-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
Thailand’s system of accountability:
Institutional mechanisms to support M&E
Phusit Prakongsai, MD. PhD.
International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
Presentation to the technical meeting on
Strengthening M&E of National Health Plan and Strategies
Hotel Victoria, Glion sur Montreux
14-15 July 2010
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
HIS for M&E in Thailand
• The HIS in Thailand is not a single system, but it consists of
multiple sub-systems of health information with involvement of
many key stakeholders in and outside the health sector:
– Vital registration from Ministry of Interior (MOI);
– Community-based household surveys from National Statistical
Office (NSO), MOPH, research institutes;
– Facility-based data from several Departments of MOPH, National
Health Security Office (NHSO), CGD;
– Disease surveillance from Department of Disease Control of MOPH;
– NHA and DRGs data from research institutes –IHPP, CHEM, etc.
• Main financing sources for HIS
– Regular government budget,
– 2% earmarked tax fund from tobacco and alcohol consumption
through Thai Health Promotion Foundation,
– Direct payments from data users, either public or private
organizations.
2
Monitoring & Evaluation of health systems reform /strengthening
A general framework
Inputs & processes
Financing
Indicator
domains
Governance
Infrastructure
/ ICT
Health
workforce
Supply chain
Information
Data
sources
Administrative sources
Financial tracking system; NHA
Databases and records: HR,
infrastructure, medicines etc.
Policy data
Outputs
Outcomes
Impact
Intervention
access &
services
readiness
Coverage of
interventions
Improved
health outcomes
& equity
Prevalence risk
behaviours &
factors
Social and financial
risk protection
Intervention
quality, safety
and efficiency
Responsiveness
Facility assessments
Population-based surveys
Coverage, health status, equity, risk protection, responsiveness
Clinical reporting systems
Service readiness, quality, coverage, health status
Vital registration
Analysis &
synthesis
Communication
& use
Data quality assessment; Estimates and projections; In-depth studies; Use of research results;
Assessment of progress and performance of health systems
Targeted and comprehensive reporting; Regular country review processes; Global reporting
Data availability for M&E system in Thailand (1)
Input
HCF
HR
H
Infra
struct
ure
Gov
er
nan
ce
Output
Med/
Healt
h tech
HIS
acc
ess
qual
ity
safe
ty
Outcome
effic
ienc
y
Interve
n
coverag
e
Impact
Risk
factor
s


Biennial HWS


Census / SPC
Equit
y
Finan
prote
ct
ion



MICS


Reproductive H
survey






NHES
NHA
Re
sp
on
siv
e

Civil registration
and vital
statistics
Biennial SES
H
outco
me




Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey,
MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population
Changes

Data availability for M&E system in Thailand (2)
Input
HC
F
Facility-based
report
H resource
survey
HRH
Infra
structu
re
Gove
r
nanc
e
Output
Med/
Health
tech
HIS



