Joint Learning Network for Universal Health Coverage

Thailand: Universal Coverage Scheme

50 million

Funding

None
None

Population Covered

All populations

Service delivery system

Both Public & Non-state

Institutional structure

Centralized
Central Government
Central Government
Central Government
Central Government
Reform summary: 
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With a great deal of popular support, the new Thai government passed the National Health Security Act in 2002. It has since become one of the most important social tools for health systems reform in Thailand. The new Universal Coverage Scheme (UCS), or “30 Baht Scheme”, combined the already existing Medical Welfare Scheme and the Voluntary Health Card Scheme to expand coverage to an additional 18 million people.

With a great deal of popular support, the new Thai government passed the National Health Security Act in 2002. It has since become one of the most important social tools for health systems reform in Thailand. The new Universal Coverage Scheme (UCS), or “30 Baht Scheme”, combined the already existing Medical Welfare Scheme and the Voluntary Health Card Scheme to expand coverage to an additional 18 million people.

Private health insurance organizations play no role in this reform, and remain only as a supplemental option for high-income groups.

The UHC scheme aims to provide universal access to essential health care and reduce catastrophic expenditures from out-of pocket payment. The UHC scheme aims to provide universal access to essential health care and reduce catastrophic expenditures from out-of pocket payments by establishing a tax-based financing system and paying providers on a capitation basis. This scheme covers 74.6 percent of the population as of 2007 estimates. The benefits package is a comprehensive package of care, including both curative and preventive care. The scheme is financed solely from general tax revenue. Public hospitals are the main providers, covering more than 95 percent of the insured. About 60 private hospitals joined the system and register around 4 percent of the beneficiaries.

The Baht 30 copayment was abolished by the next government in November 2006, and the system is now totally free of charge.

Since October 2003, the government has also embarked on universal access to antiretroviral drugs (ARVs). Through May 2007, more than 90,000 patients had been registered in the system.

Funding: 
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The Universal Coverage Scheme (UCS) is financed through general tax revenues paid to local contracting units on the basis of population size. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. In recent years, the government has responded to criticisms claiming that UCS is underfinanced by raising the budget for the scheme.

The Universal Coverage Scheme (UCS) is financed through general tax revenues paid to local contracting units on the basis of population size. The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. In recent years, the government has responded to criticisms claiming that UCS is underfinanced by raising the budget for the scheme.

General tax revenue was decided as the source of funding for the UCS because of the political urgency and focus on nationwide scale-up. The target population for the scheme is largely in the informal, agricultural sector and does do not have access to consistent cash income for any kind of regular premium payment, therefore making premium collection difficult.

A copayment of Baht 30 was also implemented. This copayment was exempted for low income people, children below 12 years old and the elderly (i.e., those above 60 years old). While this copayment did not reflect the marginal cost of interventions, it did prevent overuse.

The 30 Baht copayment was abolished in November 2006 for political reasons. However, abolition of the 30 Baht copayment had no effect on overall utilization of out-patient services. This is likely because the majority of beneficiaries have been already exempted from the copayment.

The UCS reform raised public health spending from about 66.25 billion Baht in 2000-01 to 72.78 billion Baht in 2001-02. Thus, the reform cost US $175 million. The overall budget for UCS has increased to 82.02 billion (18%) and 91.36 billion (10%) in the years 2006 and 2007 respectively.

Co-financing arrangements for the scheme are currently being considered—for example, one proposal suggests partial or non-subsidization of medical care costs for beneficiaries who decide to stay in a private room.

Population covered: 
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The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns.

The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns.

A centralized registration database, which is updated regularly, is also a useful tool in identifying and enrolling beneficiaries in the USC scheme. The central registration database consolidates information on the entire Thai population, and includes registration information of the CSMBS, the SSS and the UCS. When patients seek care, their entitlements are checked with the centralized online database to ensure that they are enrolled in an insurance scheme. If the database shows that that are not members of the CSMBS or the SSS, they are asked to register for the UCS at that time.

Benefits package: 
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UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy.

UCS beneficiaries are entitled to a comprehensive benefits package, including both inpatient and outpatient care. In addition to curative services (with some exclusions), UCS provides for preventive care for all Thai citizens, focused on health promotion and disease prevention (e.g., immunizations, annual physical checkups, premarital counseling, antenatal care and family planning services, etc.). Recently, coverage has also been extended to ARV treatment for HIV/AIDs and renal replacement therapy.

The curative package covers ambulatory and hospitalization services with some exclusions, such as cosmetic surgery, infertility treatments, organ transplants, and the provision of private room and board. For high-cost care, the UCS has adopted a similar package to the one provided by the SSS in order to standardize the packages across the scheme to minimize inequities in health care services. Thus, substantial high-cost interventions are offered. All contracted public and private providers are bound to provide registered beneficiaries with these and other preventative services.

