thailand:’ · 2012-10-30 · & thailand health profile. from world bank (2012) government...

สํานักงานวิจัยเพื่อการพัฒนาหลักประกันสุขภาพไทย

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alth System Research Ins1tute

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

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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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•  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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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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Source: IHPP (2007)

Total Disability adjusted life years (DALY) loss 9.17 million years

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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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Health Care Delivery

Na*on-‐wide coverage by Pubic Providers

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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

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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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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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Social Health Protec1on

Public Managed Schemes

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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


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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


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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

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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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Performance of

Health Care System aTer 10 years of the UC

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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


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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


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Accessibility

Source: HISRO (2008)

•  Increase u*liza*on of out-‐pa*ent and in-‐pa*ent

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Enabling Factors for UCS

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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

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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

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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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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

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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

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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


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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

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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.

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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

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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


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Is Thai UCS Sustain?

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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

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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)

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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)

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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


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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

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Social Sustainability:

Legi1macy, People Sa1sfac1on Solidarity?

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Challenges

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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

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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

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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

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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


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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

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(x 1,

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Pop 2007 POP 2020

Source: Health Care Reform Project (2008). 42


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THANK YOU

Ques1ons?

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thailand:’ · 2012-10-30 · & thailand health profile. from world bank (2012) government...

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