Financing reforms for the Thai health card scheme

Transcription

1 HEALTH POLICY AND PLANNING; 15(3): Oxford University Press 2000 Financing reforms for the Thai health card scheme SUPASIT PANNARUNOTHAI, 1 SAMRIT SRITHAMRONGSAWAT, 2 MANIT KONGPAN 3 AND PATCHANEE THUMVANNA 2 1 Faculty of Medicine, Naresuan University, Phitsanulok, 2 Health Insurance Office, Ministry of Public Health, Bangkok and 3 Social Medicine Department, Maharaj Nakhon Ratchasima Hospital, Thailand The Thai health card scheme originated from a pilot study on community financing and primary health care in maternal and child health in The scheme later changed to one of voluntary health insurance and finally received a matching subsidy from the government. The coverage of the scheme is described by a U- curve, i.e. it started with 5% of the total population in 1987, declined to 3% in 1992, with an upturn to 14% in The upturn has been the result of concerns about universal coverage policy, together with reforms of fund management. The provincial fund is responsible for basic health, basic medical, referral, and accident and emergency services. The central fund takes 2.5% of the total fund to manage cross-boundary services and high cost care (a reinsurance policy). On average, the utilization rate of the voluntary health card was higher than that of the compulsory (social security) scheme. And amongst three variants of health cards, the voluntary health card holders used health services twice to three times more than the community and health volunteer card holders. Cost recovery was low, especially in the provinces with low coverage. In the province with highest coverage, cost recovery was as high as 90% of the non-labour recurrent cost. Only 10% of the budgeted fund for reinsurance was disbursed, implying considerable management inefficiency. The management information system as well as the management capacity of the Health Insurance Office should be strengthened. After comparing the health card with other insurance schemes in terms of coverage, cost recovery, utilization and management cost, it is recommended that this voluntary health insurance should be modified to be a compulsory insurance, with some other means of premium collection and minimal co-payment at the point of delivery. Introduction The health card scheme in Thailand is known internationally as a voluntary health insurance scheme for farmers and workers in informal sectors at the community level. After 10 years of operation, the scheme has received a matching fund from government revenue for the same amount of card sales to increase cost recovery to health care providers. However, the price set for a card to provide coverage to the whole family within a year is too low to satisfy health care providers who have to absorb the costs themselves, especially for higher levels of care. The scheme further centralizes financial management to the provincial and national levels, and changes the fund management to a revolving health card fund. The implications of these changes are many-fold: crosssubsidization from big to smaller funds is possible by a reinsurance policy, the money need not be spent within the financial year, etc. It is expected that the scheme will be more attractive to both consumers and health care providers. This paper evaluates the changes in terms of financial management of the central funds, cost recovery of the funds and of health care providers, the administrative cost of the scheme and the operation of the reinsurance policy. The paper highlights utilization, selection and possible inefficiencies arising from adverse selection in the high and low coverage provinces. After comparing with other compulsory insurance schemes, it raises the policy question of whether this voluntary scheme should become compulsory. Phases in the evolution of the health card scheme The health card has survived health policy changes for more than 16 years. At the time of its inception in 1983, it was developed to complement the activities of primary health care on mother and child health (MCH). The low-price prepaid health card was an experiment to raise funds for the Village Mother and Child Health Development Fund. Buyers of the health cards were entitled to free care for simple treatments, MCH and vaccinations. After it had been tested for eight months in seven provinces and with a brief evaluation, the Ministry of Public Health (MOPH) then set the target for the second phase: to expand the health card to at least one subdistrict in each province in 1985, to all districts of each province in 1986, and to all subdistricts at the end of 1987 (see Table 1). The third phase of the health card scheme started when the

2 304 Supasit Pannarunothai et al. Table 1. Main characteristics of the health card scheme since 1983 Phase I Phase II Phase III Phase IV Conceptual framework MCH & FP (Community financing) Primary health care Primary health care and Voluntary health insurance (Community financing) voluntary health insurance Policy objectives To achieve target in MCH and FP To support PHC To provide health security To provide health security To improve referral system To improve referral system To support primary health care To achieve near universal To integrate health services coverage To change the role of health providers to be health facilitators To downsize outpatient services of big hospitals Area target 18 villages in 7 provinces: Khon All provinces, at least one All provinces, and cover all All provinces Kaen, Roi Et, Lamphun, subdistrict in each province and districts in each province Nakhon Sawan, Petchaburi, two villages in each subdistrict Ratchaburi and Songkhla Population coverage Not established From 70% of village population 30% of total population Target to subgroup of and reduced to 30% because population with no health 70% was considered too high benefit coverage Card prices Treatment & MCH B200 Family card B200 Family card B300 Family card only B500 Treatment only B100 MCH B100 Individual card B200 (MCH included) MCH only B100 MCH B100 Benefit limits Not established 8 illness episodes per card and 6 illness episodes per card and No limit capped to B2000 per episode capped to B2000 per episode Source: Adapted from Singkaew (1993). principle of the health card changed from community financing to voluntary health insurance, by moving the management of funds from villages to subdistricts with greater involvement of the health centres. When the country moved into the Sixth National Health Plan ( ), the health card scheme was renamed the voluntary health insurance project. But it was not until 1993 that the scheme received a government subsidy, in the form of an annual matching fund from the government on the same principle as the Social Security Scheme. 