Health Financing in Thailand Technical Report
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THAILAND: HEALTH MANAGEMENT AND FINANCING STUDY PROJECT ADB # 2997-THA HEALTH FINANCING IN THAILAND TECHNICAL REPORT By 1 Management Sciences for Health Health Systems Research Institute, Ministry of Public Health April 1999 ISBN 974-299-016-6 1 / Authors of this report in alphabetical order are: Dayl Donaldson, MPH, MA, ScD; Supasit Pannarunothai, MD, PhD; and Viroj Tangcharoensathien, MD, PhD TABLE OF CONTENTS Page TABLE OF TABLES..........................................................................................................iii TABLE OF FIGURES ......................................................................................................viii EXECUTIVE SUMMARY.................................................................................................xi I. BRIEF ECONOMY OF THAILAND......................................................................... 1 A. STRUCTURE OF THE ECONOMY................................................................ 1 B. PERIOD OF RAPID GROWTH /....................................................................... 2 C. CRISIS ................................................................................................................ 2 II. HEALTH SECTOR FINANCING OVERVIEW....................................................... 6 A. NATIONAL HEALTH ACCOUNTS................................................................. 6 B. MOPH EXPENDITURE..................................................................................... 9 C. PRIVATE EXPENDITURE............................................................................. 16 III. COSTS OF PROVIDING SERVICES ................................................................... 22 A. COSTS OF HOSPITAL SERVICES ................................................................ 22 B. COSTS OF PRIMARY CARE SERVICES ..................................................... 23 IV. REVENUE FROM SERVICE PROVISION ......................................................... 25 A. FEE SETTING POLICY................................................................................... 25 B. COST RECOVERY.......................................................................................... 25 V. HEALTH INSURANCE SCHEMES....................................................................... 28 A. COMPARATIVE DESCRIPTION OF SCHEMES ......................................... 28 B. CIVIL SERVANT MEDICAL BENEFIT SCHEME....................................... 31 C. SOCIAL SECURITY SCHEME AND WORKMAN’S COMPENSATION SCHEME........................................................................................................... 47 D. VOLUNTARY HEALTH CARD SCHEME (VHCS) ..................................... 63 E. THE LOW-INCOME CARD SCHEME (LICS).............................................. 76 F. SUMMARY OF RECOMMENDATIONS...................................................... 92 VI. FUTURE REFORM OF HEALTH CARE FINANCING IN THAILAND........... 95 A. OBJECTIVES OF FINANCING STRATEGY ................................................ 95 B. MOVEMENT TOWARDS UNIFICATION OF SCHEMES........................... 96 C. UNIVERSAL COVERAGE............................................................................. 97 D. NEW HEALTH FINANCING INSTITUTIONS........................................... 100 LIST OF REFERENCES 99 APPENDICES A. APPENDIX TABLES 110 B. APPENDIX FIGURES 119 C. POLITICAL MAPPING FOR CSMBS AND UNIVERSAL COVERAGE 135 D. SST FINANCIAL REQUIREMENTS 143 ii TABLE OF TABLES Page 1.1 Structure of Thailand’s Economy, 1975 to 1996 1 1.2 Distribution (%) of Households by Employment Class, Thailand, 1 1988 – 1996 1.3 Social Expenditure as a Percent of Total and Local Government 2 Expenditure, Thailand, 1987 to 1996 1.4 Medium Term Trends of the Thai Economy, 1996 – 2001 3 2.1 National Health Accounts, Thailand, 1983 to 1994 7 2.2 Allocation of Recurrent and Capital Health Expenditure by 9 Source of Financing, Thailand, FY 1994 2.3 Criteria for Allocation of LICS Funds, Thailand, <1989 – 1996/8 12 2.4 Trends in MOPH Expenditure Over Time, Thailand, 13 1982 – 1999 2.5 More MOPH Trends Over Time, Thailand, 1982 – 1999 13 2.6 Percent Allocation of MOPH Budget to Different Services 14 And Programs, Thailand, 5th to 7th Plans 3.1 Unit Costs for Health Center Services in Three Districts, Thailand 24 4.1 Comparison of Revenues to Costs, 89 Provincial Hospitals, 26 Thailand, 1988 – 1990 4.2 Comparison of Recurrent Expenditure and Non-budgetary Revenue 26 From Provincial Hospitals in the Entire Kingdom, Thailand, 1994 – 1996 4.3 Comparison of Revenues to Costs, 350 District Hospitals, Thailand 27 1987 – 1988 4.4 Comparison of Recurrent Expenditure and Non-budgetary Revenue 27 From District Hospitals