rograms, and social determinant eterminants of health

Transcription

1 Health systems, public health programs rograms, and social determinant eterminants of health Thailand Jadej Thammatach-aree Director of Bureau of Policy and Planning, National Health Security Office (NHSO); Thailand

2 Disclaimer WCSDH/BCKGRT/10/2011 This draft background paper is one of several in a series commissioned by the World Health Organization for the World Conference on Social Determinants of Health, held October 2011, in Rio de Janeiro, Brazil. The goal of these papers is to highlight country experiences on implementing action on social determinants of health. Copyright on these papers remains with the authors and/or the Regional Office of the World Health Organization from which they have been sourced. All rights reserved. The findings, interpretations and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner whatsoever to the World Health Organization. All papers are available at the symposium website at Correspondence for the authors can be sent by to sdh@who.int. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. 2

3 Introduction The development of society can be reflected in the quality of its population s health, how reasonably health is distributed across social level, and the effectiveness of health care risk protection provided from public policy (World Health Organization. 2008). These determinants have effects on health in complex ways. Social determinant of health associated with the socioeconomic and political context such as governance, social and public policies. It influences social living and behavior of people (Dedmon 2010). Health inequalities arise from unequal distribution of such determinants, which create or limit the ability of the poor to seek for health care and healthy behaviour. In order to reduce health inequity, taking action on well-planned disease control and treating existing diseases might not be only ways to improve health equity. Social and economic concerns are also crucial determinants (Marmot 2005). In Sweden, for example, incorporated social, economic and health issues into public health objectives to ensure good health on equity for its entire population. Of which, these factors determine the consequences of social structures toward personnel health-related behaviours. The objectives are set in eleven domains which are; (1) Participation and influence in society (2) Economic and social security (3) Secure and favourable conditions during childhood and adolescence (4) Healthier working life (5) Healthy and safe environments and products (6) More health-promoting services (7) Effective protection against communicable diseases (8) Safe sexuality and good reproductive health (9) Increased physical activity (10) Good eating habits and safe foods (11) Reduced use of tobacco and alcohol, in order to build a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling (Hogstedt, Lundgren et al. 2004). Equality in health is mainly determined by the increasing access to care and the decreasing catastrophic expenditure in population (Kutzin 1998). Conceptual framework for actions of social determinant of health proposed by Solar and Irwin (2007) indicated that there were two main factors affecting inequity. They are structural and intermediary determinants. Structure determinant incorporated context, structural mechanism and individual resultant socioeconomic position while intermediary determinants embodied material circumstances, psychosocial circumstances, behavioural and/or biological factors, and health system (Solar and Irwin 2007). Examples of health system affecting determinant of health are human resource, health care financing, and health service delivery. Evidence showed that health 1

4 system movement is the key role of improving equitable access to care and protect impoverishment of people from health expenditure (Marmot 2007). Thailand is an example of improving social determinant of health by implementing universal health coverage (UHC). It took a big bang change to universal health coverage (UHC) by extending coverage to nearly 30 percent of overall population who were previously uninsured (Towse, Mills et al. 2004). The important action was the financial reform that moved funding from supply side allocation to demand side by using budget per capitation for responsible catchment area resulting in shifting fund from urban hospitals to the building up of primary care units. The goal of the reform was to balancing health opportunities across the different socioeconomic groups and to narrowing the gap between the rich and the poor. The processes of this movement could be ideas for other countries for the moving of policy, not only for achievement of the UHC but can be applied to other policy issues. The aim of this report is to determine the process of health system to support the social determinant of health relating to universal health coverage implementation. Developing of universal health coverage in Thailand The development of Thai universal health coverage could be traced back to 1974 when it established workmen compensation fund to cover private employees who were injured from working. The coverage for employees who have illness not related to work came later in 1990 denoted as social security scheme (SSS). At the beginning, it covered only companies with more than 20 employees and expanded to cover more than 10 employees in Then the benefit covers every company with more than one employee in Another public health insurance scheme, the Civil Servant Medical Benefit Scheme (CSMBS) was set up in 1978 covering all government employees and dependants which are spouses, parents, and not more than two children under 18. At the same time, government set up the low income card scheme (LICS) for poor people in 1975 and expanded to community base health insurance scheme (CBHI) based on maternal and child health in This led to change from community base financing to voluntary health insurance by moving the management of funds from village level to involvement in sub-district level by introducing health card scheme (HCS) in The newest scheme; the Universal coverage scheme (UCS), was set up in 2001 by combining all the rest of population who were LICS, HCS, fee exemption groups, and uninsured people. Consequently, after 2001, Thailand health care coverage 2