acc
ess
Outcome
quali
ty
safet
y
effici
ency
Interven
coverage





Impact
Risk
factors
Res
pon
sive
Equity

HIS electronic IP
database

Dis surveillance


Behavioral H
survey

Sero-sentinel
Survey



Specific dis
registration
Quality
assurance (HA)
H
outco
me



Finan
protect
ion
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Case study on assessing the impact of
achieving universal coverage (UC) in 2002
• Key characteristics of the UC policy in Thailand
– Introducing a tax-funded health insurance schemes to cover 47
million (or 75%) of population who were neither civil servant and
social health insurance (SHI) beneficiaries,
– Promote the use of primary care as the main contractor and gate
keepers,
– Changing resource allocation from historical basis to capitation
contracting model and performance-based payments,
– Removal of financial barriers to health services.
• Five key questions on assessing the impact of the UC
policy
–
–
–
–
–
Financial risk protection from catastrophic health expenditure,
Equity in access to and utilization of health services,
Who benefits from government subsidies for health?
Who pays for health care?
Financial sustainability of the government health budget
6
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Scheme beneficiaries by income quintiles, 2004
100%
80%
10%
17%
49%
52%
23%
60%
40%
20%
0%
26%
31%
25%
11%
7%
4%
14%
25%
5%
1%
SSS
UC
CSMBS
Q1 (poorest)
Q2
Q3
Q4
Q5 (the richest)
Source: Analysis from the 2004 Household Health and Welfare Survey (HWS)
conducted by NSO.
8
6
5
% household
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Declining of catastrophic health expenditure
from 2000 to 2006
4
3
2
1
0
2000
2002
Quintile 1
2004
Quintile 5
2006
All
Source: Socio-Economic Survey 2000 - 2006 conducted by NSO.
Note: Catastrophic health expenditure refers to household out-of-pocket
payments exceeding 10% of household income
9
Improved fairness of financial contributions
Out of pocket payments, 1992-2006
% income spent on health
8
1992
1994
1996
1998
2000
2002
2004
2006
7
6
5
4
3
2
1
10
ile
9
D
ec
ile
8
D
ec
ile
7
D
ec
ile
6
D
ec
ile
5
D
ec
ile
4
D
ec
ile
3
D
ec
ile
2
D
ec
ile
D
ec
ile
1
0
D
ec
Declining of gap
9
Income Deciles
Source: Household Socio-Economic Survey 1992 - 2006 conducted by NSO.
10
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Equity in health care finance:
Financial Incidence Analysis
• Subsequent studies indicate the Concentration Index of various
sources of healthcare finance – Thailand 2002 (O’Donnell et al 2005)
CI
weight NHA
–
–
–
–
–
–
Direct tax
Indirect tax
Social insurance
Private insurance
Direct payments
Total Health Financing
– General Tax
0.9057
0.5776
0.5760
0.3995
0.4864
0.5929
0.1868
0.3155
0.0582
0.0668
0.3728
0.6996
Note:
CI, an index of the distribution of payments, ranges (-1 to 1), a positive
(negative) value indicates the rich (poor) contributes a larger share than the
poor (rich), a value of zero is everyone pays the same irrespective of ability
to pay
11
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Equity in utilization:
Concentration Indexes of OP service by level
2001 to 2007
Facility levels
2001
2003
2004
2005
2006
2007
Health centers
-0.294
-0.365
-0.345
-0.380
-0.267
-0.292
District hospitals
-0.270
-0.320
-0.285
-0.300
-0.256
-0.246
Provincial and regional
hospitals
-0.037
-0.080
-0.119
-0.100
0.028
0.013
Private hospitals
0.431
0.348
0.389
0.372
0.516
0.528
Overall
-0.090
-0.139
-0.163
-0.177
-0.054
-0.041
Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or
the poor (rich) disproportionately use more services than the rich (poor).
12
-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
Equity in health service use:
Concentration indexes of IP service by level
2001 to 2007
Types of health facilities
2001
2003
2004
2005
2006
2007
Community hospitals
-0.316
-0.293
-0.294
-0.266
-0.242
-0.293
Provincial and regional
hospitals
-0.069
-0.138
-0.114
-0.156
-0.049
-0.114
Private hospitals
0.320
0.309
0.254
0.366
0.398
0.464
Overall
-0.079
-0.121
-0.127
-0.114
-0.051
-0.080
13
Who benefits from government subsidies for health?
Benefit incidence analysis (BIA) 2001 and 2003
35
30
31
28
25
22
20
percent
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
A comparison of percent distribution of net government health subsidies among different
income quintiles in 2001 and 2003
20
17
17
15
15
16
18
15
2001
2003
10
5
0
Q1
Q2
Q3
Q4
Q5
Income quintile
Note:
-Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were
80,678 million Baht (in 2001-value)
- The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123
14
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Using evidence to develop appropriate
provider payments during the UC era
• Increase equitable access by
– A separation of payment for high cost services
– Developing underserved services:
• Excellence centers (trauma, cardiac, cancer, stroke fast
tract, STEMI),
• EMS,
• Community rehabilitation
– Expansion of benefit package: universal access to
ARV, RRT
– Compulsory licensing of high cost drugs:
chemotherapy for cancer patients.
• Improve quality & effectiveness of services
– Disease management program: DM, TB
15
500,000
400,000
300,000
200,000
100,000
0
10,000
8,000
6,000
4,000
20
03
20
04
20
05
20
06
20
07
20
08
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Increased access to particular services
after introduction of appropriate provider payments
ALS
BLS
FR
250,000
200,000
2004 2005 2006 2007 2008
Open heart
60,000
40,000
150,000
100,000
50,000
0
2,000
0
20,000
2004 2005 2006 2007 2008
Chemo
0
2004 2005 2006 2007 2008
Cataract
16
More equitable geographical access to
open-heart surgery between 2004-2007
ิ ลำเนำของผู
ภูมิลำเนำของผูป้ ่ วยในสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ ที่รบั กำรรั
ภูมิลกำเนำของผู
ษำ
ป้ ่ วยในสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ ที่รบั ภูกำรรั
