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Inte
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The 3rd Global Symposium on Health Systems ResearchCape Town International Convention Center, Cape Town, South Africa
October 1st, 2014
Reducing impoverishment from health payments:
Impact of universal health care coverage in Thailand
Phusit Prakongsai 1
Supon Limwattananon 2
Viroj Tangcharoensathien1
1 International Health Policy Program, Ministry of Public Health, Thailand2 Faculty of Pharmaceutical Sciences, Khon Kaen University, Thailand
2
Long march to achieve UHC in Thailand: from targeting to universality, GNI per capita, 1961-2009
1963: $120CSMBS
1975: $390Low Income Card
1983: $760Voluntary Health Card
1990: $1490 SSS
1997: $2710 Asian financial crisis 2002: $1870
Achieving UHC
3
Three health insurance schemes cover the entire population of Thais since 2002
• Civil Servant medical benefit Scheme (CSMBS):– Tax financed scheme for government employees and
dependants, around 5 millions, • Social Security Scheme (SSS):
– Payroll tax financed scheme for private sector employees, around 11 millions,
• Universal Coverage Scheme (UCS): – Tax financed scheme for the remaining population who are
neither CSMBS nor SHI members, around 49 millions.
4
UHC cube: Thailand status
• X axis: – 99% of population coverage
• Y axis: – Free at point of services,
very minimum OOP, – Low incidence of
catastrophic health expenditure and health impoverishment,
• Z axis: – Extensive comprehensive
package, small exclusion list, almost all high cost interventions covered.
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ObjectivesObjectives
• To assess impact of the universal health care
coverage (UHC) on household impoverishment due to
direct health payments
Our focus is on the informal sector households:
- Economically inactive
- Self-employed
- Independent work
- Family business
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MethodologyMethodology
• Comparing pre-UC (1996-2000) vs. post-UC (2002-2009)
- Descriptive analyses
- Difference-in-difference (DID) approach
• Health impoverishment refers to
(Total consumption expenditure – Health payments) < Poverty lines
– Expenditure-based poverty lines as reported annually by NESDB
• Specific to urban-rural areas in 4 regions + Bangkok
– Consumption expenditures based on nationally representative household
Socio-economic Survey (SES) by National Statistical Office (NSO)
– Health payment including
• Medicines/medical supplies
• OP + IP services
• Household is the unit of analysis
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Results (1)Results (1)
1. At national level
2. At sub-national level• Regional level (urban / rural / Bangkok)• Provincial level
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8
13.7
4.2
5.0
4.4
17.3
5.0
5.9
5.1
16.0
4.8
4.9
4.6
19.7
5.4
5.5
4.9
18.1
5.3
5.1
4.9
22.3
6.6
6.2
5.3
13.5
4.4
4.3
4.4
16.1
5.3
5.0
5.1
10.1
3.9
4.2
4.0
12.9
4.8
5.1
4.5
8.7
3.4
3.7
3.7
11.5
4.5
4.8
4.6
8.0
3.1
3.4
3.9
10.9
4.0
4.3
4.7
8.4
3.4
3.9
3.9
11.2
4.4
4.8
4.8
7.1
3.2
3.6
3.7
9.9
4.0
4.3
4.4
0
10
20
30
40
1996 1998 2000 2002 2004 2006 2007 2008 2009
All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf All Inf
PL: Poverty lines; Inf: Informal employment sector
All vs. Informal sector, 1996-2009
Poor and near-poor households
Consumption expenditure: < PL < 110% PL < 120% PL < 130% PL
Source: Limwattananon S et al. (2011)
Distribution of 76 provinces in ThailandDistribution of 76 provinces in Thailandaccording to impoverished households (informal sector)according to impoverished households (informal sector)
(Year 1996 pre-UC)
% Households with number of adult members in the informal employment sectors
% Households impoverished by health payments
2.24.410.0
22.7
60.7
13.3
16.6
20.0
23.0
27.0
23.2
22.9
21.9
19.5
12.5
2.65.7
11.2
23.8
56.7
13.6
18.3
19.5
21.9
26.7
23.4
22.9
21.5
19.6
12.6
2.75.1
13.9
29.5
48.8
12.0
19.8
17.9
21.7
28.5
24.2
23.0
22.0
18.6
12.2
3.55.510.0
24.4
56.7
10.9
19.0
20.6
22.9
26.7
23.9
22.8
22.1
19.0
12.3
3.45.9
11.6
20.7
58.4
13.0
20.5
18.7
21.9
25.9
23.5
22.5
22.0
19.8
12.1
3.76.7
10.5
22.8
56.2
13.9
18.7
21.6
20.2
25.6
23.2
22.9
23.2
18.3
12.3
0
20
40
60
80
100
0
20
40
60
80
100
CS SS UC CS SS UC CS SS UC
CS SS UC CS SS UC CS SS UC
2003 2004 2005
2006 2007 2009