5 is mainly three schemes including SSS, CSMBS, and UC scheme. The details of universal health coverage in Thailand are shown below. Before WCF 1975 LICS 1980 CSMBS 1981 Fee Exemption Type B fee exemption 1983 CBHI 1990 SSS 1991 HCS Traffic Accident Protection Program (TAP) 1993 Near Poor people poor 2002 UCS implemented nationwide Private employee Government Year employee Adapted from: NHSO 2010 Uninsured Population covered by Universal Coverage Scheme (UCS) The historical milestone is described against the economic capacity of the country measured in term of Gross National Income per capita between 1970 and The development of health insurance coverage relates to GNI per capita, for example in 1975 Thailand introduced LIC when the GNI per capita was $390 USD. During the period of low income state, Thai health system moved by introducing LIC, CSMBS which Thailand experiences showed that in the situation of low GNI per capita in Community based health insurance scheme was introduced in 1983 when GNI was $760 USD. Finally, UHC was implemented in the period of economic crisis when GNI per capita is about $1,900 USD. 3

6 US $ 4, : Asian financial crisis 3,000 2, : 29% of population are uninsured 2,000 1, CSMBS introduced Universal Coverage for entire population achieved 1, Low Income scheme introduced SHI introduced CBHI introduced From: Tangchareonsathien 2010 Health expenditure has increased steadily since UHC were implemented. The ratio of private financing source reduced from approximately 45% in 2000 to 25% in The proportion was nearly the same as OECD countries which were 73.6% of health financing across EU countries in 2008 (OECD 2010). The percentage reduction of private financing implied the decline risk of household expenditure in health care. 4

7 Million Baht 400, , , , , ,000 55% 53% 53% 46% 45% 45% 44% 44% 36% 36% 37% 37% 27% 32% 100,000 68% 45% 47% 47% 54% 63% 63% 64% 64% 50,000 55% 55% 56% 56% 0 25% 75% 73% Year Public financing sources Private financing sources From: Prakongsai et al. (2009) The diagram below showed how health system in terms of financial reform played an important role in improving equitable access of health service and health outcomes of the population. Household and individual pay tax or contribution to government in order to pooling financial risk depends on their working status. Private employees in formal sectors pay contribution to SSS while government officers and the rest of population pay tax. Government allocated the collective fund to different schemes by using different mechanisms which were tripartite contribution for SSS and general tax for CSMBS and UC scheme. Different insurance schemes contracted provider in different payment system with some different benefit packages, for example, UC scheme covers prevention and promotion of services for all people in the country while SSS and CSMBS cover only curative and some rehabilitation services. UC scheme also had matching fund with local government to provide preventive care especially in behavioral modification activities. 5

8 enterprise Payroll tax Contribution Government Contribution General Tax General Tax Activity Financial resources Performance HA = Hospital Accrditation SSS CSMBS UC scheme Local government Direct & indirect tax Capitation OP&IP FFS for OP DRG for IP Capitation for OP DRG with global budget for IP Public and private contract Matching fund for Prevention&Promotion Contribution Benefit package Service Insured/Uninsured population Equity and Access health and wellbeing Initiative of UC scheme in equity using matching fund with local government Financial arrangement of the implementation of UC scheme is mainly four approaches. Of which, are shifting the main source of health care financing from out of pocket payment to general tax, removing financial barriers to health service by limit co-payment at 30Baht or one dollar (exchange rate of 30 Baht= 1 dollar) per episode of service (abolish copayment in 2006), changing provider payment from historical allocations to closed ended payments, and promoting the use of primary care by contract PCU as the main contractor. UC scheme is designed to offer comprehensive benefit package covering from prevention& promotion, curative, and rehabilitation. The prevention& promotion can be divided into three main activities including National Priority Program, P&P for expressed demand, and P&P for area base problem. The P&P area base aims to promote people participation process and efficient use of resource by people in the sub district level to manage the prevention and promotion problem in the area (National Health Security Office 2011). 6

