Thai UC System

Somsak Chunharas
Secretary 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)
1.
UNIVERSAL HEALTH
SYSTEM AND ITS
PERFORMANCE
7/30/14
UC & informal workers
Country profiles: Thailand
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
7/30/14
4
Physicians per capita 4/10,000
ANC & hospital delivery 99-100% (2009)

Health service delivery system in Thailand

Specialized
hospitals 48
Province
Regional
hospitals 26
Provincial
hospitals 71
District
District hospitals
734
Subdistrict
Health centers
9,768
7/30/14
MOPH facilities
University
hospitals 11
25
Private
hospitals
322
Other
public
hospitals
60
Community
Medical
Centers 365
Private clinics
17,671
Pharmacy
11,154
LGUs
Long march towards universal health coverage in Thailand

using National Health Accounts (NHA) data
GNI per capita, 1970-2009
7/30/14
Brief historical overview

First health security for Thai population started
since 1975 with Indigent card 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 retrospective
reimbursement basis before 1975
Social security system established with health
insurance as an integral part for formal sector
workers since 1990
7/30/14
Brief historical overview

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 and
CSMBS)
7/30/14
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
7/30/14
Health care financing strategies of the UC policy

Promote primary care Promote the use of primary care by
contracting 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;
7/30/14
10
Population covered
Total coverage of
health insurance
99.87% by 3 major
systems
[UC 75%, SSS
16%, CSMBS 7%]
unregistered
Local admin officers
Civil servants
others
Social security
UC beneficiaries
UC beneficiaries by age groups 2013

1,123,273
15%
7,304,398
1,470,134
9,750,818
Infants
0-1 0-1 yrs
1-15 1-15 yrs

Children
15 - 59
Adults 15-59 yrs
14,939,648
29,937,321
11
: .
2556
Females in
fertile
>60
age group
>60 yrs
Elderly

Infants 0-1 yrs
7/30/14
12
Benefit
package
evolution
2013
- Expanding seasonal flu coverage to
another 2 target groups
- stem cell therapy for hematopoeitic
cancers
- long term care linking with Home care
and community care
2012
- Liver transplantation
-cardiac Surgery
2009
-High cost medications
- seasonal flu vaccine
2007
- Thai traditional
medicine
2010
- herbal medicines and orphan drugs
- Psychiatric patients institutional care
2008
-peritoneal dialysis and renal transplantation
- Methadone for drug addicts coming fpr treatment
2005
ARV, free condom, couseing and testing, CD4 count)
2002
Basic services for most curative services including diagnostic, dental,
preventive and rehabilitative services for the Thai citizen
UC per capita for medical services, 2014

Outpatient 1,056.96 ($34)
Inpatient 1,027.94 ($33)
AIDS
High cost, accident, emergency,

DMI 271.33 ($8.8)
P&P 383.61 ($12)
HMD
UC per capita
Renal
2,895.09
($93)
Rehabilitation 14.95 ($0.49)

Traditional Medicine 8.19 ($0.3)
Depreciation 128.69 ($4.2)
Hardship
Compensation 3.32 ($0.1)
2nd
prevention
for
metabolic
DX
Mitigation for providers 0.10

($0.003)
7/30/14
Source: NHSO
14
UC Budget Allocation
PP National Program
PPExpress demand
MOPH
NHSO
Outpatient
Inpatient
PCMO
-Specific services
-Out reach services
PP Express
demand
PCU (health
centres or
private clinics)
7/30/14 NHSO
Source:
Regional office
NHSO
PP Express
demand
CUP
(mostly district
hospitals)
PP Area based
Reimbursement for
inpatient
Proposal & report for
PParea based
PPCommunity
based
Proposal for PP
com based
Proposal for PP
com based
Community
Fund
Local
Authority
15
7/30/14
16
Quality Improvement towards accreditation of contracted hospital

(2003-2013)

