thailand:’ · 2012-10-30 · & thailand health profile. from world bank (2012) government...
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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THAILAND:
Universal Health Care Coverage Through PLURALISTIC APPROACHES Stakeholders Meeting on Healthcare Financing in Kenya
30 August 2012
Dr. Thaworn Sakunphanit MD., FRCPT, BA (Econ), MSc. (Social Policy Financing)
Deputy Director, Health Insurance System Research Office
1
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Contents
• Introduc*on • Health Care Delivery in Thailand • Social Health Protec*on • Performance of Health Care System • Is Thai UC sustain? • Enabling Factors for UCS • Future challenges
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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• Constitutional monarchy in Southeast Asia • GNI per capita - US $ 4,210 (2010) • Unemployment rate is 1.4% • Health Expend/cap – US $175 (2009)
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Popula1on: Elderly Society
0
200
400
600
800
1000
1200
1400
0 20 40 60 80 100 Age
Po
pu
lati
on
(x
1,0
00
)
Pop 2007 POP 2020
Source: Health Care Reform Project (2008)
Population - 67 million Total fertility rate: 1.6 (2009) Life expectancy at birth: 74 Years Under 5 Mortality: 14/ 1000 live births Maternal mortality: 48/100,000 live births
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Source: IHPP (2007)
Total Disability adjusted life years (DALY) loss 9.17 million years
0
200
400
600
800
1,000
1,200
1,400
1,600
0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+
Males Females
Dis
abili
ty A
djus
ted
life
Yea
r Lo
st ('
000s
)
Group III Injuries
Group II Non-communicable diseases
Group I Infections, maternal, perinatal and nutritional cond
Burden of Disease: Thailand (2004)
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Health Care Delivery
Na*on-‐wide coverage by Pubic Providers
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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• Successful centralized (Public) health care coverage plan for distribu*on of health care infrastructure na*onwide before financing for universal coverage for health care
• Public – private mixed – Public providers are majority – Ministry of Public Health (MoPH) owns two-‐third of all hospitals and beds across the country
– Private providers are almost in urban area • New Graduated Health care professional are compulsory to work for Government
• Maldistribu*on of health care providers among rural and urban areas
Health Care Delivery Development
7
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Coverage of health facilities Mainly under Ministry of Public Health (MOPH)
• Provinces (76) exclude Bangkok – General/Regional hospitals 100%
• Districts – Community hospitals nearly
100% • Subdistrict or Tambon
– Municipal health centres (214) – Tambon Health centres (9,738) nearly 100%
Health Care Delivery Development
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Quality:
Hospital Accreditation Voluntary program which is conducted by the Ins*tute of Hospital Quality Improvement and Accredita*on
This Thai accredita*on process is demanding from both public and private hospitals
Accredited Hospitals
0
50
100
150
200
250
1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Nu
mb
er o
f h
osp
ital
Hospitals
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Social Health Protec1on
Public Managed Schemes
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Thailand:
Path to Universal Coverage
Source: National Statistic Office, the Health and Welfare Surveys in 1991, 1996, 2001 and 2003. 11
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Services cover under
Na1onal Health Security Act • Promotive and preventive cares; • Diagnosis; • Ante-natal care; • Curative care; • Medicine, medical supplies, organ
substitutes, and medical equipments; • Delivery; • Boarding expense within health care unit; • Newborn and child care; • Ambulance or transportation for patient; • Transportation for disability person; • Physical and mental rehabilitation; • Other expenses necessary as prescribed by the
Board. 12
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Current
Social Health Protec1on Schemes
Major Schemes
Civil Servant Medical Benefit Scheme
(CSMBS)
Social Security Scheme (SSS)
Universal Coverage (UCS)
Introduced in 1960s 1990s 2002 Target beneficiaries Govt employees &
dependents, retirees Private sector employees:
To whom which not covered by CSMBS
nor SHI, Pop Coverage 7% 13% 80% Funding Govt budget Payroll contribution,
Tripartite Govt budget
Payment to health facilities
Fee-for-service for OP, and DRG for IP
Capitation (use DRG in risk
adjusted part)
Capitation + DRG
Social health protection schemes have covered all Thai citizen since 2002
13
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Differences in utilization and expenditures across the schemes
Current Social Health Protec1on Schemes
Source: HISRO (2010) calculate from database for the three schemes