9 According to the National Health Security Act 2002, it announced that in order to provide good health for all, the National Health Security Office (NHSO) has mandate to promote the collaboration in local levels to ensure health access for people in community. Under the provision of the act, from 2006 NHSO provides fund to the sub-district administrators. The sub-district or Tambon administrators who have interested in the fund will enroll and be financed by per capita payment (40 Baht or $1.3 USD in 2010). Each sub-district authority needs to pay contribution to the fund according to the size of the authority, 20%, 30% and 50% for small, middle and large size respectively. Private financing can be included if available. The most important rule for using the fund is there is essential to set up a collaboration group consisting of local administrators, their residents and delegations from local health authorities. Fund is managed by the committee and can be paid for only four purposes; managing the fund effectively, providing services according to the benefit packages, supporting health facilities in the area, and solving the health problems in community. In 2010, there are 5,504 local authorities or 70% of overall Tambon included in the project (Samnuanklang, Srithamrongswat et al. 2011). The fund helps fostering preventive activities such as chronic diseases screening, epidemic control, intensive health care for elderly and disabled, also sanitation such as eradicating the mosquito larvae and rubbish recycle, all of which, roots from the locals ideas. Empowerment is the key success of this project, not only one but all three local clusters; the local administrators, the health officers and the locals. Achievement is proved thru the information gained, working in team, transparency and building up the same goals. Although, the achievement of the program in terms of health outcome could not be concluded, some evidence showed progression of some issues. For example from health examination survey, no access to screening for hypertension declined from 71% in 2003 to 55% in 2008 (Srithamrongswat 2010). Different characteristic of three public health insurance schemes Since Thailand has three main public health insurance schemes after UC implementation covering 99.47% of its entire population (National Health Security Office 2010), the different characteristic of these schemes led to health inequity of beneficiary between schemes. 7

10 The CSMBS and UCS are financed by general tax whereas the SSS is financed by payroll tax with tripartite contribution, shared by employer, employee and the government with 1.5% of salary. Population coverage under CSMBS was about 5 millions (8% of population) and SSS was about 10 millions (16% of population) while UC scheme covered about 47 millions (75% of population). For service delivery, CSMBS beneficiaries can receive services at any public hospitals with the retrospective FFS payment on outpatient service and DRG on inpatient service. For SSS, they must receive services at the registered contractors hospital with more than 100 beds, which can be either private or public hospitals and are mostly located in Bangkok and urban areas. The payment method for the SSS is inclusive capitation for both outpatient and inpatient, with the adjusted compensation according to volume of use and risks. The UC scheme members require to receive services at the registered contracting units for primary care which almost all of them are public facilities. If the registered facilities cannot provide proper treatment, the patient will be referred to the higher level of health facility. The different characteristics of the three public health insurance schemes are shown in the table below. 8

11 CSMBS SSS UC scheme Scheme nature Fringe benefit Mandatory Citizen entitlement Population Government employees, pensioners and their dependants (parents, spouse, children under 18) Formal-sector private employees, establishments/ firms of more than one worker since 2002 The rest of population who are not covered by SSS and CSMBS 5 Million (8%) 9.84 Million (15.8%) 47 Million (75%) Source of finance General tax (~323 US$/Cap*) Tripartite from employer, employee, government rate 1.5% of salary General tax (62 US$/Cap) (maximum salary: 441 US$) (health care 37 US$ /Cap, total 63 US$/Cap) Management organization Comptroller general under ministry of finance Social security office under ministry of labor and welfare National Health Security Office (NHSO) Benefit package No preventive care No explicit exclusion Special bed Small number of limited condition e.g. Non medical plastic surgery Small number of limited condition Include Prevention & promotion Service delivery Public provider only, Private in emergency, selected disease (2011 Public and private hospital more than 100 beds (50% private Public and private contracting unit for primary care(cup) Payment OP: Fee-for-service Capitation both OP and IP OP: Capitation IP: DRGs IP: DRGs with global budget 9