20% Poorest (Q1) Quintile 2 Quintile 3 Quintile 5 20% Richest (Q5)
Graphs by year
Scheme beneficiaries by income quintile Scheme beneficiaries by income quintile (2003 - 2009)(2003 - 2009)
UHC scheme covers mostly the poor, approx 50% in Q1 & Q2UHC scheme covers mostly the poor, approx 50% in Q1 & Q2
Household OOPs as percent household income in Thailand, 2000-2011
Source: Analysis from household socio-economic surveys (SES) in various years 2000-2011, NSO
12
UHC achieved
Number of Thai HH prevented from health impoverishment, 2002-2009
15.5
13.1
18.3
9.2
7.8
5.4
3.6
5.0
3.8
19.7
18.2
27.1
12.512.0
7.6
5.5
6.8
4.9
2.5
1.00.2 0.1 0.0 0.2 0.0 0.1 0.0
10.2
5.3
9.3
3.8 3.4
1.50.8
1.70.8
13.6
11.0
12.0
8.5
5.44.6
2.4
4.74.0
All employment sectors
Informal sectors -all
Public employees -all
Private employees -all
Mixed groups
0
5
10
15
20
25
Imp
ove
rish
ed
ho
use
ho
lds p
er
1,0
00
no
n-p
oo
r h
ou
se
ho
lds
1996 1998 2000 2002 2004 2006 2007 2008 2009
Health impoverishment by employment status of household adult members
# Households (in thousands)# Households (in thousands)
- Not poor 12,971- Not poor 12,971 13,234 13,234 13,177 13,177 14,120 15,071 14,120 15,071 16,476 16,720 17,396 18,191 16,476 16,720 17,396 18,191
- Poor- Poor 2,0662,066 2,522 2,522 2,904 2,904 2,199 1,690 2,199 1,690 1,573 1,457 1,597 1,388 1,573 1,457 1,597 1,388
Reduction in health-impoverishment*Reduction in health-impoverishment*(A difference-in-difference approach)
Employmen
t sector1998
200
0
200
2
200
4
200
62007 2008 2009
All-informal -0.09 9.65 -4.85 -5.23 -9.87-
11.73
-
10.56
-
12.32
Mixed -1.13 0.75 -2.68 -5.70 -6.73 -8.62 -6.50 -7.07
All-private -3.46 1.40 -4.07 -4.27 -6.47 -6.86 -6.12 -6.95
*Absolute difference from 1996, as compared with all-public employeeall-public employee households households
in number of health-impoverished households per 1,000 non-poor households
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Results (2)Results (2)
1. At national level
2. At sub-national level• Regional level (urban / rural / Bangkok)• Provincial level
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20
8
11
27
15
14
34
2
11
1
18
8
1011
20
10
32
5
9
5
27
15
2021
36
19
38
11
24
1
13
4
67
98
24
3
8
2
12
54
9
12
7
23
5 5
1
8
2
76
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5
12
7
2
0
6
21
5
9
6
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0 0
4
7
2
1
6
8
3
13
0
2
0
5
1 1
5
7
3
8
1
4
0
0
5
10
15
20
25
30
35
Imp
ove
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ed
ho
use
ho
lds
pe
r 1
,00
0 n
on
-po
or
ho
use
ho
lds
1996 1998 2000 2002 2004 2006 2007 2008 2009
' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S . ' C N Ne S .
Region: C -Central; N -North; Ne -Northeast; S -South
Informal employment sector households
Health impoverishment by geographic region and area
Whole country
Urban area
Rural area
Bangkok
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Sub-national health impoverishment 1996 to 2008
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
1996 1998 2000 2002
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
2004 2006 2007 2008
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Total Health Expenditure: 1994-2011
UHC inceptionEconomic crisis
Total health expenditure 3.49 to 4.1% of GDP (2003-2011)
THE per capita US$ 218 (2011)
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ConclusionsConclusions• Reduction in health-impoverishment in the informal sector
and mixed groups was stronger than in the public sector.
• UCS-mitigated health impoverishment was also found at
the sub-national level:
– Impoverishment in the poorest rural Northeast dropped from
3.4% in 1996 to 2.3-2.4% in 2002-04 and 0.8-1.3% in 2006-09.
• Comprehensive benefit package and zero copayment at
points of services are key contributing factors of health
financing arrangements in reducing health impoverishment,
• In addition, the extensive geographical coverage of health
infrastructure, adequate finance and functioning primary
healthcare are other key contributing factors.
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2020
Phusit Prakongsai
International Health Policy Program (IHPP)
Acknowledgement
• Ministry of Public Health (MOPH), Thailand
• National Statistical Office (NSO) ,Thailand
• National Health Security Office (NHSO), Thailand
• Health Equity and Financial Protection in Asia
(HEFPA)