1 During this phase, policy development (including policy content, strategic plan and implementation process) was unclear. None of the three successive Permanent Secretaries for Health made an explicit policy on the health card scheme. This led to uncertainty among the provinces about the fate of the health card (Hongvivatana and Charusomboon 1993). The fourth phase of the health card is the period of policy reforms, which started in 1994 and form the main concern of this paper. The reforms did not come in a comprehensive package but rather evolved in a piece-meal fashion. The main theme has been to make the scheme more centrally policy guided to ensure greater coordination. The principle of the scheme is the mix between voluntary health insurance and public subsidy. The changes are described as follows: The national government gives an annual matching fund from tax revenue. In 1993 the cabinet agreed to subsidize the scheme at 500 baht per card if households purchase the card at the price of 500 baht. The matching budget was calculated under the assumption of cost-recovery within all levels of the MOPH service providers including hospitals. This budget has been in effect since fiscal year The health card fund has been changed to manage like a revolving fund. The restrictions imposed by the requirement that the government budget be used within a fiscal year are expected to be resolved by changing the management to a revolving fund. In 1995, the Ministry of Finance set up an accounting system for the central and provincial health card funds that complies with the regulations of the government revolving fund. Pooling of risk at the central level facilitates portability of benefits and risk sharing amongst provincial funds. From the revenue from each card sale, 2.5% of 1000 baht is deducted and transferred to the central fund to pay for cross-boundary services used in different provinces and high cost services within the same or in different provinces. This policy started in In 1994, free health cards were given to community leaders and village health volunteers to provide free health care for their families. However, the Budget Bureau argues that these types of health cards should be classified as a public assistance scheme and be financed under the low income card scheme.

3 Financing the Thai health card scheme 305 Institutional arrangements The health card came out about 8 years after the launching of the low income scheme in Because people were stigmatized by the low income card, the MOPH invented the prepaid community financing scheme as a choice for the poor or near poor to get access to health care to reduce demand for the low income card. Health providers were encouraged to sell health cards on the grounds that money raised from the health card was additional for the overall health finance system and better than the low income scheme which had paid nothing to health providers. In the early stages, the health card scheme even gave other incentives for health card holders, with provision of a green channel (to deliver faster services) and courteousness being used as marketing strategies. However, the providers of the health card scheme were mainly confined to the MOPH s facilities. Cost recovery was not the original objective of the health card scheme. The MOPH set guidelines that money raised from the health card be divided amongst provincial, district hospitals and health centres proportionally at the end of the operating year. 2 Allocation of the low income scheme s budget is different, in that it is channelled through the provinces and down to health facilities within the province at the beginning of the fiscal year on a population-utilization basis. However, after the country implemented the compulsory insurance scheme for formal workers in 1993, 3 allocation of some provincial health card funds adopted a crude point system as used in the social security scheme. Methodology This research is a retrospective cross-sectional study undertaken during The main sources of data were the Health Insurance Office, Ministry of Public Health, and the provinces. Data collection at the national level was by a postal questionnaire sent to every province in An in-depth study was carried out in four provinces selected purposively, to highlight the situation in provinces with high and low coverage. The postal questionnaire contained questions on the number of health cards sold, service utilization, cost of providing services and fund allocation. The in-depth study complemented the postal questionnaire by providing time trend data of the health card activities in the study provinces. Furthermore, key informants at provincial health offices, district health offices and hospitals were interviewed to give detailed information on administrative costs of health card activities. The in-depth study was also carried out at the Health Insurance Office, where key informants were asked to estimate the time allotted for managing the compulsory and voluntary insurance schemes, so that costs of administering each scheme could be derived. Coverage, revenue raised and benefit The coverage of the health card has changed over time. After the first expansion target had been