12 Adapted from: (Mills, Tangchareonsathien et al. 2005) The characteristic of beneficiary under each scheme is different. The UCS mainly covers poor people. Nearly 50% of population in the scheme are categorize into poorest quintile one and two while SSS covers poorest quintile only 7% nearly the same as CSMBS which is 6%. 100% 80% 60% 40% 20% 0% 20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest 11% 12% 18% 16% 35% 48% 55% 57% 38% 24% 34% 24% 21% 23% 24% 6% 26% 1% 4% 9% 7% 1% 6% 3% UC SS CS UC SS CS From: Limwatananon et al.(2009) The difference of payment methods leads to the inequity of services given among the three schemes. There has been evidence supporting the belief that services provided to beneficiaries under the three schemes are different. For example, from the data of health and welfare survey 2005, SSS increased the probability of ambulatory care visits by 41% compared to UC scheme membership, while there was no significant difference between UC scheme and CSMBS groups (Thammatacharee 2009). In terms of quality, evidence from claims data showed that readmission in chronic complication of DM patient in UC scheme had 23% higher chance of readmission compared to SSS and CSMBS. Greater access to selective care by the CSMBS patients is also obvious for two selected health interventions based on the national IP data from all types of hospitals during Both Cesarean section and laparoscopic cholecystectomy were much more common in CSMBS than in UC and SSS. These gaps are consistent over the 4-year period. One explanation of this result was that there 10

13 was incentive for physicians to provide services more frequent than the other schemes because of the fee-for-service payment system (Limwattananon, Limwattananon et al. 2010). Cesarean section Laparoscopic cholecystectomy 60% 50% 45% 47% 48% 50% 52% 50% 51% 53% 54% 55% 56% 54% 56% 58% 59% CS 60% 50% 49% 48% 51% 47% 47% 52% 50% 51% 53% 55% 55% 55% 56% 54% 51% CS 40% 30% 20% 10% 17% 17% 16% 17% 18% 20% 20% 22% 21% 20% 19% 20% 16% 16% 17% 17% 18% 18% 19% 20% 20% 20% 20% 20% 20% 21% 21% SS UC 40% 30% 20% 10% 28% 24% 25% 24% 23% 22% 24% 21% 22% 20% 30% 26% 26% 27% 27% 26% 22% 23% 23% 22% 18% 28% 27% 29% 28% 28% 24% 24% 24% 26% SS UC 0% % From: Limwatananon et al. (2009) This pattern is also consistent in the prescription of expensive drug. Propensity to receive expensive drugs is shown by monthly time-series over five years in the graphs below. CSMBS patients utilized very much more expensive drugs than patients in SSS and UC scheme. For example, Angiotensin receptor blockers were prescribed to CSMBS patient more than 20% while SSS and UC scheme were less than 10% during four year period from 2003 to This prescription pattern was the same as other expensive drugs such as Statins, Coxibs and the anti-platelet drug, Clopidogrel. 11

14 Angiotensin II receptor blockers Single source statins and new antihyperlipidemia CS SS UC CS SS UC Clopidogrel Coxibs CS SS UC CS SS UC From: Limwatananon et al. (2009) In general, CSMBS consumes more resources than other two schemes. With its fee-for- service reimbursement model, the total expenditure of CSMBS was dramatically increased every year especially after The main incretion was outpatient service while inpatient service seemed to be stable after implementation of prospective payment by using DRG payment in

