How Thailand has reached universal coverage: a reflec5on spanning from 1990s to 2010s

Transcription

1 How Thailand has reached universal coverage: a reflec5on spanning from 1990s to 2010s Supasit Pannarunothai, MD, PhD Centre for Health Equity Monitoring Founda<on ILO- China- ASEAN High Level Seminar to achieve the SDGs on Universal Social Protec<on through South- South and Triangular Coopera<on, 6 8 September 2016, Yuyang Hotel, Beijing, China

2 Scope 2

3 Background Thailand s universal health coverage policy had long been discussed with various stakeholders over a decade before becoming real. * * * ********** UHC Workshops HSRI

4 Objec5ves of Thai UHC Equity Quality Efficiency Social Accountability 4

5 Streams of health reforms Health care reform dance Big bang policy change Kingdon s window of opportunity Bureaucrat stream Policy stream Triangle that moves the mountain Knowledge Social movement Poli<cal decision 5

6 Before the big reforms Was Thailand delivering equitable health care? Was there any issue of financial barrier to health care? How much did we need to intervene health care market (achieving monopsonis<c power)? Was a law approach effec<ve? 6

7 Policy analysis triangle Context Content Actors Individuals Groups Organizations Source: Walt and Gilson, 1994 Process 7

8 Timeline ader the Big Bang Security Act Enactment of National Health Security Act New Government Draft bill came to parliament National Health Security Act was launched Jan 2001 Apr Jun Oct Apr 2002 Nov provinces 15 provinces Whole country (72 provinces) Achieved UC Expansion of insurance coverage Pitayarangsarit

9 ADer the big reforms the good Na<onal Health Security Act 2001 Capita<on payment for outpa<ent services Diagnosis related group payment within a global budget for inpa<ent care Na<onal Hospital Accredita<on Body Na<onal Health Act

10 Other important issues Na<onal Health Assembly Na<onal Health Commission Thailand Reform Movement: Ci<zen Power 10

11 Conflicts in the purchaser- provider split Figure 6: UCS institutional arrangements National Health Security Board NHSO Admin budgets Minister of Public Health Coordination MOPH Financial flow Command line Regional NHSO Contracting Referral hospitals Other public UCS CUPs budgets Regional NHSB Health Regional Inspector Provincial Health Office District Governor District Health Office CUP Board MOPH CUPs Non-UCS budgets (including salaries) Full cost Private CUPs Subdistrict Health Funds MOPH PCUs Local govt administrative offices HSRI

12 Scheme Social Security Scheme (SSS) Population coverage Private sector employees, excluding dependants Financing sources 16% Payroll tax financed, tripartite contribution 1.5% of salary, equally by employer, employee, government Benefits package Comprehensive: outpatient, inpatient, accident and emergency, high-cost care, with very minimum exclusion list; excludes prevention and health promotion Purchasing relation Contract model: inclusive capitation for outpatient and inpatient services Access to service Registered public and private competing contractors Per capita expenditure 2010 US$ 71 Civil Servant Medical Benefit Scheme (CSMBS) Government employees plus dependants (parents, spouse and up to two children age <20) 9% General tax, noncontributory scheme Comprehensive: slightly higher than SSS and UCS Reimbursement model: fee for service, direct disbursement to public providers for outpatients; conventional DRG for inpatients Free choice of providers, no registration required US$ 367 Universal Coverage Scheme (UCS) HSRI 2012 The rest of population not covered by SSS and CSMBS 75% General tax Comprehensive: similar to SSS, including prevention and health promotion for the whole population Contract model: capitation for outpatients and global budget plus DRG for inpatients Registered contractor provider, notably district health system US$ 79 12

13 Varia5ons of services by scheme 13

14 Scientific Working Group on Health Finance Sustainability To country, government, households in the long run Adequacy For equal access to care free from catastrophic spending SAFE Fairness In financing, delivery and health outcomes Efficiency Efficient use of health resources, timely, with good quality

15 Conclusions The universal health coverage policy in Thailand came to existence by the big bang phenomenon but with con<nuous efforts from academicians (including technocrats) and civil society over a decade. The policy window was narrow related to the general elec<on in

16 Conclusions The UHC in Thailand is a mul<- payer system, operated by three government purchaser schemes. Sustainability phase required long incremental interac<ons of technocrats (including academicians) dealing with the diverse health systems to achieve overall efficiency and to reduce gaps. Benefactors of each scheme can help protect equitable sources of financing in the long term. It is interes<ng to follow what would be the recommenda<ons from the newly appointed working group towards the sustainability of the UHC in Thailand 16