1 US$ = 34 Baht in 2009
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Performance of
Health Care System aTer 10 years of the UC
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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0
1
2
3
4
5
6
7
8
9
Decile
1
Decile
2
Decile
3
Decile
4
Decile
5
Decile
6
Decile
7
Decile
8
Decile
9
Decile
10
Income Deciles
% in
com
e sp
ent
on
hea
lth
19922000200220042006De
clining of gap
Poorest Richest
EQUITY: Income Spending on Health by Income Groups
Before UC
After UC
Source: Socio-Economic Survey 1992 - 2006 conducted by NSO. 16
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Impacts of Universal Coverage
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Distribution of Patients by Treatment Outcome
0%
20%
40%
60%
80%
100%
2003-4 2008-9 2003-4 2008-9 2003-4 2008-9
Hypertension Diabetic Hypercholesterol
No diag No trearment Uncontrol Control
Decrease Poverty from Health Care Spending
Improve Health Outcome
Source: National Health Examination Survey 2003-2004 and 2008-2009
Source: Limwattananon (2010): analysis of Socioeconomic Survey (various years)
2000 280,000
Households
2008 88,000
Households
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Accessibility
Source: HISRO (2008)
• Increase u*liza*on of out-‐pa*ent and in-‐pa*ent
18
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Enabling Factors for UCS
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Enabling Factors for UCS
• State commitment to health – Socioeconomic (growth & poverty reduction) – Legitimacy -> constitution & political perspective
• Centralized (Public) health care coverage plan • Planning and utilization of human resource • Improvement of Institution Capacity on Health system:
– health system research, health care financing, model development
• Support and collaboration with health care professional, civil societies and politicians
20
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Source: HISRO (2012) Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010).
State Commitment to health
21
Developing Country
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Centralized (Public) health care coverage
Source: Patcharanarumol W et al (2011). Why and how did Thailand achieve good health at low cost?10
Developing Country
Developing Country Developing Country
Developing Country
Decade of hosp 1977-‐ 1986 Decade of health centre 1992-‐2001
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Regional disparities: Improve but Still Exist
Source: Pagaiya, N, et al (2008) Thailand’s Health Workforce: A Review of Challenges and Experiences. & Thailand Health Profile. From World Bank (2012) Government Spending and Central-Local Relations in Thailand’s Health Sector. Health, Nutrition and Population (HNP) Discussion Paper (Forth coming)
Centralized (Public) health care coverage
Developing Country
Developing Country
23
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Centralized (Public) health care
coverage • Public Health Care Provides have been allowed to keep
revenue since 50+ year ago. – Sense of ownership,
• Step by step increase flexibility and autonomy to health facilities – 1990 Competition between Public and Private facilities for
SSO member – 2002 (the UC era): Almost money to public facilities come
from “Insures” (except salary) • Provincial health officer is responsible to integrated health
service in provincial level
24
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Planning and utilization of
human resource • Compulsory Service for Government
– Start in 1968: Medical students have to work for government for three years. Finally, it applied to dentist, pharmacist, nurse, and other paramedical personnel
• Increase number of new-comers • Non-financial incentive & Moral Motivation • Financial Incentive
– Hardship allowances for working in rural area, no-private practice allowances, Pay for performance 25
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Improvement of Institution Capacity on Health system:
• Strong leadership in MOPH to create its “brain” from generation to generation
• Talent new comers have been identified – opportunity to join model development researches,
intensive apprenticeship type training, formal training aboard and come back to work in those fields
– Researches and model developments can traced back to before 1980
• In 1992 Health System Research Institution, which is autonomous agency equivalent to Department level is established in MoPH
26
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Improvement of Institution Capacity
on Health system (Example) • Capitation
– Aggregate performance reports was in placed since 30+ year ago – Research on hospital cost accounting’s started since 1980 – First use of Capitation of SSO in 1990
• DRG – Before 1990: Research on DRG has started – 1990+: implemented ICD10, Basic Minimum Data Set, Simple
Computerized Hospital System – DRG version 1 has implemented in 1999
• Model developments were implemented during 1980 – until now.