15 61,304 62,196 20% 54,904 23% 20% 46,481 45,531 46,588 16% 12% 15% 10% 12% 26,043 37,004 38,803 12% 13% 30,833 13,587 16,440 17,058 20,476 6% 13,905 21,896 3,156 4,316 6,000 1,729 2,337 9,954 3,374 4,826-2% 5,866 7,007 9,509-2% Annual grow th (real term) Total expenditure (million Baht) Outpatient (million Baht) Inpatient From: Comptroller General Department, Ministry of Finance These findings have allowed the inequity issue among the schemes become more intense. The major critics are; who pay more and who pay less, or what kind of benefits should be added for scheme which paid more. The rationale behind SSS is that beneficiaries contributed for health service each month from salary and they also pay general tax while UC scheme pay only tax without contribution but SSS seems to get the same service or less in some situations. CSMBS members believe that they accepted low salary compared to private since they needed to have more privilege of health service when they retired. UC scheme by law had a section to allow merging fund from CSMBS, SSS and TAP but they did not enough knowledge how to move in the way as mention in the act although some propose that this should be a basic benefit package that everyone in the country could receive while each scheme can add some privilege benefit to their beneficiaries such as special room. This issue might still the debate in Thai society for a long time. How health inequity issues moved in Thailand? The inequity in Thailand has begun to be a policy issue since The government introduced the low income card in order to help the poor patients obtained health care from public facilities without charge. The initial idea was not complicated since it covered only the poor who had income per year lower than 13

16 1,000 Baht ($30 USD approximately in 2010 rate) (Suksiriserekul 1998). Normally, the National Economic and Social Development Plan have been implemented through the government policies. When it came to the era of the fifth five-year National Economic and Social Development Plan ( ), the inequity problems were apparently emphasized in the plan that it aimed to solve impoverishment of the people in the specified areas. Consequently, public facilities have been widespread to the rural, for example, community hospitals covered in most districts (Termpitayapaisit and Paem 2009). Health welfare scheme was reconsidered to separate the card holders into 3 types; elderly, children and the poor (Suksiriserekul 1998). In the sixth five-year National Economic and Social Development Plan ( ), the plan stated to increase the country development capacity, the economic grew prosperously reflected in the GDP growth around 10.9% per year. Nonetheless the political and social movements to improve inequity, income disparity has become wider (Termpitayapaisit and Paem 2009). Gini coefficient 1 for income distribution has increased more rapidly from 0.45 in 1975 to 0.49 in 1988 and to 0.54 in 1992 (Sakunphanit and Suwanrada 2011). Many of the poor dared not to use the low income cards due to doubt in the quality of care given for free. Insufficient and inappropriate budget distribution of low income card also presented (Suksiriserekul 1998). Social problems and inequity became more explicit after the global economic crisis in late 1997; in addition, the circumstance also brought the Thai health care reform to light. An independent institute, Health System Research Institute Research (HSRI) with an assistant team from Asian Development Bank (ADB) provided evidence-based recommendation that Thai health system needed to be reformed in order to achieve equity, efficiency and quality (Pannarunothai and Srithamrongsawat 2000). The reform plan originally was to combine the three public health insurance schemes into one universal coverage scheme. However this idea met resistance from civil servants in other government sectors who benefited from running the other two schemes(towse, Mills et al. 2004). 1 Gini coefficient is a measurement of inequality of distribution. The value is between 0 and 1, 0 means total equality which 1 means total inequality. 14

17 Apart from the financial issue, distribution of health workforce was also problematic. The ratio of population per doctor was different across regions in Thailand. Northeastern area has the highest population per doctor proportion in the country which emphasis the disparity gap when comparing with that in Bangkok area. However, the situation tends to improve so far. There were a few policies to ease the problem such as the increasing production of doctors and the new university admission system that promote the rookies to work in rural areas. As a result, the ratio of population per doctor in the Northeastern region increased from 7,614 in 2001 to 2,870 in Region Bangkok Central 3,375 3,566 3,301 3,134 3,054 2,963 2,683 2,839 1,864 Northern 4,488 4,499 4,766 4,534 3,768 3,351 3,279 3,386 2,002 Southern 5,127 4,984 4,609 3,982 4,306 3,789 3,354 3,694 2,250 Northeastern 7,614 7,251 7,409 7,466 7,015 5,738 5,308 5,028 2,870 From: (Wibulpolprasert 2010) Universal Coverage Move in Thailand To move important policy such as universal coverage in Thailand, there is an approach proposed by Prof. Prawase Wasi called Triangle that moves the mountain. Mountain is a symbol representing tough problem. Triangle stands for a system consisting three mountain movers, working together, such movers are; 1) research-based knowledge, 2) social movement or social learning and 3) regulations form political movement (Wasi 2000). Thailand has long been invested in research and capacity building before proposing policy option in moving to universal health coverage. For example, cumulative experience provider payment both fee for service in CSMBS and capitation in SSS result in moving to capitation payment in UC scheme(tangcharoensathien, Prakongsai et al. 2007). Social movement from NGOs to mobilize more than 50,000 people to support universal health coverage bill played an important role for parliament to consider the bill. Political movement was a crucial part of universal health coverage in Thailand. Leadership of politician with influenced campaign of 30 Baht cure all 15