set, health cards covered 5% of the total population in In terms of area coverage, it achieved 100% of provinces, 96% of districts and 70% of subdistricts (missing 30% of the target). In 1988, the first census survey of the health card was undertaken by Kiranandana et al. (1990). Subsequent figures are from the reports of the Health Insurance Office. Population coverage decreased from 1988 to 1992 and then increased from 1993 to 1997 (see Table 2). The decrease from 1988 to 1992 was the result of unclear policy direction from the MOPH, while the increase from 1993 was due to the concern of the Health Minister and successive reforms described above. Coverage in 1995 was higher than in 1996 because information during the previous year was less reliable due to changes in information systems. These figures do not include about cards given to community leaders and village health volunteers. In 1994, the MOPH launched a new type of health card for community leaders and village health volunteers (VHVs). The new health card is given free to target groups as a state fringe benefit, because both community leaders and VHVs work for the government without substantial payment. In terms of extra revenue raised from the scheme, the highest revenue raised was in 1997 which was about three times higher than in 1987 in real terms (the increase was almost the same as the expansion of the scheme). The change from voluntary health insurance to the mix between voluntary insurance and public subsidy has doubled the flow of funds to the scheme. The matching fund from the government in 1993 was not earmarked in the Budget Act, so only one-fifth of the obligated matching amount could be mobilized from the low income scheme budget of the MOPH with approval from the Budget Bureau. Table 2. Coverage of health card and revenue raised from 1987 to 1997 at current and 1996 prices 1987 a 1988 a 1991 b 1992 b Card sales (million) Population covered (mil) % population covered Revenue raised, million baht At 1996 price Matching fund, million baht None None None None At 1996 price None None None None a Kiranandana et al. 1990; b MOPH 1992.

4 306 Supasit Pannarunothai et al. Portability of the health card is considered to be an important issue. Health card holders who have to work for some months away from home can ask for an individual cross-boundary card at no extra charge. This card provides them access to health care in other provinces on the same terms as in their own province. Providers to cross-boundary users can claim reimbursement of all medical expenses from the central fund without charging users. However, the rate of issuing the individual cross-boundary card was only 1.4% of total family cards. Utilization Utilization rates of health card holders have been increasing over time, especially for outpatient visits. From 1988 to 1992, the rate of outpatient visits was about once a year for every card member. The figures from five provinces under the Thai German research project showed that their outpatient visit rate among card holders was twice as high as the national rate of card holders (Supachutikul 1993). The reported figures of the health card consistently show that utilization under the scheme was two to four times higher than the social security scheme (SSS). However, rather than suggesting that the health card users are a high risk/high user group, the low use rates in the SSS were explained by low access to care and the healthy worker effect (see Table 3). The postal survey in 1995 can distinguish use rates amongst health cards, community leader cards, health volunteer cards and the patterns of use of cross-boundary cards. The health card holders visited outpatient services and were hospitalized at a higher rate than community leader card holders and health volunteer card holders (see Table 4). Referral rates were also estimated amongst different types of card holders. For voluntary card holders, one in 100 was referred for treatment in other provinces, while only three in 1000 community leader card holders and only two in 1000 health volunteer card holders were referred. The utilization rate for the cross-boundary card holders could not be estimated because there was no information to link the issue of cross-boundary cards and health services used. However, on average these groups used higher levels of care than the other groups. This implies that the cross-boundary card holders moved to work in urban areas more than rural areas. The average length of stay varied according to level of care as well as to type of card held. The stays in regional hospitals were the longest and community hospitals the shortest. Community leader card holders stayed in community hospitals longer than other types of card holders. It is questionable whether they were more seriously ill or were privileged to stay as long as they wanted to. However, the cross-boundary card holders tended to be more seriously ill, judging from the longer lengths of stay when they were admitted in community and regional hospitals (see Figure 1). Table 3. Utilization rates of health card holders, compared with other schemes 1988 a 1991 b 1992 b 1992 c Health card OP/person/year d 2.04 f Health card IP/person/year Health card IP day/admission SSS OP/person/year e 1.23 e SSS IP/person/year SSS IP day/admission General pop OP/person/year 0.53 General pop IP/person/year 0.07 General pop IP day/admission 3.94 OP = outpatient visits; IP = inpatient admission; IP day = inpatient days; SSS = social security scheme. a Kiranandana et al. 1990; b Singkaew 1992; c Supachutikul et al. 1993; d adapted from Pannarunothai 1995; e Social Security Office 1996; f Srithamrongsawat Table 4. Utilization of different types of card holders Health card Community leader Village health volunteer OP IP OP IP OP IP Health centre 52% 0 60% 0 62% 0 Community hospital 34% 54% 34% 60% 33% 62% General hospital 11% 38% 4% 33% 3% 30% Regional hospital 3% 8% 2% 7% 2% 8% Average/person/year OP = outpatient; IP = inpatient.

