Transcript Reaching the Poor: The Case of Universal Coverage in Thailand

Reaching the Poor: The Case of
Universal Coverage in Thailand
Chutima Suraratdecha
Somying Saithanu
Viroj Tangcharoensathien
International Health Policy Program, Thailand
Reaching the Poor Conference, 18-20 Feb 2004, Washington DC
Program characteristics
 Universal Coverage Policy
 UC, Gold card, 30 Baht Policy, 30 Baht treat
all
 April 2001, pilot project in 6 provinces
 April 2002, national coverage
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Characteristics
MWS
CSMBS
SSS
WCF
Health Card Scheme
Nature of the
scheme
Social welfare
Fringe benefit
Compulsory
Compulsory
Voluntary
Model
Public
integrated
model
Public
reimbursement
model
Public
contracted
model
Public reimbursement
model
Public integrated model
Population
covered
The poor,
elderly,
children under
12 years old,
secondary
school student,
the disabled,
monks and
veterans
Government
employees,
pensioners and
their dependents
(parents, spouse,
children)
Private formal
sector
employees, >10
worker
establishments
Private formal sector
employee, >10 worker
establishments
Non-poor households not
eligible for medical
welfare scheme,
community leader and
health volunteer’s
families
Source of funds
General tax
General tax
Tripartite
1.5% of payroll
each (reduce to
1% since 1999)
Employer, 0.2-2% of
payroll with experience
rating
Household 500 Baht +
tax 1000 Baht
Financing body
Ministry of
Public Health
Ministry of
Finance
SSO
SSO
Ministry of Public
Health
Payment
mechanism
Capitation plus
global budget
Fee for service
Capitation
Fee for service
Proportional
reimbursement among
primary, secondary,
tertiary care
Types of
benefits
Comprehensive
package
Comprehensive
package
Non-work
related illnesses,
injuries
Work related illness,
injuries
Comprehensive package
Characteristics
UC
Nature of the scheme
Social welfare
Model
Public contracted model
Population covered*
People not covered by SSS
and CSMBS (45.7 million)
Ambulatory services
Registered public & private
Inpatient services
Registered public & private
Choice of provider
Registration required
Cash benefit
No
Types of benefits
Comprehensive package
Conditions excluded
12 conditions
Maternity benefit
Yes
Annual physicals
Yes
Prevention and
promotion
Yes
Services not covered
Private bed, special nurses
Source of funds
General tax
Financing body
Ministry of Public Health
Payment mechanism
Inclusive capitation or
capitation for OP and DRG
for IP
Co-payment
30 Baht per visit
SSS & WCF
CSMBS
Research questions
 How effective is the UC implementation?
 Coverage?
 Indicators across insurance schemes?
 Impact on providers?
5
Methodology
 Six-month sample of households
interviewed by the 2002 SES
 Random sample of 515 households
(1834 individuals) in Tak,
Sakolnakorn and Narathiwat
representing 3 regions, low income
and high HIV prevalence provinces
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Respondents profile (1834 individuals)
No Ins.
9%
Others
17%
UCP
30%
Male
48%
Female
52%
UCE
44%
>49
19%
Voc., >
secondary
9%
0-4
9%
>4-15
24%
>15-49
48%
No edu
19%
Secondary
17%
Primary
55%
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Performance: coverage
Concentration curve for insurance type
cumulative % respondents in each
insurance group
100
90
80
70
60
50
nonUC
40
UCE
30
UCP
20
Uninsured
10
Equality
0
0
20
40
60
80
100
cumulative %respondents
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Performance: coverage
 164 respondents (8.9%) had no health insurance
Voc.,>secondary
4%
Richest
17%
Secondary
14%
No Edu
47%
Prim ary
35%
Poorest
39%
Fourth
18%
Middle
13%
>49
14%
Second
13%
0-4
18%
Female
43%
>15-49
39%
>4-15
29%
Male
57%
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Performance: coverage
73%
66.50%
OTHER
%
VHC
MWS
No ins
22.30%
18.60%
5.70%
2.60%
UCE
5.80%
5.30%
UCP
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Performance: across insurance schemes
Consumption expenditure
Health Status
Other, 3991.8
Other, 89.8
%
Baht
UCP, 2183.4
Other, 89.8
UCE, 81.9
UCE, 1498.4
UCP, 80.9
No treatment
UCE, 41.4
%
Other, 12.4
UCP, 59.1
Other, 44.1
UCE, 8.6
%
UCP, 59.1
IPD
UCP, 6.1
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Performance: across insurance schemes
Know STI
Family planning method
Other, 98.3
Other, 90.1
UCP, 98.1
UCP, 71.3
%
%
UCE, 53.1
UCE, 92.9
Know AIDS
UCE, 92.9
Know AIDS transmission route
Other, 98.1
Other, 97.6
UCP, 97.5
UCP, 94.6
%
%
UCE, 95.8
UCE, 88.6
UCE, 94.1
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Performance: Illness and health
care seeking behavior
ML probit estimation with selection
Variable
Coefficient
Variable
Coefficient
Dependent variable: treatment Dependent variable: illness
Constant
-1.10
Constant
-0.53*
UCE
-0.17
Age 16_30
-0.15
UCP
-0.22
Age 31_45
0.08
Uninsured
-0.54*
Age 46_60
0.42**
Lncons
0.19**
Age 61&up
0.52**
Urban
-0.09
Lninc
0.06*
Primary
0.70**
Male
-0.24**
Secondary
-0.19
Uppersec
-0.38*
# of obs = 1834, censored obs = 959
Wald test P = 0.8304
*, ** denote significant levels at 95% and 99% confidence level
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Performance: Illness and health
care seeking behavior
ML probit estimation with selection
Coefficient
Variable
Coefficient
Variable
Dependent variable: illness
Dependent variable: facility
-1.13**
Constant
0.23
Constant
-0.24*
Age 16_30
-0.35**
UCP
0.13
Age 31_45
-0.06
Lncons
0.42**
Age 46_60
-0.28*
Urban
0.64**
Age 61&up
0.62*
Primary
0.16**
Lninc
-0.07
Secondary
-0.24**
Male
-0.36
Uppersec
# of obs = 1355, censored obs = 682
Wald test P = 0.5030
*, ** denote significant levels at 95% and 99% confidence level
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Performance: impact on providers
 857 health staff from 216 UC facilities
 Inadequate supply
 Inadequate financial resources
 Lack of understanding on benefits and coverage
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Policy implications
 Universal coverage
 Targeting issue - UCE vs. UCP
 Quality of care, long waiting time, poor
attitude of health provider
 Out-of-pocket expenditure
 Inequality across health insurance schemes
and economic classes
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