Thai UC System

8/19/2019 Thai UC System

http://slidepdf.com/reader/full/thai-uc-system 1/54

Somsak ChunharasSecretary general

National Health Foundation

Thailand



Presentation Outlines

1. Thai UC system overview

2. Informal workers and Social Security

System

3. Efforts and innovations for health

promotion and diseases prevention

among informal workers

4. Marginalized population and Thai UC

system (migrant workers, Thais without

citizenship, tribal population)



UNIVERSAL HEALTH

SYSTEM AND ITS

PERFORMANCE

1

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UC & informal workers



4

• Population - 67 million

• GNI 2010 US$4,210 per capita, Gini 40

• Total Health Expenditure (2010NHA)

• US$194 per capita, 3.9% GDP,

• Sources: Public 65%, SHI 8%, Private

25%, OOP 14% of THE,

• GGHE 13.1% GGE

• Health status

• Total fertility rate 1.6 (2009)

•

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)

Country profiles: Thailand

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Health service delivery system in Thailand

Health centers9,768

CommunityMedical

Centers 365

District hospitals

734

Provincialhospitals 71

Pharmacy11,154

Private clinics17,671

Otherpublic

hospitals60

Privatehospitals

322

Regional

hospitals 26

25

Universityhospitals 11

Specializedhospitals 48

MOPH facilities

LGUs

Sub-district

District

Province

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5



Long march towards universal health coverage in Thailand

using National Health Accounts (NHA) dataGNI per capita, 1970-2009

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6



Brief historical overview

• First health security for Thai population startedsince 1975 with Indigent cardห for the poor giving

free services for health services at public sector

facilities.• Civil servants have had health security provided

by the government on a retrospectivereimbursement basis before 1975

• Social security system established with healthinsurance as an integral part for formal sectorworkers since 1990

7

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• Up to 2001 there was still around 25% of Thai

population without health security and can

face catastrophic illnesses

• Discontinuing indigent cards for the poor and

used general tax to start a new UC system for

the poor and the rest of Thai population not

covered by the other 2 major systems (SSS andCSMBS)

8

Brief historical overview

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Health care financing strategies of the UC policy

•

Removal of financial barriers to health services;• Risk sharing expand UC scheme to uninsured and merge LIC

and health card scheme

• Shift of the main source of HCF from OOP to general tax;

• Sustainable system – Policy sustainability Law

– Financial sustainability

– Institutional sustainability

•

Participatory process• Protect people right complaint system, public hearing

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Health care financing strategies of the UC policy

•

Promote primary care

Promote the use of primary care bycontracting a primary care unit (PCU) as the main contractor and

gatekeeper

• Benefit package of the UC scheme is quite comprehensive

comprising OP, hospitalization, health promotion and disease

prevention, most of the high cost care, dental care, medicines

and operations

• Decentralization purchaser provider split

• Cost containment Changing provider payment from historical

allocations to close-ended payments;

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11

ทมา

: ส านักบรหารงานทะเบยน สปสช. ณ กนัยายน 2556

Total coverage of

health insurance

99.87 by 3 major

systems

[UC 75 , SSS

16 , CSMBS 7 ]

1,470,134

9,750,818

29,937,321

14,939,648

7,304,398

1,123,273

UC beneficiaries by age groups 2013

ทารก 0-1 ป

เดก 1-15 ป

ผ ใหญ 15 - 59 ป

หญงวัยเจรญพันธ

ผ ส งอาย>60ป

ผ พการ

Infants 0-1 yrs

Children 1-15 yrs

15%

Population covered

Civil servants

Social security

Local admin officers

unregistered

others

UC beneficiaries

Infants 0-1 yrs

Elderly >60 yrs

Adults 15-59 yrs

Females in

fertile age group



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12



2010

- herbal medicines and orphan drugs- Psychiatric patients institutional care

2007

- Thai traditionalmedicine

2008

-peritoneal dialysis and renal transplantation

- Methadone for drug addicts coming fpr treatment

2005

ARV, free condom, couseing and testing, CD4 count)