HA 2546 - 2556

100
6.12
6.74
15.98
16.18
80
22.10
60
13.86
15.82
20.00
4.96
22.58
26.67
23.48
53.34
51.78
4.26
3.07
2.42
2555
2.50
2556
48.22
56.16
65.59
63.56
54.73
42.89
50.62
25.43
17.58
14.44
10.02
8.64
0
2546
42.65
31.34
26.45
40
20
39.98
20.81
63.60
55.81
29.86
2547
2548
HA
2549
5.77
2550
3.76
2551
2.73
2552
0.91
2553
5.97
0.61
2554
7/30/14
informal
workers
: (.) UC &
2556
30 2556,
17
()
()
people
120
2546 - 2556
95.49
100
92.75 90.79
88.37 89.32 89.76
83.01 83.42 82.35 83.91 83.16
(8.81) (8.63) (8.58)
(8.54) (8.58) (8.77)
(8.23) (8.26) (8.18) (8.26) (8.04)
80
60
40
20
78.75
(7.64) 66.86 68.48 67.61
56.57 60.75 60.27
(6.99) (7.08) (7.01)
50.99
47.72
45.66
(6.50) (6.64) (6.53)
39.34 (6.14) (6.28)
(6.15)
(6.22)
providers
2546
2547
2548
2549
2550
2551
2552 2553 2554 2555 2556
( ..-..2546, ..-..2547, ..2548, ..-..2549, ..-.. 2550-2551, ..-.. 2552- 2553, 9-25 .. 54, ..-.. 2555,
.
7/30/14
18
Outcome: increased government health spending

Thailand THE 1994-2010
2010
2009
2008
2007
2006
2005
2004
0.0%
2003
0
2002
1.0%
2001
100,000
2000
2.0%
1999
200,000
1998
3.0%
1997
300,000
1996
4.0%
1995
400,000
% GDP
5.0%
UHC
achieved
1994
Mil Baht
500,000
Year
Government spending
Source: NHA1994-2010
7/30/14
non-government spending
THE, %GDP
19
Outcome: reduction in out of pocket payment

UHC
achieved
100%
75%
37% 35% 35% 34% 33%
17% 14% 15% 15% 14%
69%
67%
67%
2008
2009
2010
2001
69%
2007
2000
64%
2006
1999
56%
2005
50%
58%
2004
51%
57%
2003
50%
58%
2002
50%
1998
44%
50%
1997
42%
44%
1996
25%
1995
50%
1994
44% 43% 42%
27% 27% 26% 27%
0%
Year
Public
7/30/14
SHI
Households
Other private
20
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
1,000 households
160
140
120
100
80
60
40
142.3
UHC
131.3
124.0
120.1
77.2
69.7
58.8
49.0
39.8
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
7/30/14
21
Source: analysis from Health and Welfare survey conducted by National

Statistical Office, Thailand
Incidence of catastrophic health spending

OOP>10% total consumption exp.
Source: Analysis of Socio-economic Survey (SES)
Protection against health impoverishment
UHC
achieved
7/30/14
23
2.
INFORMAL WORKERS
AND SOCIAL SECURITY
SYSTEM (SSS)
7/30/14
24
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%)
7/30/14
25
Situation: Informal economy

No legal protection
Social Security Act (1990)
Labor Protection Act (1998)
7/30/14
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
26
Informal workers and SSS

While SSS covered around 15 mil formal workers
(compulsory), only 1,820,379 informal workers (out of
total 25,140,771 => 7.24%) registered with SSS
(voluntary)
All of the registered informal workers did not receive
health insurance benefits but emphasize on other
benefits because active recruitment of informal
workers only started in 2014 when the government
decided not to enforce long term pension fund but
enacted the inactive article 40 in the existing SSS Act.
7/30/14
27
SSO informal workers registered
7/30/14
Construction workers
Agricultural workers
Vender / peddler
Freelance singer, actor, translator
Transport drivers
Home-based workers
Skilled workers
Other Self-employ / freelance
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
7/30/14
29
SSS benefits for Formal Workers

(compulsory)
7/30/14
Compensation for lost income

Disability compensation
Maternity benefits
Health insurance
Pensions
Life insurance
Workmen compensation (work-related
injuries and death)
30
Health insurance: Comparing 3 schemes

