 2003 2001 Concentration indices of ambulatory service use among different types of health facilities in 2001 & 2003

  40. Selected concentration curves of ambulatory service use among different types of health facilities in 2003

  41. The distribution of hospitalization among different socio-economic groups in 2001 and 2003, by types of health facilities 2001 2003 Concentration indices of hospitalization among different types of health facilities in 2001 & 2003

  42. Selected concentration curves of hospitalization among different types of health facilities in 2003

  43. Who benefits from public subsidiesLimwattananonet al 2005 • Benefit Incidence Analysis: compare pre-UC 2001 and post-UC 2004 using NSO HWS2001, 2004 • OP care • Post UC 2004, the pro-poor subsidy was very pronounced at District Health System (DHS) • Concentration Index = - 0.3326 and - 0.2921 for Health Centre and District Hospital respectively. • Less progressive at provincial hospitals (PH) • CI = - 0.1496. • IP care • More progressive in favour of the poor at DH • CI = - 0.3130 in 2001 and - 0.2666 in 2004. • Weaker progressive in favour of the poor at PH • CI = - 0.1104 in 2001 and - 0.1221 in 2004 • Conclusions • The pro-poor subsidy were strongest for DHS. • Lessons indicates DHS plays key role in fostering the pro-poor nature of public subsidy. • Close to client services, better accessed

  44. Percent distribution of net government health subsidies among different income quintiles in 2001 and 2003 Note: • Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were 80,678 million Baht (in 2001-value) • The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123

  45. Concluding remarks 1 • Enabling factors for achieving UC • Strong political supports • Health systems capacity and its resilience to rapid nation-wide program scale-up in 6 months • Lessons from predecessors • SHI capitation contract model • CSMBS “no go” fee for service, due to cost escalation and inefficiencies • Voluntary Health Card Scheme – adverse selection and non-viable financially • Linking evidence to policy decision • Integral relationship among researchers – reformists – politicians • Pragmatism • Limited chance to achieve UC by contributory scheme, especially among informal sector, not feasible for contribution collection and enforcement • Learning from SHI, UC takes further advanced steps, • Well thought systems design towards efficiency, cost containment, ensure referral, advocates of primary care contractor

  46. Concluding remarks 2 • UC Schemes covers the poor, half belongs to Q1 and Q2 • However, the Scheme faced chronic under-funding, capitation was below than the proposed figures based on cost and utilization • Significant increase in utilization more on OP than IP • In view of under-funding and increased utilization  danger of poor quality of services and serious hospital financial constraints • Empirical evidence indicates • Pro-poor budget subsidy, DHS is a major hub of fostering the pro-poor nature of financing healthcare • Policy msg.  invest more in DHS • (further) reduction in the incidence of catastrophic illnesses • (further) reduction of impoverishment from medical bills

  47. IIA. Ongoing major work: Universal offer of VCT

  48. The potential VCT uptake with zero price 10.4% 32.6% Current price 11.7% 39.7% Current price

  49. Predicted Demand for VCT by Regions Gen. Pop. SW MSM IDU

  50. IIB. Ongoing major work: Major program review of cervical cancer control