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BANGKOK --  An evening talk on healthcare financing in Thailand took place in Bangkok on the sideline of the Prince Mahidol Award Conference 2010. Organized by the World Bank’s Human Development Network, this event was the Bank’s contribution to an ongoing dialogue in Thailand on how healthcare financing should be done. Two World Bank experts, Dr. Armin Fidler, Lead Advisor, Health Policy and Strategy, Human Development Network, and Dr. Adam Wagstaff, Research Manager (Health), Development Research Group, joined other six speakers to share their thoughts on existing proposals to improve healthcare financing in Thailand. Rationale for this event:
Over the past three decades, Thailand has been able to improve the well-being of its citizens through the provision of healthcare and other basic social services. With the introduction of Universal Health Coverage scheme (UC) in 2001, for which a 30-baht (around US 93 cents) co-payment was required, the government essentially allowed the poor people to gain access to health services without paying high price for the care.  Almost all Thai citizens are now covered by public health insurance schemes – the UC scheme, the Social Security Scheme (SSS), and the Civil Service Medical Benefits Scheme (CSMBS). The UC scheme, which currently requires no out-of-pocket cost from the patients, has contributed to more equitable utilization of health services by making health care costs more affordable to the low-income population. Nevertheless, important challenges remain. Although health expenditure as a share of GDP remains low by international standards, cost pressures are building up in the system. The CSMBS has seen dramatic increases in spending in recent years, particularly following the introduction of direct disbursement to providers for outpatient services in October 2006. Furthermore, the fragmentation of health financing arrangements, with insurance coverage through three separate schemes and a lack of clarity on roles and responsibilities across central and local governments, has contributed to a duplication of administrative costs and other inefficiencies Successive governments have been trying to address this challenge. Many proposals are now on the table. To contribute to this discussion, the World Bank invited Thai and international speakers to join a panel discussion on the topic.  The Bank is a dedicated partner of the annual Prince Mahidol Award Conference and of the Country Development Partnership in Health (CDP-Health), a knowledge-sharing program with the Thai government.
This event provided an opportunity for government officials responsible for the management of the three health insurance schemes to inform one another of the progress, as well as the challenges, of the implementation. The World Bank and other international experts contributed to this discussion by sharing international experiences with them, drawing lessons from other countries that may help Thailand reshape its policy going forward. List of speakers (in picture from left to right): Dr. David Evans, Director, Department of Health Systems Financing, World Health Organization Dr. Sittichai Puttiparasert, Advisor to the Secretary-General, Social Security Office Dr. Adam Wagstaff, Research Manager , Development Research Group, World Bank. Dr. Ammar Siamwalla, Distinguished Scholar, Thailand Development Research Institute Dr. Armin Fidler, Lead Advisor, Health Policy and Strategy, Human Development Network, World Bank Dr. Winai Sawasdivorn, Secretary-General, National Health Security Office Dr. Anne Mills, Head of the Public Health and Policy Department, London School of Hygiene and Tropical Medicine Khun Pongpanu Svetarundra, Director-General, Comptroller-General Department, Ministry of Finance
 To kick off the discussion, Dr. Somsak Chunharas, Secretary-General, National Health Foundation, presented an overview of healthcare financing in Thailand, focusing on the challenges arising from the introduction of the universal health coverage scheme in 2001.Â
Dr. Somsak highlighted 4 challenges for Thailand’s health financing. First, he discussed the constant demands for costly care to be added to the Universal Coverage (UC) scheme, and the need to rethink whether the current financing model is sustainable. Second, he commented on recent calls to harmonize or merge the three major public health insurance schemes in Thailand, noting that a new committee was needed to take the lead in restructuring the 3 schemes to bring about harmonization and avoid duplication. Third, he suggested that the government needs to think how existing money for the schemes can be used more efficiently. Finally, he pointed out that there is no single body appointed to oversee the overall healthcare system, and that there is a need to strengthen overall system governance. Dr. Somsak further pointed out that there are some reform issues on the table, which include merging the three schemes, improving efficiency of CSMBS, reorganizing how services are purchased (partly in the context of decentralization), and harmonizing/standardizing health information system. During the panel discussion, the question about merging and harmonization of the three schemes was raised. Mr. Pongpanu and Dr. Sittichai did not endorse the idea of merging the schemes. Mr. Pongpanu saw CSMBS as fringe benefits for civil servants who receive low pay (warranting the higher benefits that CSMBS offered, compared with UC and SSS). Dr. Sittichai said that it would be difficult for his office to join the other two as it also had the role of compensating contributors when they were out of work. Also, he pointed out that unlike CSMBS and UC, members of SSS and their employers contributed to SSO. Thus, if the UC offered exactly the same benefits as SSS, who would want to contribute? Dr. Ammar and Dr. Winai agreed that though there is no need to merge public health insurance schemes in Thailand into one fund, there should be some forms of harmonization for schemes, e.g. harmonizing provider payment system and health information system. Public-private partnership should also be promoted. The panelists also shared other important challenges on Thailand’s health financing. Mr. Pongpanu highlighted that the budget needed for 3 health insurance schemes is expected to double in the next 7 years. Referring to the high cost of CSMBS, he suggested that there is a need to control medical care cost of CSMBS. Until now, the Comptroller-General Department has only acted as cashier, and has not had the responsibility of a regulator or purchaser. There is now a proposal going to cabinet to set up a governing body to proactively manage CSMBS, and to put active control on usage of non-essential drugs. Dr. Ammar highlighted the challenges on human resources in health. He said that public hospitals and health centers in the provinces are in dire straits and facing staff shortages. Thailand has about 37,000 doctors working in private and public sectors. With high workload in many parts of the country, health workers often cannot afford to spend more than 2 minutes with each patient under the UC scheme. He also called for the Ministry of Public Health should be more proactive, as it is the main controllers of labor and capital for public health facilities. International experts on health policy also contributed to this discussion by highlighting additional challenges and explaining how some other countries with similar challenges as Thailand. Professor Anne Mills has emphasized that there will be greater pressure on Thailand’s healthcare system over the next 10 years, particularly due to demographic transition. She suggested that Thailand should improve the balance between primary care and hospital care, and make sure that more people are treated in primary care centers. She further suggested that Thailand decentralize health workforce management, and put a cap on CSMBS to relieve the pressure. Finally, she pointed out that Thailand needs more research evidence on health financing to support future policy and implementation. Both Dr. David Evans and Dr. Adam Wagstaff agreed on the need for the government to focus on rural population. Dr. Wagstaff noted that the redistribution of resources down to the rural level and to primary care was a big challenge for Thailand. Merging the three schemes should be planned carefully. Employers might be encouraged to abandon the SSS, as has happened in some Latin American countries. Dr. Armin Fidler pointed out that as countries become richer, they tend to spend more money on health. Thus, Thailand needs to get things right from the beginning, and acquire the capacity of analysis and execution. Following comments and questions from the audience, Dr. Somsak delivered closing remarks. He highlighted five messages that the audience could take away from this debate:- (1) Thailand might have enough money, but it needs to be careful about the sustainability in future, and needs to find ways to ensure that money is spent efficiently; (2) Thailand needs to proactively manage purchasing; (3) Thailand needs good governing mechanism for the health system; (4) Thai health policy experts need to brainstorm on healthcare system redesign, which emphasizes primary care linkage and better manpower management; (5) Thailand needs to promote knowledge finding and research with evidence to guide future policy and implementation. |
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