(Social Security, Civil Servants Medical Benefit, Universal Coverage)
Services for Occupational Illness
SSS
CSMBS
UC
WCF + SSO
No categorized
No categorized
Yes
No
No
Compensation
WCF + SSO
No
No
Health Examination
Employer +
NHSO
Comptrollers
General Dept.
No/Not Clear
NHSO
NHSO
NHSO
Employer
No
No
No
No
No
Employer +
NHSO
No
No
Medical care
Rehabilitation for work
Chronic Diseases Screening

Health Risk Evaluation
Health Risk Evaluation (Basic)
Health Examination based on Risk
Environment
Note: WCF = Workmans Compensation Fund
SSO = Social Security Office
NHSO = National Health Security Office
Problems found
Working environment
Occupational Illness
Inadequate light /
lucidity
Inappropriate ergonomic
sitting on the floor
Inappropriate machine,
equipment and tools
Dusty environment
Chemical exposure
Long hour working
7/30/14
Eyesore, headache
Joints and muscle pain
Injuries
Respiratory diseases /
illness
Allergy
Gastritis, Urinary
infection
Family problems
32
Health Problems
Occupational Illness
7/30/14
Others
Injuries
Drug allergy
Asthma
Muscle pain
Stomachache / Gastritis
Eye/ Sight problems
Stress
Diabetes Mellitus
Hypertension
Arthritis
Myocadial infarction
Brest Cancer, Cervical
Cancer
Caries
Cataracts
33
3.
EFFORTS AND
INNOVATIONS TO
ADDRESS SPECIFIC
HEALTH NEEDS OF
INFORMAL WORKERS
7/30/14
34
Risk Management for informal workers

Liver, Kidney functions
CXR
Eyesight, Hearing,
Muscle, Lung, Chemical
toxin
Individual Health Risk
Screening forms
WISE, WISH
JSA, NB01
7/30/14
Additional Health
Examination
(Health Effect)
Hospital
Health Examination
For specific Risk Group
Hospital
General Health Screening
PCU, Community
Health
volunteers
Environmental Health Risk

Evaluation
(Community Survey)
Community
Health
volunteers
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
7/30/14
36
Number of PCUs and occupational classes

at District Level, Lamphun Province
Wicker work, weaving, carving
Muang
Agriculture, Weaving
Pa Shang
Banthi
Clothing, Agriculture,
Furniture making
15
13
9
Agriculture
Viang Nong Long
Agriculture
Ban Hong
Mae Ta
Clothing,
Agriculture
Tung Hua chang

Clothing,
Agriculture
13
Note: TBH Tambon (Subdistrict) hospital = health centerF
LE
E
Agriculture
Number of PCUs, Khon Kaen Province

6
Phupaman
Sichompoo
Nongnakham
5
13
Suankwang
Ubonrat
11
Banfang 26
Choompae
12
Nampong Kannuan
Viangta Phuviang
17
18
Nongruea 15
Samsung
Muang
5
11
Prayouen
7
Manjakiri
Kokpochai
Had
Banpai
4
11
Chonnabot Nonsila
Wangyai
Phon
Wangnoi
5
7/30/14
13
13
13
3 Peuynoi
Nongsonghong
38
Occupational Groups, Khon Kaen

Weaving, Wickenwork, F&B
Weaving, Wickenwork, Broom

Agriculture, Carpet,
Traditional Dabber
Weaving, Wickenwork, Mat
Weaving, Weaving, F&B, Clothing

Wickenwork
Weaving, Wickenwork, Food
Weaving, Wickering, Artificial Flower
Weaving, Wickenwork, F&B

Weaving, Mat, Artificial Flower
F&B, Weaving, Wickenwork

Weaving, Wickenwork, Home decorations
Weaving, Mat,
prickled prok
Weaving, Wickenwork
Weaving, Wickenwork,
liquor distiling
Weaving, Wickenwork, Mat
7/30/14
Weaving, Wickenwork, food

Weaving, Wickenwork, Broom
Weaving, Wickenwork,
liquor distilling
39
7/30/14
Source of image: http://commons.wikimedia.org/w/index.php?title=User:Samulili/testi&oldid=10201495"
40
Health Promotion and Prevention - Output

Local Health
Situation for
planning
Health Risk Evaluation
Occupational Health Risk (1)
Health Risk (2)
Set up program for screening