in the Entire Kingdom, Thailand, 1994 – 1996 5.1 Characteristics of Health Insurance Schemes, Thailand 29 iii 5.2 Benefits of Insurance Packages in Thailand 30 5.3 Source of Funds, Insurance Payment Mechanism, and Utilization 31 Of Services, Thailand, 1996 5.4 Total CSMBS Expenditure by Type, Thailand, 1988 - 1998 at Current 32 Prices 5.5 Major Contents of Two Intervention Phases (CSMBS) 35 5.6 Average Monthly Expenditure (million baht) before and after 36 Copayment Intervention, Khon Kaen, FY 1998 5.7 Public Hospital Inpatient Charge Profiles, Khon Kaen, FY 1998 38 5.8 Payment Options for Ambulatory Care for CSMBS Beneficiaries 39 5.9 Payment Options for Inpatient Care – CSMBS 42 5.10 Mean Vote by 15 Committee Members, Maximum Score 100 44 If Mechanism Totally Achieved the Policy Objectives 5.11 Total Score Weighted by Relative Weights of Nine Policy 44 Objectives 5.12 Frequency of Vote for Rank One to Three for the Merit of each 1-7 45 Options, by 10 Committee Members, without Prior Recognition of Quantitative Results 5.13 Budget Ceiling for Four Types of Expenditure, CSMBS, 1988 46 5.14 Age Adjusted Capitation Rate 46 5.15 Inpatient Expense, baht/case 46 5.16 Loss Ratio and Experience Rate, WCS, 1993 48 5.17 Collected Contributions and Paid Benefits, million baht, WCS, 49 1986 - 1995 5.18 Estimate of Labor Force, Employment, Unemployment in 50 Thailand, 1997 and 1998 (in thousands) 5.19 Laid-off Labor as Revealed by Establishment Inspection and Labor 51 Court Records, Thailand (January 1, 1997 – July 31, 1998) iv 5.20 Financial Scenario of Four Benefit Coverage Extension, prepared 52 By a Task Force for the 13th Session Meeting 5.21 Loss Ratio and Experience Rate, WCS, Thailand, 1993 54 5.22 Collected Contributions and Paid Benefits, Thailand, WCF, 55 1986 - 1997 5.23 The Occupational Injury and Disease Claims, by Categories of 55 Compensation, WCS, Thailand, 1997 5.24 The 1997 Occupational Injury and Disease Claims, by Region 56 Thailand 5.25 Incidence Rate per 100 Beneficiaries by Age Group and Type of 57 Compensation, Thailand, 1997 5.26 Proportion of Outpatient and Inpatient Claims, SSO Area Five 58 Office, Thailand, 1998 5.27 Public-Private Share in WCF in Prachachurn SSO Area Office, 58 Thailand, 1998 5.28 Average Claim by Public and Private Hospitals 58 5.29 Capitation Rate, Various Scenarios of X baht/visit and Y baht/case 59 5.30 Reference Price from CSMBS: Current Government Official, 60 1996 5.31 Main Characteristics of the Voluntary Health Card Scheme 64 Since 1983, Thailand 5.32 Coverage of Voluntary Health Card and Revenue Raised at current 65 Prices, Thailand, 1987 - 1997 5.33 Utilization Rates of Different Population Groups under the VHCS, 66 Thailand, 1991 and 1996 5.34 Proportions of the Coverage by VHCS, all Insurance Schemes, 67 And the Uncovered by Urban/Rural and Income, Thailand, 1995 5.35 Proportions of the Coverage by Income and Dependency 67 Ratios in Three Provinces, Thailand 5.36 Cost of Providing Care to Voluntary Health Cardholders, 68 v Thailand, 1997 5.37 Reported Response to a Price Increases for the VHC, Thailand 69 5.38 Reason for Imposing Copayment 70 5.39 Affordable Rate of Copayment 71 5.40 The Management of High Cost and Cross-Boundary 72 Cases in 1997 5.41 Number of Low-income Cardholders (in millions) by Region, 77 Thailand, 1981 to 1998 5.42 Poverty Lines and Cut-Off Points of Means Tests, Thailand, 79 1975/6 to 1997/8 5.43 Target and Performance of LIC Issuance (in millions), Thailand, 80 1998 5.44 Changes in the LICS Allocations per Capita, Thailand, 1981 – 1999 83 5.45 Budget and Expenditure of the LICS, Thailand, 1987 to 1997 83 5.46 Utilization Rates, Charges per Case, and per Capita Expenditure 84 In baht, LICS, Thailand, 1998 5.47 Per Capita LICS Budget (in baht) Allocated to Regions, Thailand, 84 1988 to 1994 5.48 Weights Given for Allocation of the LICS Budget, Thailand, 85 1990/1 – 2000 5.49 Budget Allocation to Public Health Facilities other than the 88 Office of the Permanent Secretary, Thailand, 1996 - 1999 5.50 The LICS Budget and Spending for Medical Schools, Thailand, 88 1995 5.51 Per Capita Budget (in baht) Allocated to Regions, Thailand, 89 1996 to 1999 6.1 Suggested Charge Schedule for Accredited Service Provider 99 under SST vi 6.2 Comparison of the Roles of the PHO with those Proposed for 102 A PHB A.1 Trends in Population, Economic, and Health Financing, 1982 – 1999 111 A.2 Conversion of the 1994 Medical Care CPI to 1996 Base Year 112 A.3 Monthly Household Health Expenditure by Provider and Region, 113 Thailand, 1986 – 1996 A.4 Monthly Household Health Expenditure by Employment Category, 114 Thailand, 1986 – 1998, Real ’96 Baht A.5 Monthly Household Health Expenditure by Employment Category, 115 Bangkok, 1986 – 1996, Real ’96 Baht A.6 Monthly Household Health Expenditure by Employment Category,