1

Achieving Universal Health Coverage: The Roles of

Evidence, Social Movements and Policy Commitment

Dr. Suwit WibulpolprasertSenior Adviser on Disease Control, MoPH, Thailand,

PHA3, July 9th, 2012University of Western Cape, South Africa

2

Thailand at a glance (2011)

• Lower middle income with good health status

- Gross National Income: US$ 3,760 per capita – Poverty – 2% of population– Gini index 42.5 - MMR 30/100,000 LB and IMR 20 per 1,000 LB

• UHC achieved in 2001 under three schemes – the CSMBS, the Social Security and the UC

• Health expenditure (THE): •US$ 300 per capita – 6% GDP•Half from public – 13% of National Budget•Less than 50% out of pocket health

expense

Five important points

• UHC is for poverty reduction not only health benefits

• UHC can be started at low level of income

• The need to ensure availability of satisfactory services.

• Mobilizing more resources for UHC• Getting more health for the

existing resources3

Ho

us

eho

lds

wit

h c

ata

stro

ph

ic il

lne

sse

s1. UHC for Poverty reduction (MDG 1)1. UHC for Poverty reduction (MDG 1)

109,247100,604

121,358136,622

208,338195,845

176,981

156,301

125,551

62,97579,237

97,517

50,000

100,000

150,000

200,000

2539 2541 2543 2545 2547 2549 2550 2551

ถ้�าไม่�ม่�หลักประกนสุ�ขภาพถ้�วนหน�า ค่�าพยากรณ์�ตาม่สุถ้านการณ์�จร�ง

1996 1998 2000 2002 2004 2006 2007 2008

Prediction without UC Actual situation

2. We can start UHC when we are still low income

390

710

760

1490

2,7

00

1,9

00

0

1,000

2,000

3,000

4,000

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

US $

1997: Asian financial crisis

1990 SHI introduced

1980 CSMBS introduced

1983 CBHI introduced

1975 Low Income scheme introduced

2002 Universal Coverage for entire population achieved

2001: 29% of population are uninsured

year

Long march towards Thai UHC: You don’t have to wait until you are rich to start and achieve UHC

National Health Security Act was proposed by 50,000 Thai citizens and it has 5 influential board members from civil society organizations

Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand7

NHSO

CSMBS

SSSSOO Contribution

20

01

NHSO

Comptroller SSOSSO Capitation

80 $US/y“Fee for service”

350 $US/y

Capitation75/y

“Public / Private Provid

ers

4 8 mil. 6.0 mil. 9.0 mil.

Private roomnon- ED

InsureesInsurees, ,

Right hoRight holderslders

TAX19

9 1

Services

1963

Gold card Civil servants Employees

The Three Schemes of UHC - 2010

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand8

• Extensive expansion of rural health services in early 80s, as part of PHC/HFA and rural development policies – inspite of economic crisis

• How? - Freeze new capital investment in urban health facilities for 5 years and reallocate the budget to build rural health centers and district hospitals, with extensive production of Community Health Workers

• Extensively increased use of rural facilities

3. Ensuring universal availability of satisfactory health services

Health Systems Strengthening as essential components of the UHC

• Useless to have financial protection when the quality essential health services are not universally available

• Adequate facilities, manned by dedicated well-trained HRH

• Retention of Health Professionals in the rural areas – multiple ‘supply’ and ‘demand’ side measures.

• Diabetic Conditions in some countries

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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Reallocation of budget during Economic Crisis in early 1980s, to build rural facilities and HRH

3.1

2.732.43

2.272.232.152.041.88

3.68

3.153.0132.9

2.642.4

1.68

0

0.5

1

1.5

2

2.5

3

3.5

4

1982 1983 1984 1985 1986 1987 1988 1989

Year

Bu

dg

et

(bill

ion

Ba

hts

)

Provincial

District

Fast tracking rural health

No investment in urban areas for 5 yrs.

Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand11

Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population

Adequate and appropriately manned rural health facilitieis

Rural community hospital with 2-8 doctors cover 30-80,000 population

Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential.