2012

- Liver transplantation

-cardiac Surgery

2009

-High cost medications

- วseasonal flu vaccine

2013

- Expanding seasonal flu coverage to

another 2 target groups

- stem cell therapy for hematopoeitic

cancers

- long term care linking with Home careand community care

2002

Basic services for most curative services including diagnostic, dental,preventive and rehabilitative services for the Thai citizen

Benefit

package

evolution



UC per capita

2,895.09 ($93)

AIDS

Renal

2nd

prevention

formetabolic

DX

Hardship

HMD

Outpatient 1,056.96 ($34)

Inpatient 1,027.94 ($33)

High cost, accident, emergency,DMI 271.33 ($8.8)

P&P 383.61 ($12)

Rehabilitation 14.95 ($0.49)

Traditional Medicine 8.19 ($0.3)

Depreciation 128.69 ($4.2)

Compensation 3.32 ($0.1)

Mitigation for providers 0.10 ($0.003)

UC per capita for medical services, 2014

Source: NHSO

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14



NHSO

Regional office

NHSO

MOPH

PCMO

CUP(mostly district

hospitals)

PCU (healthcentres or

private clinics)

PP National Program

PP Area based

Local

Authority

PPCommunitybased

CommunityFund

UC Budget Allocation

PPExpress demand

PP Expressdemand

PP Expressdemand

Source: NHSO

-Specific services-Out reach services

Outpatient

Inpatient

Reimbursement forinpatient

Proposal & report forPParea based

Proposal for PPcom based

Proposal for PPcom based

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15



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16



Quality Improvement towards accreditation of contracted hospital

(2003-2013)

55.8150.62

17.58

8.64

5.77 3.762.73 0.91

0.61 2.42 2.50

22.1026.45

63.60

54.73

42.89

25.43

14.44

10.025.97 4.26 3.07

15.98 16.18 4.96

20.81

31.34

48.22

56.16 65.59

63.5653.34 51.78

6.12 6.7413.86 15.82

20.00 22.58 26.67 23.4829.86

39.98 42.65

0

20

40

60

80

100

ป 2546 ป 2547 ป 2548 ป 2549 ป 2550 ป 2551 ป 2552 ป 2553 ป 2554 ป 2555 ป 2556

ร อยละ

ร อยละโรงพยาบาลในระบบหลกัประกันสขภาพถวนหนา จาแนกตามขันการรับรองคณภาพตามมาตรฐาน HA ปงบประมาณ 2546 - 2556

รับรอง HA รับรองขัน 2 รับรองขัน 1 กาลังพัฒนา

ท มา: สถาบนัรบัรองคณภาพสถานพยาบาล (สรพ.) ป 2556 ข อมล ณ 30 กันยายน 2556, วเคราะห โดยสานักกากับคณภาพและประเมนผลลพัธ สขภาพ สปสช.

17

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83.01

(8.23)

83.42

(8.26)

82.35

(8.18)

83.91

(8.26)

83.16

(8.04)

88.37

(8.54)

89.32

(8.58)

89.76

(8.77)

92.75

(8.81)

90.79

8.63)

95.49

(8.58)

45.66

(6.15)

39.34

(6.22)

47.72

(6.14)

50.99

(6.28)

56.57

(6.50)

60.75

(6.64)

60.27

(6.53)

78.75

(7.64)

66.86

(6.99)

68.48

7.08)

67.61

(7.01)

0

20

40

60

80

100

120

ป

2546

ป

2547

ป

2548

ป

2549

ป

2550

ป

2551

ป

2552

ป

2553

ป

2554

ป

2555

ป

2556

ร

อยละ

คะแนน

)

รอยละ คะแนน

)

ความพงพอใจประชาชนและผใหบร าร

ภาพรวม

ปงบประมาณ

2546 - 2556

ประชาชน

ผใหบร าร

หมายเหต: ร อยละของความพงพอใจได จากผลรวมร อยละผ ท ตอบว าพงพอใจและพงพอใจมาก

ท มา: ผลการสารวจความพงพอใจ โดยศนย เครอข ายวชาการเพ อสังเกตการณ และวจัยความสขชมชน มหาวทยาลยัอัสสัมชัญ (สารวจ พ.ค.-ม.ย.2546, เม.ย.-ม.ย.2547, ม.ย.2548, พ.ค.-ม.ย.2549, ม.ย.-ก.ค. 2550-2551, ส.ค.-ก.ย. 2552- 2553, 9-25 ก.ย. 54, ส.ค.-ก.ย. 2555,

วเคราะห โดยสานักบรหารยทธศาสตร สปสช.

