Policy in Action: Health Policies in Thailand

1. Viroj Tangcharoensathien MD PhD.ERF-UNICEF Workshop onSocial and Economic Policies for Child Rights with Equity Royal Orchid Sheraton, Bangkok, 1 July 2013 Policy in Action: Health Policies in Thailand

2. Country profiles: Thailand • Population - 67 million • GNI 2011 US$4,440 per capita, Gini 40 • Fiscal space: tax to GDP 17.6 (2011), revenue to GDP 21.3 (2011) • Total Health Expenditure (2010NHA) • US$194 per capita, 3.9% GDP, • Sources of finance: Public 65%, SHI 8%, Private 25%, OOP 14% of THE, GGHE 13.1% GGE • Health status • Total fertility rate 1.6 (2010) • Life expectancy at birth 74.1 years • U5MR 14/1000 • MMR 48/100,000 • Physicians per capita 4/10,000 • ANC & hospital delivery 99-100% (2009)

3. Objectives • How two contrast policies on health protection are translated into implementation • Health protection for Thai citizens • Health protection for non-Thai migrant workers • Conclusion and lessons

4. I. Health protection for Thai citizens: policy coherence and effective implementation

5. GNI and UHC trajectory 1975-2002

6. UC cube: what has been achieved? X axis: 99% pop overage by 3 schemes [UCS 75%, SHI 20%, CSMBS 5%] Y axis: Free at point of services, very minimum OOP, Low incidence of catastrophic health expenditure and health impoverishment Z axis: Extensive and comprehensive benefit package, very small exclusion list, Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines (Essential drug list)

7. Outcome: Increased utilization, low unmet needs Source: BMC Public Health 2012; 12: 923

8. UHC achieved Outcome: increased government health spending Source: NHA1994-2010

9. UHC achieved Outcome: reduction in out of pocket payment

10. Outcome: decreased incidence of catastrophic health spending [OOP>10% total consumption exp]. Source: Analysis of Socio-economic Survey (SES)

11. UHC achieved Outcome: Protection against health impoverishment

12. Outcome: health impoverishment subnational 1996 to 2008

13. How policies were translated into implementation and good outcome?

14. Health systems foundation: health workforceThreshold 2.28 MD+N+M per 1000 population Source: Kanchanachitra C et al Lancet 2011

15. Pre-UC expansion of health infrastructures and human resources UC scheme Asian economic crisis Asian economic crisis UC scheme Asian economic crisis UC scheme Sources: MOPH’s Health Resource Surveys (various years)

16. U5MR versus HSD 1970-2010

17. Effective implementations: enabling factors Systems design focus on equity and efficiency Supply side capacity to deliver services Extensive geographical coverage of functioning PHC and district health systems Long-standing policy on government mandatory bonding of all graduates (doctors, nurses, pharmacists and dentists) for rural services since 1972 Strong leadership with sustained commitment Continued political support despite changes in government: 11 Ministers of Health (2001-13) Capable technocrats Active civil societies

18. Effective implementations: enabling factors • Strong institutional capacities • Information systems • Burden of Disease, National Health Accounts, National Drug Account, National AIDS Spending Account, national household datasets for routine equity monitoring • Health technology assessment capacities • HITAP contributions and institutional links • Key platforms for evidence informed decisions • National Essential Drug List sub-committee • Benefit package sub-committee • Health systems research • Self-reliance, national resources supporting HSR • Capacities: evidence generation + policy uptakes

19. II. Health protection for non-Thai citizens: policy dilemma and poor outcomes

20. Size of non-Thai citizen by group2011 estimates

21. Contributions to the Thai economy • ILO 2007 estimate: • Migrant labour: 5% of total Thai labour • Contribution to economy: US$ 2 billion, 6.2% of GDP • 7-10% of industrial, 4-5% of agriculture sector

22. Health protection for non-Thai citizen • Policy incoherence across sectors: • health, labour, security, foreign affairs • Policy dilemma: • National interests versus human rights • National interests: • Rights to health by Thai citizens • Discourse: Thai budget for Thai citizen • Obligations as State Party to various international laws • Universal Declaration of Human Rights 1948 Article 25 (1) • Convention on the Elimination of All Forms of Discrimination against Women1979, Article 12(1) • Convention of the Rights of the Child1989 Article 24 • Convention on the right of persons with disabilities 2006 Article 25

23. Health protection mechanisms for non-Thai Incoherent policies result in fragmentation and very low coverage by various schemes Health insurance for people with citizenship problem (PCP) Social health insurance Compulsory migrant health insurance (CMHI) Out of pocket (OOP) Hospital fee exemptions International development partners

24. 1. Health Insurance for people with citizenship problems (PCP) Newly established in 2010 by cabinet resolution Strong civil society pressures on government Tax financed by Government, 2000 Baht capitation Half allocated to provider network, other half pooled at MOPH for payment IP and others Covers 0.45 to 0.5 million PCP Low use rate: lack of awareness, geographical, socio-cultural and language barriers.

