location: nan, 'Thailand 
year: 2002 source: HSRI 
title: The monitoring and evaluation of universal health coverage in Thailand, first phase 2001/02 
abstract:This report summarizes major findings and recommendations from the research project “The Monitoring and Evaluation of Universal Health Care Coverage in Thailand, First Phase 2001-02.” The universal coverage of health service in Thailand consists of four major schemes, namely: (1) Civil Servant Medical Benefit Scheme (CSMBS), (2) Social Security Scheme (SSS) and Workmen Compensation Fund (WCF), (3) 30 Baht Scheme, and (4) Car-accident Compensation Scheme. Both WCF and the Car-accident Compensation Scheme could be considered as supplementary schemes where funds are collected from those who liable for the workplace or traffic accidents. The study employs a mix of methods that range from gathering and analyzing secondary data from various sources—including the data that come through reporting systems, review of previous studies, in-depth interviews and focus groups, content analysis of medias, observing meetings of committees, working groups, participating in seminars organized by various groups, and field works that include using questionnaires and analyzing hospital and patient records. The findings of this study are summarized as follows:	CSMBS provides health care benefit to government officials and their dependents (parents and up to three children). The payment mechanism is retrospective fee-for-service. During the past 13 years (1988-2001), the program cost has increased by six-fold, averaging 15 percent per annum. A reform was implemented in the late 1990s that cut down certain benefits such as limiting uses of private hospitals to emergency cases only, cutting lengths of stay at public hospitals and covering only medicines in the Essential Drug List. After the reform, the program cost subdued temporary, then rebounded back to the original trend. The present reform—based on an HSRI research which was approved by the cabinet in 2000, aims primarily at changing the payment mechanism to pay the inpatient cost according to the Diagnostic-Related Groups (DRG). This new payment mechanism is scheduled to be in full force in 2004, provides a gradual four-year transition that involves IT development and setting up the Central Information Center. At present, the reform is undertaken but is about 1.5 year behind the schedule due to the late start.	SSS is primarily a compulsory scheme that covers private employees in the formal sector. The scheme is based on the Social Security Fund where the main revenue comes from social security taxes that are imposed on employers, employees, along with by-law contribution from the government. At present, SSS provides six benefits to the employees—one of which is health benefit that covers cares for illnesses that are not work-related. Health care costs for work-related accidents and injuries are paid for by the Workmen Compensation Fund (WCF), which is also administered by the Social Security Office (SSO) and collects premium solely from the employers. Each employee in SSS could choose a listed hospital as the main-contractor. SSS pays the main contractors prospectively, mainly per capitation. (WCF pays any hospitals on fee-for-service basis, but with a ceiling per accident or injury). Each main contractor in the SSS could arrange with smaller hospitals or clinics to serve as its subcontractors and with larger hospitals to be its supra-contractors. To date, SSO appears to leave these arrangements to the main contractors, which, at times, leads to having unqualified subcontractors. In some provinces, the private hospitals that are SSS’ main contractors are blacklisted by their supra-contractors because of poor payment record. This could prohibit the insured to get quality care when needed. Since April 2002, all employees in the formal sector are required to enroll in the SSS. Thus far, only one-fourths to one-fifths of the newly-required workers has enrolled. As a result, more people would be covered by the 30 Baht Scheme than the number of the truly eligible. This would have negligible fiscal implications, however, since the burden the government shoulder for both programs are almost the same for this group of workers in the FY 2002.	The 30 Baht Scheme is a new scheme that covers the rest of population who are not under CSMBS or SSS. Thus far, the Ministry of Public Health (MOPH) has been the administrator of this scheme. The scheme started as a pilot project in six provinces in April 2001 and then expanded to 21 provinces in June. Since October 2001, the scheme has consolidated all existing health insurance programs undertaken by the MOPH—including the Health Welfare Program for the Low Income and Disadvantaged and the (voluntary) Health Card Scheme (better known as the 500 Baht Health Card for Family). While the phrase “universal coverage” and the slogan “30 Baht fee for curing every disease” have been high in the government’s discourse, the major reform that affects the health care providers most in the past year has been health care financing reform with the aim to redistributing resources, and thence physicians, to the deprived areas on a more equal basis. The financing reform allocated three-fourths of the MOPH budget based on capitation, resulting in having more money go to highly-populated and under-staffed hospitals in rural areas. Larger hospitals in major cities that used to attract most physicians in the past have found themselves in trouble, as their costs are rather high compared with the budget received and they are not allowed to charge the patients the way they used to. Hospital-based data suggest that, during the first six-month of the full-scale 30 Baht Scheme, number of outpatient visits has increased substantially from the same period last year. Number of inpatients has been in line with in the past few years. Hospital death rate has decreased. However, inpatient death rate increased slightly in the first half of FY2002. There have also been concerns on effects of payment mechanism (such as inclusive capitation) on delayed treatment or referral. Contrary to popular beliefs, thus far the 30 Baht Scheme has not cost the taxpayers dearly. In FY 2002, the scheme added about 10 billion baht to the MOPH regular budget (approximately 16 percent increase from 60 billion baht in FY 2001) while providing health coverage to additional 25 million people. The outlay is expected to increase only slightly in the FY 2003, even less than the increment in the SSS. It is unlikely that the three major health insurance schemes would be merged in the near future. This has caused concerns on equity and overlapping coverage. Part of the overlapping coverage is due to incentive problem, i.e., multiple cardholders still benefit from having more than one card as there has been no one dominant scheme under which the benefit package is better than other schemes in every aspect. One plausible measure to solve the incentive problems is to elevate certain benefits under the CSMBS that are still below than those of the SSS and the 30 Baht scheme and also elevate certain benefits of the SSS that are still below that of the 30 Baht scheme. In addition, reform on payment mechanism is needed to curtail health providers’ incentive that could lead to double/multiple standard in taking care of patients under different schemes.