5 Financing the Thai health card scheme HC CL VHV CB Figure 1. Average lengths of stay by hospitals and types of card: white bars = Community; grey bars = General; black bars = Regional. HC = health card; CL = community leader; VHV = village health volunteer; CB = cross-boundary The rates discussed above are the national average figures which obscure the effects of adverse selection in some provinces. Figures 2 and 3 show variations of inpatient hospitalizations and outpatient visits against population coverage of the voluntary health card scheme by provinces. Hospitalization rates were quite stable (at 0.1) for high coverage provinces (population coverage above 15%). However, the rates varied five-fold, from 0.05 to almost 0.25 admissions/ person/year amongst low coverage provinces. Outpatient visit rates follow the same pattern as hospitalization rates. The visit rates were around 1.5 to 2.5 visits/person/year for high coverage provinces, and varied four-fold from 0.9 to 3.5 amongst low coverage provinces. These variations suggest, to some extent, that some provinces with low health card coverage sold the cards to only the high risk groups because the cards were sold in the hospitals and the qualifying period of two weeks could not exclude cases that had appointments for further treatment. Costs Each level of care reports the costs of care provided to health card holders to the Health Insurance Office on a monthly basis. These reported figures are charges that health service providers would have billed the patients if the patients were to pay for the services themselves. Because different levels of care charge non-uniformly, we use the cost to charge ratio to convert the charges into costs. 4 Health centres 5 were the cheapest health care outlet; they would charge approximately the same (35 41 baht per outpatient visit) for any types of card held. The outpatient charges ranged from baht per visit at community hospitals, baht per visit at general hospitals and baht per visit at regional hospitals. On average, the charges for outpatient visits at different levels of care did not vary with the type of card held. Charges for inpatient care were different from charges for outpatient services. The high charges amongst cross-boundary card holders at community, general and regional hospitals confirmed that these individuals were more seriously ill. The non-cross groups were charged at baht an admission at community hospitals, baht at general hospitals and baht at regional hospitals. The crossboundary groups at community, general and regional hospitals were charged an average of 3546, 3821 and 7927 baht per admission respectively. Figure 2. Population coverage and hospitalization rate The total costs of care provided to one person in a year, or to all members listed in a card during one year was estimated, taking into account both the utilization rate and the costs of care. Voluntary health card holders consumed the most health care compared to the other two. Excluding the charges from cross-boundary consumption, one voluntary health card cost all levels of care about 1871 baht a year, or about 446 baht per person per year. The compulsory community leader card cost significantly less, i.e. 695 baht a year, and the village health volunteer card cost about 554 baht per year. In short, the compulsory community leader cards and health volunteer cards provided better risk pooling and compensated the deficit from operating the voluntary health cards. Figure 3. Population coverage and outpatient (OP) visit rate Considering costs per card in relation to population coverage and utilization, it is observed that provinces with low coverage of health cards were more likely to face higher utilization rates and higher health expenditure per card than provinces with high population coverage (see Figure 4). However, the lowest average cost per card was already more than 1000 baht in all provinces, no matter how high the population coverage (but it can be seen that provinces with high coverage also had high cost recovery). Therefore, the health card fund provided on average only 50% subsidy to the regional

6 308 Supasit Pannarunothai et al. Figure 4. and general hospitals, while providing 80% subsidy to the community hospitals and the full cost to health centres. Financial management Population coverage and cost per health card Following the change of the fund to a revolving fund model, a new accounting system was established in 1995 (Health Insurance Office 1995), because the decentralized system requires good central financial management. However, this requirement was not fulfilled as can be seen by the long delay in financial transactions even after In 1994, when the government first gave the matching fund to the Office, this fund should have been transferred to the provincial fund as soon as possible in order to encourage provider satisfaction. Because the 1994 fund was only half of what it should have been, this amount of money was allocated rather quickly, by July, the ninth month of the fiscal year. In 1995, the full matching fund was given. However, the transfer of this matching fund was delayed