18

people

providers

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Outcome: increased government health spending

Thailand THE 1994-2010

0

100,000

200,000

300,000

400,000

500,000

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Year

MilBaht

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

%

GDP

Government spending non-government spending THE, %GDP

UHC

achieved

Source: NHA1994-2010

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19



Outcome: reduction in out of pocket payment

42 % 44 % 44 % 50 % 50% 50 % 51% 50 %

58% 5 7% 58 % 56 %64 %

69 % 69 % 67 % 67 %

44% 43% 42%37% 35% 35% 34% 33%

27% 27% 26 % 27% 17%

1 4% 15% 15 % 14%

0%

25%

50%

75%

100%

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Year

%

Public SHI Households Other private

UHC

achieved

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20



21

Thailand: UHC prevents health impoverishment

• UHC can reduce poverty, in addition to improving health and

better access to health• Thai experience: UHC can reduce the number of households

with impoverishment

Source: analysis from Health and Welfare survey conducted by NationalStatistical Office, Thailand

142.3131.3

124.0 120.1

77.269.7

58.849.0

39.8

0

20

40

60

80

100

120

140160

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

1,000 householdsUHC

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Incidence of catastrophic health spendingOOP>10% total consumption exp.

Source: Analysis of Socio-economic Survey (SES)



23

UHC

achieved

Protection against health impoverishment

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INFORMAL WORKERS

AND SOCIAL SECURITY

SYSTEM (SSS)

2

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Situation informal workers, 2009

• Number of workers (38.4 Million)

– Informal workers 24 - 25 Million (63%)

– Forormal workers 14.1 Million (37%)

• Informal workers – Agriculture 14.4 Million (59%)

– Whole sale and retail trade 3.9 Million (16%)

–

Hotel and restaurant 1.9 Million (8%) – Factory 1.3 Million (5%)

– Construction 0.92 Million (4%)

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25



Situation: Informal economy

• No legal protection

– Social Security Act (1990)

– Labor Protection Act (1998)

•Instability of work and income

• Unfair hiring

• Lack of opportunity for training and development

•

Inadequate safety/ protection• Less accessibility to financial support / sources

• No union / lack of negotiation power

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26



Informal workers and SSS

• While SSS covered around 15 mil formal workers(compulsory), only 1,820,379 informal workers (out oftotal 25,140,771 => 7.24%) registered with SSS(voluntary)

• All of the registered informal workers did not receivehealth insurance benefits but emphasize on otherbenefits because active recruitment of informalworkers only started in 2014 when the government

decided not to enforce long term pension fund butenacted the inactive article 40 in the existing SSS Act.

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27



SSO – informal workers registered

• Construction workers

• Agricultural workers

• Vender / peddler

• Freelance – singer, actor, translator

• Transport drivers

• Home-based workers

• Skilled workers

• Other Self-employ / freelance

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28



SSS benefit(article 40 SSS Act – Voluntary member)

• Benefit Package 1 – $3/Month (B100)Self:Government = 2:1

– Compensation for lost income (illness leave)

– Disability compensation

– Money for funeral

• Benefit Package 2 - $5/Month (B150)

– Package 1

– Old age Pension

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29



SSS benefits for Formal Workers

(compulsory)

• Compensation for lost income

• Disability compensation

• Maternity benefits

• Health insurance

• Pensions

• Life insurance

• Workmen compensation (work-relatedinjuries and death)

30

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Health insurance: Comparing 3 schemes(Social Security, Civil Servant’s Medical Benefit, Universal Coverage)

Services for Occupational Illness SSS CSMBS UC

Medical care WCF + SSO No categorized No categorized

Rehabilitation for work Yes No No

Compensation WCF + SSO No NoHealth Examination Employer +

NHSO

Comptroller’s

General Dept.