Based on risk factors
Program for health screening
Individual
Health Status
Surveillance
Monitoring
Advocacy
Interpret Results
Normal
(1+2)
Risk/ Abnormal
Findings (General
health) (2)
Risk/ Abnormal
findings (Specific to
work (1)
Risk/ Abnormal both

(1+2)
Program 1
Program 2
Program 3
Program 4
Service data
For
performance
assessment
by NSHO
4.
MARGINALIZED
POPULATION AND
INFORMAL WORKERS
7/30/14
42
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 for
special population groups (selected tribal
population)
Migrant workers (not formally recognized - illegal)
Cross border poor population seeking health
services in Thailand
7/30/14
43
Existing Health Insurance Package

for Migrant Workers
7/30/14
44
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)

7/30/14
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

ARV and High cost medical service (National/Central level) $0.5
7/30/14
46
Health insurance for Temporary work permit

migrating workers (Myanmar, Laos and Cambodia)
and family members
3-month insurance: $32 (B1,000/person)



7/30/14
47
Health insurance for Temporary work permit

migrating workers (Myanmar, Laos and Cambodia)
and family members



7/30/14
48
Health insurance for general foreign employee
One year insurance: $90 (B2,800/person)


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

7/30/14
49
Health insurance for Migrating workers awaiting social

security health insurance



7/30/14
50
Challenges for marginalized

populations
Public system providers treated these population on a
merit basis no budget allocated to the health
facilities concerned. Some may receive special project
funds (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 integrate
them into the system (thru either UC or SSS)
7/30/14
51
Conclusions
Informal workers are entitled to comparable benefits
as formal workers when it comes to health insurance
though thru 2 separated schemes
Health risks prevention and management are poorer
for informal sector workers though initiatives existed but could
not scale up
District health system plays crucial role in providing

cost-effective services and equitable access for all
covered under UC scheme
Future of health benefits for informal sector
(+migrant workers) still unclear could shift to
contributory system and integrated within SSS.
7/30/14
52
Challenges for further reforms

The 3 major schemes of health insurance will continue
to be managed by separated governing structure with
pressure for system harmonization
Institutionalizing health preventive and promotive
services/intervention to reduce general and workrelated 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
7/30/14
53
Thank you for your attention
7/30/14
54

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Somsak Chunharas

UC & informal workers

Country profiles: Thailand

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

Total Health Expenditure (2010NHA)

Physicians per capita 4/10,000

ANC & hospital delivery 99-100% (2009)

Health service delivery system in Thailand

UC & informal workers

Long march towards universal health coverage in Thailand

UC & informal workers

Brief historical overview

UC & informal workers

Brief historical overview

UC & informal workers

Health care financing strategies of the UC policy

UC & informal workers

Health care financing strategies of the UC policy

UC & informal workers

UC beneficiaries by age groups 2013

0-1 0-1 yrs

1-15 1-15 yrs

Adults 15-59 yrs

UC & informal workers

UC per capita for medical services, 2014

High cost, accident, emergency,

Rehabilitation 14.95 ($0.49)

Compensation 3.32 ($0.1)

Mitigation for providers 0.10

UC & informal workers

UC & informal workers

Quality Improvement towards accreditation of contracted hospital

2552 2553 2554 2555 2556

Outcome: increased government health spending

Outcome: reduction in out of pocket payment

37% 35% 35% 34% 33%

17% 14% 15% 15% 14%

44% 43% 42%

27% 27% 26% 27%

UC & informal workers

Thailand: UHC prevents health impoverishment

Source: analysis from Health and Welfare survey conducted by National

Incidence of catastrophic health spending

Source: Analysis of Socio-economic Survey (SES)

Protection against health impoverishment

UC & informal workers

UC & informal workers

Situation informal workers, 2009

UC & informal workers

Situation: Informal economy

Instability of work and income

Informal workers and SSS

UC & informal workers

SSO informal workers registered

Benefit Package 1 $3/Month (B100)

Benefit Package 2 - $5/Month (B150)

UC & informal workers

SSS benefits for Formal Workers

Compensation for lost income

Health insurance: Comparing 3 schemes

Chronic Diseases Screening

UC & informal workers

UC & informal workers

UC & informal workers