18 disease and bridging political movement with evidence helped universal health coverage moved rapidly. Dr. Sanguan Nitayarumphong, who was a very first campaigner of universal health coverage move in Thailand gave details of universal coverage program move in his book Struggling along the path to universal health care for all into three phases as shown in diagram below (Nitayarumpong 2006). The main three steps comprised of policy move, implementation, and sustainability of the program. The policy move was based on the concept of triangle that moves the mountain of Dr. Prawas Wasi as mention above. From his experience, he proposed two important policies to various political parties during election which were 1) generation of revenue into public health finance program by using sin tax and 2) universal health care (UHC) coverage. Of which, the Thai Rak Thai party leader accepted the second one to be policy of the party. The other important issue was how to apply that policy of UHC. This implementation plan was crucial as a policy movement. The UHC implementation composed of three reform issues which were new health care financing, new budget allocation, and new health care delivery model. The proposal of new health care financing was based on objective of reduce out of pocket payment system and equalize health care financing by collective financing mechanism. Tax finance was one of easily way to generate the adequate level of government revenue. Since 1978, past experiences from the public insurance schemes have provided ideas for the new budget allocation mechanism. For examples, CSMBS payment by fee-for-service proved that it encouraged the increasing health care costs. SSS provided a successful story of using capitation both in outpatient and impatient service to limit the costs. Low income card gave experience of using prospective case based payment by diagnosis related groups (DRGs). Furthermore, a global budget in provincial level under a number of beneficiaries provided information of closed end budget management(towse, Mills et al. 2004). Another important movement was the new idea of direct contracting to the primary care units (PCUs); the fund could flow directly to the PCUs instead of general or regional hospitals. A PCU was a unit in the network of primary care consisting of a district hospital and health centers in the catchment area. A new concept of creating health by people was introduced to promote good health. 16

19 However, this movement is still in a long way to success since there is need to change attitude of both beneficiaries and providers. Adapted from: Wasi P. (2000), Nitayarumphong (2006) As mentioned above, policy move and implementation is a tough and long process of movement not only the UHC program but also other important policy issue. However, the harder movement is how to sustain the program in the system in order to achieve the policy objectives. The crucial sustainability of a policy move is to manage the triangle continuously. Further knowledge of how to improve health system and popular support of the program must be maintained while the political decision making must not be allowed to decline. In UHC movement, there are three challenges that support the program including assuring quality of care, job satisfaction for healthcare provider, and effective management. Quality of care of the UHC in Thailand is the most important measurement to assess the value of UHC. Lacking of quality of care would turn people back to the old system and end up with collapse of the program. To develop full confidence for the society on UHC, the quality of personnel and technical service should be enhanced; timely diagnosis with effective treatment should be improved. 17