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

1212

From reverse to upright triangle: From reverse to upright triangle: PHC utilization (OP visits)PHC utilization (OP visits)

46.2%(5.5)

29.4%(3.5)

24.4%(2.9)1977

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals

( ) : Number of OPD visits (millions)( ) : Number of OPD visits (millions)

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals200046.1%(51.8)

35.7%(40.2)

18.2%(20.4)

Source : Rural Health Division, MoPH

27.7%(10.9)

32.8%(12.9)

39.4%(15.5)

1989

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals

Budget shift

Peace, econ gwt, democracy

Satisfaction of UC people & Satisfaction of UC people & providerprovider

83.0 83.4 83.2 84.0 83.1 88.3 89.3 89.8

45.6 39.347.7

50.9 56.5 50.760.3 78.8

0.010.020.030.040.050.060.070.080.090.0

100.0

2003 2004 2005 2006 2007 2008 2009 2010

UC People provider

Percent

Expand financial incentives

Source : Report 5, 0110 , Yr 2003 – 2011 Source : Report 5, 0110 , Yr 2003 – 2011

2003 2004 2005 2006 2007 2008 2009 2010 2011

14

15Source : NHSO IP data in Yr. 2003-2011 Source : NHSO IP data in Yr. 2003-2011

2003 2004 2005 2006 2007 2008 2009 2010

15

16

Source of finance 1994-2010Increased public financing sources with less OOPs

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

58% 57% 58% 56%64% 69% 69% 67% 67%

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

27% 27% 26% 27%17% 14% 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

4. Mobilize more resources• Peace and Economic growth – less proportion

of budget to security and serving public debt

• National public health expense increased from 5% of national budget in 1980s to 13% in 2010

• ‘Community Health Development Fund’ – co-pay by local governments - $US 150 m in 2010

• Dedicated Health Promotion Fund – 2% additional levy on tobacco and alcohol excise tax – $US 100 m in 2010 – ‘support HiTAP’

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Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

1818

From security and debt service budget to healthFrom security and debt service budget to healthP

erce

nta

ge

Year

Source: Bureau of Budget

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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More Budget to Health

1972

1990

2004National budget

PH budget

29,000 mil. ฿

986.6 mil. 986.6 mil. ฿฿(3.4%)(3.4%)

16,225.1 mil. 16,225.1 mil. ฿฿(4.8%)(4.8%)

335,000 mil ฿

77,720.7 mil. 77,720.7 mil. ฿฿ (78x) (78x) (8.1%)(8.1%)

1,028,000 mil ฿ (35x))

2010 PH budget rose to 14% of National buget

5. Better Value for Money

• Close end capitation based budget with mixed payment mechanisms mainly on capitation (OP) and Case Mix (IP) and some FFS and PC as gate keeper

• Base on National Essential Drug List and use of TRIPs flexibilities - article 31(b) and Doha declar, and strict control of high price EDs

• Base on intensive study on cost-effectiveness of health technologies – IHPP, HITAP, etc.

• Central bargaining and purchasing with VMI• Drug price of all hospitals on web site 20

Health Insurance coverage of three population groups in selected Asian countries in 2009

21Source: Tangcharoensathien V et al, Health Financing Reform in South-East Asia (2009)

Comparing % of Out of Pocket Health Expense and % of Public Expenditure on Health

in 2010

%

ASEAN plus three HMM Joint Statement July 6th, 2012

…….We commit to collectively accelerate the progress towards UHC in all countries by ……….the formation of an ASEAN Plus Three network on UHC. We concur and will collectively move the issue of UHC to be discussed and committed at the highest regional and global development forum, including the ASEAN Plus Three Summit, and the United Nations General Assembly.

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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10 ASEAN Plus China Health Minister Meeting – July 6th 2012

• Most of them agreed with removal of Tobacco from the Free Trade Agreements

• All agreed to support ‘specifically dedicated fund from tobacco and alcohol tax to be used for tobacco and alcohol control and other health promotion activities’

• Thai Health Promotion Foundation – 2% additional levy on top of the excise tax to tobacco and alcohol – 100 million per year

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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What we must reiterate to politicians and society

“Because we are poor, we can not afford

not to have primary health care based Universal Health Coverage”

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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“Triangle that move the mountain”

“Tipping point”

Knowledge generation & management

Socialmovement

Political/Policy

linkagesStickiness of

the issue

Three groups of people

Conductive Environment