because of conflicting information on card sales between the reported figures in the MOPH system and the bank statements from the Agriculture and Agricultural Cooperatives Bank detailing how much money was raised from card sales. Eventually, the first transfer was made on almost the last day of the fiscal year, and the last was 6 months after the end of the fiscal year. Considering the overall use of funds, the proportion for medical services, including reinsurance and cross-boundary services, was only partly used. Less than 10% of the approved budget on reinsurance was used, and less than 10% of what should be used for administration was transferred to provincial funds (see Table 5). The low use rate was another sign of inefficiency. Reinsurance policy The reinsurance policy was set up to reduce big financial risks for small provincial funds and to provide all health card holders with comprehensive and continuous care. Of the total fund, 2.5% is pooled at the central level to pay for crossboundary and high cost services. For cases that need to be referred to university hospitals (which are not in the same network as MOPH hospitals), the health card fund at central level will share responsibility with the provincial fund to pay for these high cost referrals, as these cases are expected to be complicated and expensive. During 1995, the central fund paid only 3.4 million baht for cross-boundary services and 1.5 million baht for high cost care. In 1996, a lower amount was spent for cross-boundary care but a little more paid for high cost care. However, in the approved budget about 50 million and 60 million baht could be spent for cross-boundary and high cost care in 1995 and 1996 respectively. The low spending, less than 10%, shows the inefficiency in fund management. The list of those waiting for reimbursement was not minimal. There were too few responsible persons and they had insufficient knowledge of their jobs. The Health Insurance Office has no incentive to clear the claims quickly. The facilities as well as the provincial health card funds bear the costs of waiting for reinsurance payment. Information on reinsurance from the Health Insurance Office during these periods was not accurate. There were no summary details on clinical information or the charges by each service. However, it can be estimated that a case reimbursed for cross-boundary care was about 1151 baht (averaged between outpatients and inpatients), while a case claimed as high cost care cost on average about 9529 baht (see Table 6). The cases reimbursed for cross-boundary care were mostly outpatients, compared with the high cost cases which were inpatients. Administrative costs It is difficult to estimate administrative costs for the health card programme alone because resources are used jointly between the health card and other health activities. At the national level, the total cost of administering the Health Insurance Office was 23.7 million baht in 1996 (including salary, other recurrent costs and some capital costs on office equipment). The Health Insurance Office is responsible for all activities related to health insurance, both voluntary and compulsory, within the Ministry of Public Health. From Table 5. The use of health card funds (in million baht) for medical services, reinsurance and cross-boundary care Year Medical services Reinsure and cross-boundary Approved Transferred Approved Transferred Table 6. Payment from the central fund for cross-boundary and high cost services Million baht Charge (baht)/case Cross-boundary High cost Cross-boundary High cost

7 Financing the Thai health card scheme 309 interviews with key informants, the voluntary health insurance activities were estimated to account for 60 70% of the overhead cost of the Health Insurance Office, with 30 40% for the compulsory scheme. The high share of the health card was because more efforts were put into the marketing, monitoring and transferring of funds back and forth from provinces to the Office, while the compulsory scheme needed less input. (This is rather out of proportion with the scope of responsibility, i.e. the compulsory scheme covered four times the population and money of the health card scheme.) The total cost of administering the health card programme would therefore be 17.4 million baht, compared with 6.3 million baht for compulsory health insurance (see Table 7). This was only 1.4% of 1239 million baht, the turnover of 1996 health card activities. This estimate did not include the costs borne by other divisions within the Ministry when they came to work for the health card programme. Comparison with other schemes Considering the expansion of the main health insurance schemes from 1987 to 1995, given in Table 8, we can see that the fastest growing scheme was public welfare, which included the low income scheme, the elderly, children 0 12 years old, the handicapped and religious leaders. This was the result of the government policy from 1993, after realizing that 25 million Thais were uninsured. Coverage of the civil servant medical benefit scheme (CSMBS) did not expand because the government capped the number of civil servants. The