20 Concurrently, UHC could not survive without sustaining the worker confidence. The UHC has created tremendous workload and misunderstanding about job security and technology advancement. Therefore, maintaining satisfaction of healthcare personnel by using both financial and non financial incentive is a prime concern of the government. The last burden of sustaining UHC is that social want to receive high quality of care with proper tax burden. The system needs to be transparent, accountable, and incorporate public participation. The addressed problems need to rapidly solve to maintain atmosphere of ongoing improvement. The budget allocation needs to be more efficient. The system needs to be more equitable and efficient. Even though the UHC achievement in Thailand has progressed constantly, there are still problems of some issues, for example, whether Thailand should follow the solidarity idea as the European countries or based on ability to pay as leaded by the USA. The solution of any problems in health system cannot solve easily without comprehensive knowledge, good planning of implementation, sustaining solutions and continuous improvement of implementation. Adapting this conceptual framework into the implementation, UHC in Thailand was planned as a rapid move by dividing the implementation into four phases to coverage people all the country within two years. The first phase was to cover beneficiaries in six provinces. After that, the scheme expanded to fifteen provinces within six months. The third phase was to spread out to all provinces in the country except Bangkok. Then the final phase was to implement in Bangkok. Case study of political move in stateless people rights One example of implementing conceptual framework of political movement related to UHC move was the return rights of stateless people in Thailand. In Thailand, there are groups of people who are identified as undocumented person, refugees, minority, migrant workers or a common term, stateless person. Such of these people share one problem in general, they do not have Thai nation. Many of them, for example minorities or undocumented persons, were Thai born and have long been stayed in the country waiting in the process for citizenship. Possession of Thai nationality is not only for living with respect in social, but also a crucial access to fundamental rights especially, the right to healthcare services. Before the era of UC, stateless persons used to have low income health card that they used to get care in public health facilities with none of 18

21 charges. Nonetheless, after launching UCS, the low income health card became invalid and these people were excluded from UC eligibility. The reason was because stateless people do not have Thai nationality and by interpreting the National Health Security Act 2002 that universal coverage was reserved only for Thais. As a result, 457,409 people were withdrawn from the universal coverage (NHSO 2010). Consequences of the UHC implementation, stateless persons were denied access to free health services in public facilities. The reason given was that government did not allocate any budgets for them. In one case, a severe patient had to tell a lie to healthcare officer that she had enough money to pay for treatment, actually she did not otherwise she would not get the adequate services. Another case of a cancer patient, he passed away and left a huge debt to his family which they did not know how they could pay back. In addition to unable to obtain personnel health care, social problems followed. Contagious diseases such as malaria, tuberculosis, severe diarrhea and sex transmitted diseases were concentrated among the stateless people. Rare cases were found in new areas, especially the borderlines. Bad debts were financial burden for hospitals of humanity without any support from the government. In 2008, for stateless persons who got services from public health facilities, the health expenditure of 468 million Baht or 117 million USD was reported (NHSO MOPH and HISRO 2009). This problem had been in public awareness and there were attempts from various sectors to move the mountain forward. In 2005, the National Security Council offered the cabinet the strategic plans for dealing with citizenship and the rights of stateless person. Nonetheless, the strategies were agreed especially in education problem, but there was lack of practical procedures to pursue in health issue. At that time, the National Health Security Board (NHSB) proposed the cabinet to approve the health insurance for stateless person, twice in 2005 and 2006 but both were rejected for the concern of national security. However, the movement has gone forward by launching a series of six studies to identify the health problems of statelessness in Thailand in order to scope the problems conducted in 2008 by NGO researchers, probe the current situations and design the appropriate solutions for this matter. At the same time, the NHSB proposed the cabinet for reconsidering the health insurance issue, again it was rejected and the cabinet advised to seek for stakeholders views. Therefore, the National 19

22 Health Assembly held a forum consisting of a range of government agencies, for examples, from the National Security Council, Ministry of Public Health, Ministry of Education, Ministry of Labour, Ministry of Interior, Immigration Office and the National Health Security Office. The forum agreed in principle that it was the responsibility of the government to establish good health for its residences. Therefore, giving health security for stateless persons would be providing fundamental rights of human to support and strengthen the system as a whole. In 2010, NHSB once again tendered the proposal to the cabinet. The cabinet finally approved. Accordingly, the targeted stateless people, 600,000 approximately were then entitled to the UCS with the rights to access healthcare equally to Thai under UCS. The cost of health care was 2,067 Baht/Capitation since this group of people is mainly in the working age group with some of children as shown below; therefore, overall Baht/capitation was lower than Baht/capitation of overall people. In addition, a communicable diseases control fund was set up particularly for bordered hospitals in order to support their control of disease activities. This success story could prove that success movement of important policy issue from three pillars, knowledge, political movement, and civic movement. From: NHSO