No/Not Clear

Chronic Diseases Screening NHSO NHSO NHSO

Health Risk Evaluation Employer No No

Health Risk Evaluation (Basic) No No No

Health Examination based on Risk

Environment

Employer +

NHSO

No No

Note: WCF = Workman’s Compensation Fund

SSO = Social Security Office

NHSO = National Health Security Office



Problems found

• Working environment

– Inadequate light /

lucidity

–

Inappropriate ergonomic – sitting on the floor

– Inappropriate machine,

equipment and tools

–

Dusty environment – Chemical exposure

– Long hour working

• Occupational Illness

– Eyesore, headache

– Joints and muscle pain

–Injuries

– Respiratory diseases /

illness

– Allergy

– Gastritis, Urinaryinfection

– Family problems

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Health Problems

• Occupational Illness

– Injuries

– Drug allergy

– Asthma

– Muscle pain

– Stomachache / Gastritis

–

Eye/ Sight problems – Stress

• Others

– Diabetes Mellitus

– Hypertension

– Arthritis

– Myocadial infarction

– Brest Cancer, Cervical

Cancer

– Caries

– Cataracts

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EFFORTS AND

INNOVATIONS TO

ADDRESS SPECIFIC

HEALTH NEEDS OF

INFORMAL WORKERS

3

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Risk Management for informal workers

Environmental Health Risk

Evaluation

(Community Survey)

General Health Screening

Health ExaminationFor specific Risk Group

Additional Health

Examination

(Health Effect)

Hospital

Hospital

PCU, Community

Health

volunteers

Community

Health

volunteers

Liver, Kidney functions

CXR

Eyesight, Hearing,Muscle, Lung, Chemical

toxin

Individual Health Risk

Screening forms

WISE, WISH

JSA, NB01

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35



Collaboration 2012- 2015

DDC

• Technical Support

• Tools Development

• Health Surveillance

System

PCMO & DHO

• Capacity Development

• Monitoring & Evaluation• Policy Implementation

NHSO

• Financial Support• Evaluation

Service Provider Unit

• PCU as direct providers• Supporting network

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36



Number of PCUs and occupational classes

at District Level, Lamphun Province

15

2

4

9

9

4

13

Wicker work, weaving, carving

Agriculture

Note: TBH – Tambon (Subdistrict) hospital = health centerF

Ban Hong

Agriculture Viang Nong Long

Pa ShangAgriculture, Weaving 13

Muang

Banthi Clothing, Agriculture,

Furniture making

Mae Ta

Tung Hua chang

Clothing,

Agriculture

AgricultureLE

E

Clothing,

Agriculture



Number of PCUs, Khon Kaen Province

12

18

6

8

11

13

5

6

17

5

15

8

26

5

7

11

3

13

3

6

11

5

5

13

13

PhupamanSichompoo

Choompae

Viangta

Nongnakham

Phuviang

Ubonrat

Suankwang

Nampong Kannuan

Samsung

Nongruea

Banfang

Muang

Prayouen

HadManjakiri

KokpochaiChonnabot

Wangyai

Wangnoi

NonsilaBanpai

Phon

Nongsonghong

Peuynoi

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38



Occupational Groups, Khon Kaen

Weaving, Wickenwork, F&B

Agriculture, Carpet,

Traditional Dabber

Weaving, F&B, Clothing

Weaving, Wickenwork, Food

Weaving, Wickering, Artificial Flower

F&B, Weaving, Wickenwork

Weaving, Wickenwork, Home decorations

Weaving,

Wickenwork

Weaving, Wickenwork, Broom

Weaving, Wickenwork, Mat

Weaving, Wickenwork, F&B

Weaving, Mat, Artificial Flower

Weaving, Mat,

prickled prok

Weaving, Wickenwork

Weaving, Wickenwork,

liquor distiling

Weaving, Wickenwork, Mat Weaving, Wickenwork,

liquor distilling

Weaving, Wickenwork, Broom

Weaving, Wickenwork, food

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39



Source of image: http://commons.wikimedia.org/w/index.php?title=User:Samulili/testi&oldid=10201495"