25. 2. Voluntary social Health Insurance Low population coverage Implemented by the MOL Social Security Office, through MOU with 3 neighboring countries In 2012, of total 0.5 million eligible migrants (from Laos, Cambodia and Myanmar), only 0.2 million covered Limitations Employee contribution only, neither from employers nor government Employees not aware of their right and which is the contractor hospital hence low use rate Inefficient management: delay in documentation of eligibility to receive services Benefit package not response to their real health needs

26. 3. Compulsory Migrant Health Insurance (CMHI) First launch 1994: 500 Baht premium per worker per year Implemented by MOPH targeting workers not covered by social health insurance 2001, cabinet resolution formalize CMHI: Registered migrant paid 300 Baht for annual health screening and 1,200 Baht for curative services Required copayment 30 Baht per visit 2004, annual premium increased Screening 600 Baht, services 1,300 Baht 2013, CMHI for children <15 yrs at 365 Baht One Baht a day premium campaign with low uptake

27. 4. Out of pocket • Dominant source of financing among • unregistered migrants • Registered but uninsured by CMHI • People with Citizenship Problems • International displaced persons • Health seeking behavior • Purchasing drugs for self medication from private pharmacies • Low cost health facilities, • Lower cost outpatient mostly from private facilities • Public facilities for high cost inpatient services

28. 5. Exemption by public hospitals • At hospital discretion, for migrants who • Cannot pay for mostly IP, A&E and delivery • On humanitarian basis • Financial burden to hospitals, esp. clustering at the border areas • No clear budget line for subsidies • Paid by hospital revenue, no incentive to exempt • Tak Province, Thai-Myanmar border, 2012 • Total exemption 112.3 million THB for the uninsured migrants • Revenue 16.9 million THB from the insured migrants • As results of civil society pressure, • The government allocated 360 million THB to border hospitals as temporary relief measure

29. 6. International Donors • Very insignificant • NGOs, e.g. • Medecins Sans Frontieres (MSF) • World Vision Foundation of Thailand (WVFT) • Volunteer clinics: • Mae Toa Clinic in Mae Sod District

30. Financial sources for healthcare services Source: Srithamrongsawat, Wisessang & Ratjaroenkhajorn, 2009

31. Reform choices • Expand the size of registered migrants • Minimize the size of non-registered, foresee huge resistance from corrupted bureaucrats, change mind set of all concerned parties 1. For registered migrants • Payroll tax financed scheme, covered by • Either by SHI managed by SSO or CMHI managed by MOPH: both require major reform • SHI • Legislative reform, significant changes in mindsets • CMHI • Purchaser provider splits, MOPH as purchaser and providers has conflict of interests and non-responsiveness • We prefer to terminate SHI and CMHI and transferred to be managed by NHSO • NHSO demonstrates transparent, capable purchaser, ensure right of members and very larger risk pooling

32. Reform choices 2. For remaining dependents of migrants • Tax financed subsidies through retrospective allocation of budget, managed by MOPH 3. Supply side reform • User and dialect friendly services • Availability of interpreters facilitate services

33. Reform roadmap

34. Conclusion • Deficiencies • No policy champions • Lack of policy coherence • Opportunities • Effective implementation platform is available but variation in policy and political commitment results in different outcomes

35. Key reading list • Balabanova D., McKee M., and Mills A., eds. Good health at low cost’ 25 years on. What makes a successful health system? London : LSHTM, 2011. • Jongudomsuk P., et al Evidence-based health financing reform in Thailand. In Clements B., Coady D., and Gupta S., eds. The Economics of public health care reform in advanced and emerging economies, 307-26. Washington, DC : International Monetary Fund, 2012. • Limwattananon S et al. Why has the universal coverage scheme in Thailand achieved a pro-poor public subsidy for health care? BMC Public Health 2012; 12(suppl 1): S6. • Kongsri S., et al. Equity of access to and utilization of reproductive health services in Thailand: national reproductive health survey data, 2006 and 2009. Reproductive Health Matters 2011; 19: 86–97. • Tangcharoensathien V. et al. Health-financing reforms in southeast Asia: challenges in achieving universal coverage. The Lancet 2011; 377: 863-873. • Limwattananon S., et al. Equity in maternal and child health in Thailand. Bulletin of the World Health Organization 2010; 88: 420-427. • Prakongsai P., et al. The Equity impact of the universal coverage policy : lessons from Thailand. In Dov Chernichovsky, and Kara Hanson, eds. Innovations in health system finance in developing and transitional economies, 57-81. London: Emerald Group Publishing Limited, 2009.

36. Thank you for your attention