23 Evidence of health equity achievement in Thailand from Universal Coverage Scheme The implementation of the UCS as the attempt to provide access to health for all and protect household catastrophic has shown the positive effects in a number of studies. For examples of financial evidence, there were percentage reductions of financial health indicators. Of out-of-pocket paid for health per household income gradually declined as the most obvious in the lowest income deciles, from 6.4% in 1992 to 2.3% in 2006 (Prakongsai, Limwattananon et al. 2009). This result corresponded to another study (Somkotra and Lagrada 2008) which found that the richer income quintiles were at more tendency to pay from their own resources. Type of health Kakwani index Share of healthcare finance payments Out of pocket % 27.9% 26.4% 23.2% payments Direct tax % 18.8% 20.8% 24.5% Indirect tax % 38.2% 37.1% 35.2% Private insurance NA 9.6% 9.2% 8.9% NA premium SHI contribution NA 5.3% 5.9% 6.8% NA Private insurance NA NA NA NA NA NA 17.1% premium & SHI contribution Overall Kakwani index % 100.0% 100.0% 100.0% From: Limwattananon, Vongmongkol et al. (2011) Catastrophic health spending which specified as a stage that out-of-pocket payment for health higher than the threshold of 10% of total household consumption decreased steadily in all income quintiles 21

24 during the UC implementation with the power to reduce spending in the poor group the most (Somkotra and Lagrada 2008; Prakongsai, Limwattananon et al. 2009). For healthcare induced impoverishment indicator, usually, out-of-pocket cost borne by inpatient services was the main cause of impoverishment. However, in the UC period this figure went down from 11.9% in 2000 to 2.6% in 2004 (Prakongsai, Limwattananon et al. 2009). Data from Health and Welfare Survey in various year showed that the incidence of catastrophic health expenditure reduced in both poorest quintiles and least poor quintiles with more reduction on poorest quintiles as shown in the table below (Limwattananon, Vongmongkol et al. 2011). Although there was still 2% of the population faced with catastrophic expenditure, this was significantly lower in poorest quintiles which was 0.9%, compared to least poor quintiles which was 3.3%. Income quintiles Q1 (poorest) 4.0% 1.7% 1.6% 0.9% Q5 (least poor) 5.6% 5.0% 4.3% 3.3% All quintiles 5.4% 3.3% 2.8% 2.0% From: Limwattananon, Vongmongkol et al. (2011) Regarding the service coverage findings, after implementing the UC there was wider and greater outpatient utilization, particularly the lower income quintiles at health centres and district hospitals as demonstrated by negative concentration indices (CI) (Prakongsai, Limwattananon et al. 2009). The CI ranges from -1 to +1. A CI of zero means an equal distribution of particular indicator throughout the economic gradients. A negative CI indicates a concentration among who are poorer group while a positive CI reflects concentration in richer group. Mother and child health also distributed quite well though, the wealthy mothers appeared to have better access to antenatal and delivery care due to the higher level of education (Limwattananon, Tangcharoensathien et al. 2010). In addition, child malnourishments also concentrated on poorer group. The CI was between in wasting to in under weight. Additionally, the high cost benefit packages which once were excluded from the UCS caused either barriers to adequate treatment or bankrupt by health spending to poor patients 22

25 (Prakongsai, Palmer et al. 2009). Equity in service utilization in outpatient and inpatient were shown below. The negative value meant that service pro poor while positive value meant pro rich. Data analyzed from Health and Welfare Survey in various year showed that for ambulatory care in health centres, district hospitals, and provincial hospitals were pro poor while university hospitals seem to pro rich. This result can be implied that district health centres, district hospitals, and provincial hospitals performed well in terms of pro poor utilization. This might be due to the geographical proximity to rural population who are vastly poor. This pattern was consistent before and after UHC implementation meant that pro poor utilization was maintained. However, the pro rich pattern of university and private hospital might be explained that main customers of these hospitals are CSMBS and SSS patients who are better off than UC scheme patients. This pattern was similar in hospitalization of inpatients Ambulatory care Health centre District hospital Provincial hospital a University hospital Private hospital Hospitalization District hospital Provincial hospital a University hospital Private hospital From: Limwattananon, Vongmongkol et al. (2011) 23

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