ART treatment and renal replacement therapy coverage was extended beginning in October 2003 and January 2008 respectively, because of strong social movements pushing for these inclusions. In January 2008, based on a cost-benefit analysis, the NHS Board decided to provide the seasonal flu vaccination to high-risk groups. There was no increase to the budget because it was determined that it costs less to vaccinate for the flu than to treat it. Evidence from a cost-benefit analysis showing that the cost of treatment and care for flu patients in high-risk groups is higher than the cost of vaccination has resulted in the decision to provide seasonal flu vaccination to high-risk groups.

The decision to expand benefits to include renal replacement therapy from January 2008 is forecasted to increase the burden on the health care system.

The table below illustrates some high cost inclusions and exclusions in the UCS.

Included services

  • Chemo for cancer
  • Radiation therapy for cancers
  • Open heart surgery including prosthetic cardiac valve replacement
  • Percutaneous transluminal coronary angioplasty
  • Coronary artery bypass grafting
  • Stent for treatment of atherosclerotic vessels
  • Prosthetic hip replacement therapy
  • Prosthetic shoulder replacement therapy
  • Neurosurgery
  • Antiretroviral treatment
  • Renal replacement therapy including kidney transplants for patients with end stage disease

Excluded services

  • Other organ transplants
  • Cosmetic surgery
  • Infertility treatment
Service delivery system: 
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The UCS service delivery network includes both public and private health care facilities. However, prior to registration, private health facilities must submit required documentation and are investigated according to standard criteria of the UCS. No similar process exists for public health care facilities and they are automatically registered in the delivery network.

The UCS service delivery network includes both public and private health care facilities. However, prior to registration, private health facilities must submit required documentation and are investigated according to standard criteria of the UCS. No similar process exists for public health care facilities and they are automatically registered in the delivery network.

The Thai insurance system is based on the health system that is founded on the principles of primary care. For UCS in particular, primary care provider units (PCUs) have been designated as gatekeepers to provide care for UCS beneficiaries. As gatekeepers, PCUs are expected to provide people in their catchment areas with continuous and comprehensive care with a holistic approach. According to the services provided, health facilities under the UCS can be classified into three groups:

  • Contracting unit for primary care: These CUPs are primary health facilities offering curative, promotive, preventive, and rehabilitative services such as ambulatory care, home care, and community care. They can be facilities ranging from community hospitals to tertiary care public or private hospitals. Each CUP has its own catchment area and population.
  • Contracting unit for secondary care: The CUSs are health facilities that offer secondary care, mainly in patient health services. They can be facilities ranging from community hospitals to tertiary care public or private hospitals.
  • Contracting unit for tertiary care: The CUTs provide expensive care and specialized care with high technologies. They can be regional hospitals, university hospitals, or specialized health institutes.

Private health facilities are investigated by the UCS before contracts are signed. There is no such investigation for public health care facilities as they are automatically registered in the delivery network.

In principle, UCS beneficiaries are free to choose their primary providers. However, because of limited number of primary providers in rural areas, beneficiaries are assigned mainly to public primary providers close to their communities or their workplaces.

Institutional structures: 
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UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board.

UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Furthermore, the NHSO has regional and provincial branch offices to handle beneficiary questions and requests.

Governance in the Thai public health insurance system is fragmented. The National Health Security Office manages and oversees the UCS, while the Ministry of Finance and Ministry of Labor oversee the other public insurance schemes as well as the private insurance market. The figure below presents a snapshot of the governance structure of Thai public insurance.

Thailand, the Health Insurance Model, 2007

While there are no standardized coding and reporting systems among Thai health care facilities and among insurers, the various public health insurance schemes have joined an initiative to integrate utilization databases among the schemes to develop statistical analysis of utilization activity, planning and monitoring processes.

The National Health Security Board has autonomy by law to steer overall management of the scheme. Co-payments, benefits package, standard guidelines, quality standards, contract processes, and payment mechanisms are decided by Board. There is a Standard Board which is responsible to prepare quality standards and oversee beneficiary complaints and grievances.

The UCS has its own IT infrastructure. While the clinical information system of the UCS is similar to other schemes, it is not identical. The UCS has also developed specific applications for health facilities to collect data for reimbursement in specific disease management programs (e.g. leukemia, diabetic mellitus, HIV/AIDS, etc.).

The UCS also has dedicated customer service facilities including a dedicated call centre. Branch offices and the call centre are available to beneficiaries to answer questions and request. Complaints and grievances are reviewed at branch offices and at the central office. Finally, outstanding grievances are decided in a subcommittee of the Standard Board.

The NHSO has regional branches offices and province branch offices to handle beneficiary questions and requests.

Provider payment mechanisms: 
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UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003.

UCS uses capitation as the main provider payment mechanism. Initially, providers were given the option of receiving reimbursements based on either total capitation or capitation for outpatient services and DRG for inpatient services at the provincial level. However, due to the disincentive of paying providers for high-cost care and delays in case referrals, UCS began using a single payment system in 2003.

The current payment mechanism for UCS is a mixed system of risk-adjusted capitation for primary care, a DRG-based capped global budget, and fixed rate fees for some services.

It should be noted that health promotion and prevention services for all Thai citizens are paid by the UCS.

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