กษำ ป้ ่ วยในสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ ที่รภูบั มกำรรั
มิลำเนำของผู
กษำ ป้ ่ วยในสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ ที่รบั กำรรักษำ
โรคหัวใจในโรงพยำบำล Excellence Center ปี 2547
โรคหัวใจในโรงพยำบำล Excellence Center ปี 2548
โรคหัวใจในโรงพยำบำล Excellence Center ปี 2549
โรคหัวใจในโรงพยำบำล Excellence Center ปี 2550
กรุงเทพฯ
นนทบุรี
ปทุมธำนี
นนทบุรี
กรุงเทพฯ
จันทบุรี
กรุงเทพฯ
ปทุมธำนี
จันทบุรี
ชลบุรี
Less than 21.06
Less than 21.06
Less than 21.06
Less than 21.06
21.06 – 42.12
21.06 – 42.12
21.06 – 42.12
21.06 – 42.12
42.12 and More
42.12 and More
42.12 and More
42.12 and More
หน่ วย : อัตรำต่อ 100,000 ประชำกรสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ
หน่ วย : อัตรำต่อ 100,000 ประชำกรสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ หน่ วย : อัตรำต่อ 100,000 ประชำกรสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ หน่ วย : อัตรำต่อ 100,000 ประชำกรสิ ทธิ หลักประกันสุขภำพถ้วนหน้ ำ
แหล่งที่มำ : ข้อมูลจำกฐำนข้อมูลผู้ป่วยใน สำนักงำนหลักประกันสุขภำพแห่งแหล่
ชำติ งที่มำ : ข้อมูลจำกฐำนข้อมูลผู้ป่วยใน สำนักงำนหลักประกันสุขภำพแห่
งชำติ
แหล่
งที่มำ : ข้อมูลจำกฐำนข้อมูลผู้ป่วยใน สำนักงำนหลักประกันสุขภำพแห่
แหล่งงชำติ
ที่มำ : ข้อมูลจำกฐำนข้อมูลผู้ป่วยใน สำนักงำนหลักประกันสุขภำพแห่งชำติ
17
Financial sustainability:
Total health expenditure 1994-2005
300,000
4.50%
4.00%
250,000
3.50%
3.00%
2.50%
150,000
2.00%
100,000
%GDP
Mil. Baht
200,000
1.50%
1.00%
50,000
0.50%
0
0.00%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
public
private
%GDP
Total health expenditures, 2003-2005: 3.55 – 3.49% of
GDP, THE per capita approx 100 USD
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Using evidence for decision making on the benefit package
of the UC scheme
Years
Alendronate
(million USD)
2009
15.6
2010
22.8
2011
26.3
2012
29.4
2013
27.7
2014
27.5
2015
26.9
2016
23.2
2017
21.8
Long-term budget
impact (million
USD) from
providing
treatment for all
women with
osteoporosis in
Thailand
Source: Maleewong U, Kingkaew P, Ngarmukos C, Teerawattananon Y. ECONOMIC EVALUATION OF
SCREENING AND TREATMENT STRATEGIES FOR POSTMENOPAUSAL OSTEOPOROSIS: EVIDENCE TO INFORM
DECISION MAKERS FOR SELECTION TO THE NATIONAL LIST OF ESSENTIAL MEDICINES IN THAILAND. HITAP
2008
19
19
How equity and efficiency were achieved?
Breadth and depth coverage,
comprehensive benefit package, free
at point of services
In-feasible for informal
sector (equally 25%
belong to Q1 and Q2) to
adopt contributory
scheme
2. Minimum catastrophic health expenditure
3. Minimum level of impoverishment
EQUITY GOALS
1. Equity in financial
contribution
Tax financed scheme,
adequate financing of
primary healthcare
Provider payment method: capitation
contract model and global budget + DRG
1. Long term
financial
sustainability
2. Technical efficiency,
rational use of services at
primary health care
EFFICIENCY GOALS
4. Equity in use of services
5. Equity in government
subsidies
Functioning primary health
care at district level, wide
geographical coverage of
services, referral back up to
tertiary care where needed,
close-to-client services with
minimum traveling cost
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Key factors contributing to institutionalization of
M&E in Thailand
•
Gradual evolving culture among policy makers in using evidence for
decision making,
•
Demand from users  e.g. policymakers, health strategic planners,
directors of policy and planning division, health system and policy
researchers, etc.
•
Adequate financing and skilful human resources for HIS development,
•
Long-term capacity building and skills in data generation, compilation,
processing, synthesis & analyses, dissemination, communication to
the public and policymakers,
•
Good collaboration and close relationship between data producers and
data users, and policymakers,
•
Networking with key stakeholders at sub-national, national, and
international levels.
21
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Structure of Health Information System
Development and Networking in Thailand
MOPH
Thai Health
Promotion Foundation
Health System Research
Institute (HSRI)
NESDB
NHSO
Civil societies
Health Information
System Development
Plan and Networking
NSO
NGOs
Steering committee
Academics
Management office
Data owners
Professionals
22
Network and
coordination
Reviews for HIS
Demands and indicators
Data analysis and
synthesis for report
production and
publication
Utilization
mechanism
Research and development
for improving health
information system
Reviews for health
information systems
Data quality
assessment
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Remaining key challenges in
institutionalizing HIS in Thailand
•
Many HIS institutes/organizations are responsible for different
components of M&E  duplication, inefficiency, and difficulties in
networking and standardization,
•
Gaps in data quality and availability, particularly data of the private
sector,
•
Despite adequate financing, more investment in HIS – both human and
financial resources is needed,
•
Variations in level of technical capacity in data generation, compilation,
data processing, data analysis & synthesis, and communication, in
responsible institutes,
•
Problems in standardization of data generation, collection, and
analyses,
•
Low utilization of evidence by some policymakers,
•
Need long term capacity building and champions in HIS for M&E
24
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Acknowledgement
•
•
•
•
•
•
•
•
Ministry of Public Health (MOPH) of Thailand
National Statistical Office of Thailand (NSO)
Health Systems Research Institute (HSRI)
Health Information System Development Office (HISO)
Thai Health Promotion Foundation (THPF)
National Health Security Office (NHSO)
WHO long-term fellowship program of WHO-SEA region
Department of Health Statistics and Informatics, WHO-HQ
25