figures fluctuated because different calculation methods were applied to estimate the eligible which included their spouse, parents and siblings under the age of 18. The compulsory insurance, social security scheme, was implemented in It almost doubled its numbers from 1993 to 1995 because the law extended the coverage from working establishments of 20 workers and above to those of 10 workers and above. The scheme will expand again if it agrees to cover the workers as well as their dependents. The highest possible coverage would be triple the figure of The uncovered group has reduced from 31.5 million in 1987 to 15.9 million in This group should whither away when the country economy maintains the level of middle-income country. But which carrier will reach the uncovered group? The expansion of the social security scheme may reduce the uncovered group, but cannot reach all. The crucial question is whether the health card can bridge the gap found in this fragmented insurance system. According to the history of the health card given in Table 2, the scheme has expanded from 2.7 million in 1987 to 8 million in The highest revenue raised was about 1000 million baht in This amount was about 2% of the total MOPH budget. Conclusions The health card scheme in Thailand has evolved through four stages over 16 years. The period of central management has Table 7. Cost of running the Health Insurance Office in 1996 Item Voluntary health insurance Compulsory health insurance Planning Support Total Person Meeting Salary Pay Stipend Supplies Utility Research Equipment Total Extra allocation Grand total Table 8. Health insurance coverage (million people) from 1987 to 1995 Insurance scheme 1987 a 1993 b 1995 c Prospect Social security scheme Will expand Private health insurance na Likely to expand Civil servant medical benefit Not expand Public welfare Likely to expand Health card Likely to change Total Not covered a Vuthipong 1989, p. 30; b Supachutikul et al. 1994, p. 75 6; c Health Insurance Office.

8 310 Supasit Pannarunothai et al. achieved the highest coverage, at about 15% of the population. This was the result of the active promotion of sales in many provinces. Many times, the promotion undermined the ideal health delivery system, for example allowing bypassing to bigger hospitals for any conditions of illness. Some provinces used the administrative budget (10% of the total revenue allocated for management at national and provincial levels) for lucky draw prizes to promote health card sales. The national advertisement on television promoted the benefits of the scheme to individuals rather than promoting solidarity principles. The target population of the health card, the not rich and not poor, may have been missed, because they were not attracted by the campaigns. Many hospitals were the outlets of card sales and no validation period was required. This increased moral hazard of consumers. The weaknesses of voluntary health insurance were difficult to prevent. Cost identification of the management of the voluntary health insurance scheme was three times higher than for the compulsory scheme, while population coverage of the former was one-quarter of the latter. This implies that managing the voluntary scheme was more costly and less efficient than the compulsory scheme. A lot of effort was put into card sales every three months, including the managing of funds, but the coverage of the scheme was no higher than 14% of the total population, and the yields of card sales were about 1 2% of the MOPH budget. The reforms provide strong purchasing power to the central fund as seen by the reinsurance policy, but the management of the revolving central funds should be deregulated. Financial management should be upgraded, especially the accounting and banking skills of the Office. In terms of cost recovery, low coverage provinces had lower cost recovery rates than high coverage provinces. The allocation of funds favoured the lower levels of care, giving higher subsidy than the higher level of care. Unless the cost is fully recovered, health providers are more willing to provide care to the health card holders compared to other schemes. Low cost recovery was also caused by adverse selection. The compulsory health cards for community leaders and health volunteers prevented adverse selection and increased cost recovery. It is time to rethink the future of the voluntary health card, whether it should be integrated into the public welfare scheme, and use some other means of prepayment mechanism, as well as minimal co-payments at the point of delivery, to achieve near universal coverage for health care. Endnotes 1 Thailand has introduced a compulsory health insurance scheme under the Social Security Act This scheme is financed equally by three sources: employees, employers and tax revenue. 2 It was recommended that 30% of the village health card fund be allocated to provincial hospital, 30% to community hospital and 15% to health centres. The remaining 25% was for administration from card sale promotion to incentive payments to health personnel. 