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Health Promotion and Prevention - Output

Health Risk Evaluation

Occupational Health Risk (1) Health Risk (2)

Set up program for screening

Based on risk factorsProgram for health screening

Interpret Results

Risk/ Abnormal

Findings (General

health) (2)

Risk/ Abnormal

findings (Specific to

work (1)

Risk/ Abnormal both

(1+2)Normal

(1+2)

Program 1 Program 2 Program 3 Program 4

Local Health

Situation for

planning

Individual

Health Status• Surveillance

• Monitoring

• Advocacy

Service data

For

performance

assessment

by NSHO



MARGINALIZED

POPULATION AND

INFORMAL WORKERS

4

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Health security of marginalized

populations

• Existing health insurance system under SSS

and UC does not adequately cover the

following groups

– Thai citizen without proper citizen ID or ID forspecial population groups (selected tribal

population)

–

Migrant workers (not formally recognized - illegal) – Cross border poor population seeking health

services in Thailand

43

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44

Existing Health Insurance Package

for Migrant Workers

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Health insurance for Migrating workers (Myanmar,

Laos and Cambodia) and family members

• One year insurance: $68 (B2,100/person)

– Health examination: $16

–

Health insurance: $52• Health Promotion and prevention (Provincial Level) $7

• Medical care and services (Hospital) $29

• ARV and Others (National/Central level) $10

•High cost medical service (National/Central level) $1.5

• Management (National/Central level) $4

(estimated exchange rate B31 = $US 1)

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45



Health insurance for Migrating workers (Myanmar,

Laos and Cambodia) and family members

• One year insurance for under 7 yrs child: $12

(B325/person)

– Health examination: free of charge

– Health insurance: $12• Health Promotion and prevention (Provincial Level) $2


• ARV and High cost medical service (National/Central level) $0.5



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46

Health insurance for Temporary work permit



p y p

migrating workers (Myanmar, Laos and Cambodia)

and family members

• 3-month insurance: $32 (B1,000/person)


–




•High cost medical service (National/Central level) $0.4



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47

Health insurance for Temporary work permit



p y p

migrating workers (Myanmar, Laos and Cambodia)

and family members



–




•

High cost medical service (National/Central level) $0.8• Management (National/Central level) $2


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48



Health insurance for general foreign employee

• One year insurance: $90 (B2,800/person)


–




•

High cost medical service (National/Central level) $2• Management (National/Central level) $4


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49



Health insurance for Migrating workers awaiting social

security health insurance



–




•

High cost medical service (National/Central level) $0.3• Management (National/Central level) $1


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50

Ch ll f i li d



Challenges for marginalized

populations

• Public system providers treated these population on amerit basis – no budget allocated to the healthfacilities concerned. Some may receive special projectfunds (hill tribe population in particular) => small

border hospitals or those with• Diseases surveillance and certain diseases prevention

interventions existed through CDC teams (Filariasis,AFI, malaria, tuberculosis,)

• Needs to change legal framework to better integratethem into the “system” (thru either UC or SSS)

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Conclusions

•

Informal workers are entitled to comparable benefitsas formal workers when it comes to health insurancethough thru 2 separated schemes

• Health risks prevention and management are poorer

for informal sector workers though initiatives existed but couldnot scale up

• District health system plays crucial role in providingcost-effective services and equitable access for all

covered under UC scheme• Future of health benefits for informal sector

(+migrant workers) still unclear – could shift tocontributory system and integrated within SSS.

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Challenges for further reforms

• The 3 major schemes of health insurance will continueto be managed by separated governing structure withpressure for system “harmonization”

• Institutionalizing health preventive and promotiveservices/intervention to reduce general and work-related health risk

• Health systems capacity to cope with – Increased workload and very strained health workforces

– Decentralization context –threats and opportunities

– Public private dialogues, better trust and collaboration

• Medical tourism and internal brain drains

• Long term financial sustainability – Universal access to renal replacement therapy-heavy fiscal pressure

– Second and third lines ARV – Medical technology advancement-main drivers in OECD

53

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Thank you for your attention

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