27
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Collaboration Among Health Care
Professional, Civil Societies and Politicians: Triangle that moves mountain
Health Reform
Social Movement
Accumula*on of Knowledge
Poli*cal Linkage
Source: Dr. Prewase Wasi
28
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Political ProcessTechnical Process
First Draft of NHA
Fie
ld M
odel
Dev
elopm
ent
Policy
Res
earc
h
Move
men
ts o
f C
ivic
G
rou
ps
Cre
ati
on
of C
riti
cal
Mass
In
side
MO
PH
Draft NHA Approved by the Parliament
Tech
nic
al In
pu
t fo
r
the P
olicy
Develo
pm
en
t
Pro
cess
Draft NHA by Civic Groups was submitted to the Parliament
First National Forum on HCR
Network of Civic Groups were organized and supported
Chronological Events of UC Policy Development Process
Source: NHSO (2009) Pilot Information and financing model in 6 provinces 29
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Is Thai UCS Sustain?
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Source: Saltman et al (2004). Social health insurance systems in western Europe. European Observatory on Health Systems and Policies Series
Political Sustainability Financial Sustainability
Social Sustainability
31
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Share of Total Spending Financed by
Government Has Been Rising
Source: World Bank (2012) Government Spending and Central-Local Relations in Thailand’s Health Sector. Health, Nutrition and Population (HNP) Discussion Paper (Forth coming)
32
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Thailand Spends a Rela1vely High Share of
Government Spending on Health
Source: World Bank (2012) Government Spending and Central-Local Relations in Thailand’s Health Sector. Health, Nutrition and Population (HNP) Discussion Paper (Forth coming)
33
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Projection of Total health expenditure as
Percentage of GDP (1994-2020) is not High
Source: Hennicot JC, Scholz W and Sakunphanit T. Thailand health-care expenditure projection: 2006–2020. A research report. Nonthaburi, National Health Security Office, 2012 34
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Poli1cal Sustainability:
Commitment of Poli1cal Par1es
-‐2.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Gov Health Exp as % Gov Spending GDP Growth (Nominal)
GDP Growth (Norminal)
Gov Health Exp as % of Gov Spending
35
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Social Sustainability:
Legi1macy, People Sa1sfac1on Solidarity?
36
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Challenges
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สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Harmonized
Social Protec1on Scheme • Mul*ple schemes using the same payment mechanism
• Harmonized life serving and high cost care among three schemes
• Try to iden*fy basic health care package • Services more than basic package are depended on Schemes or People
38
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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National Health Commission Cabinet
Net work of technocrats
Net work of medias
Net work of Civil societies
Prime Minister
National Heath Security Office
Civil Servant Medical Benefit
National health
assembly
Social Security
Office
Minister of Health Minister of Labour Minister of Finance
Parliaments
System governance and Harmonisation - “Tax (Contribution)” - Benefits - Administration
Harmonized Social Protec1on Scheme:
System Governance at national Level
39
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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IndicesReports & Analysis-Cross-section-Time series
Modeling
Demographic data
Macroeconomic data
CSMBSScheme
PrivateHospitals
MoPHHospitals
OtherMinistriesHospitals
National Clearing House
SSSScheme
UCScheme
OtherSchemes
National Financial
Monitoring
Coding Standard Payment Method
Design & Costing for Benefit Package
Harmonized Social Protec1on Scheme:
Proposed Functions at national Level
40
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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More Efficient and more
Quality Health Care • Cost containment focus on Drug and Investigation
– Promote using of “Generic name” not Trade name – Practice guide lines and indications for new drugs – National Procurement for some expensive drugs and/
or compulsory licensing • Continuum of care
– Primary care and Referral Center in every regions • More “Efficient” public provider & public private
partnership 41
สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย
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Mi1ga1ng and Coping of Aging Society:
New Con1nuum of Care Self care, Acute, Subacute, Chronic and Long Term Care
0
200
400
600
800
1000
1200
1400
0 20 40 60 80 100 Age
Popu
lation
(x 1,
000)
Pop 2007 POP 2020
Source: Health Care Reform Project (2008). 42
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