3 The Social Security Scheme lays out the contractual model between the Social Security Fund and the main contractor (hospital of more than 100 beds) to provide care to the insured workers on a capitation basis. The main contractor reimburses medical expenses to subcontractors in the province on a crude point system, e.g. an outpatient visit at health centre is 70 points, at community hospital is 110 points, etc. 4 It was estimated that the cost to charge ratios (non-salary recurrent cost) at public hospitals were 0.88 of the charges at regional and general hospitals, 0.93 at community hospitals and 1.0 at health centres (Supachutikul 1994). 5 A health centre is the lowest level of government health care manned by paramedics with a limited list of drugs. References Budget Bureau Correspondence to the Cabinet Secretariat on approving government reserve budget to the Health Card scheme for community leaders and health volunteers. Most urgent 0413/27076, dated July 1, Health Insurance Office Accounting system for the health card revolving fund. Bangkok: Ministry of Public Health, Health Insurance Office. Hongvivatana T, Charusomboon W The health card and policy on voluntary health insurance: the past, present and future. A paper presented at the meeting on Lessons Learned from the Thai German Health Card Project, August 30, Kiranandana T et al Evaluation of the health card project, Ministry of Public Health. Bangkok: Health Planning Division. MOPH Annual report of the Health Insurance Office Bangkok: Ministry of Public Health, Health Insurance Office, p. 24. Pannarunothai S What the health card information system can tell us. Bangkok: Ministry of Public Health, Health Insurance Office. Singkaew S Comparison of voluntary and compulsory health insurance. In: Annual report of the Health Insurance Office, Bangkok: Ministry of Public Health, Health Insurance Office. Singkaew S Health card project: the history, evolution, objectives, outcomes and activities. A paper presented at the meeting on Lessons Learned from the Thai German Health Card Project, August 30, Social Security Office Annual report of the Social Security Office Bangkok. Srithamrongsawat S Evaluation of the health card, Bangkok: Ministry of Public Health, Health Insurance Office. Supachutikul A et al Presentation describing administrative set-up and current activities and lessons learnt from the five project provinces. A paper presented at the meeting on Lessons Learned from the Thai-German Health Card Project, August 30, Supachutikul A et al Analysis of the implementation of the low income card scheme. Health Systems Research Institute, Ministry of Public Health, Thailand. Vuthiphong P et al Health insurance system in Thailand. Mahidol University, Health Policy Centre. Acknowledgements The authors acknowledge the stimulation of doing this research from the National Health Systems and Policies, Division of Strengthening of Health Services. We would like to thank Dr Sanguan Nitayarumphong, the former Director of the Health Insurance Office, who supported research activities as a means to gain knowledge for health development. We would like to thank the health people in the provinces who participated in this research. Thanks also have to be made to Andrew Creese and Joseph Kutzin, WHO, Geneva, who commented on the framework and the results of the activities. Thanks are also given to the helpful comments from the anonymous reviewer. Finally, we thank WHO, Thailand Country budget and WHO, Geneva for their financial support.

9 Financing the Thai health card scheme 311 Biographies Supasit Pannarunothai obtained his medical degree from Ramathibodi Hospital, Mahidol University. He worked in Buddhachinaraj Hospital, a regional hospital, for more than 10 years and worked in the Provincial Hospital Division, Ministry of Public Health for some time. After completing his Ph.D. at the London School of Hygiene and Tropical Medicine (LSHTM), he returned to Buddhachinaraj Hospital and worked as a full-time researcher. In 1998, he joined the Faculty of Medicine, Naresuan University undertaking teaching and research at the Centre for Health Equity Monitoring. Samrit Srithamrongsawat obtained his medical degree from Chulalongkorn University. He has 6 years of experience as the director of two community hospitals, and 6 years as deputy provincial chief medical officer and head of communicable diseases control section at Phuket Provincial Health Office. He moved to the Health Insurance Office after completion of an MSc in Health Service Management from the LSHTM in 1995 and is now Deputy Director. Manit Kongpan obtained his medical degree from Chiangmai University. He had further training in the Field Epidemiology Training Programme of the Ministry of Public Health. He currently works at the Social Medicine Department, Maharaj Nakhon Rajsima Hospital, Thailand. Patchanee Thumvanna is a nurse by training and had further training at Chulalongkorn University obtaining an MSc (Health Economics). She now works with the Health Insurance Office, Ministry of Public Health, Thailand. Correspondence: Supasit Pannarunothai, Centre for Health Equity Monitoring, Faculty of Medicine, Naresuan University, Phitsanulok 65000, Thailand.