UHC in developing countries ,
Health system : Ethical dilemmas.
Dr. Peerapol Sutiwisetsak
Deputy Secretary General
National Health Security Office
Thailand
1
•
Population - 64 million
•
GNI 2012 US$5,090 per capita, Gini 42.5
•
UHC achieved in 2001 under 3 scheme
•
•
civil servants, social security and UC
Health status
 Life expectancy at birth 74 years
 IMR 20/1000 LB, MMR 30/100,000 LB
 Physicians per capita 5/10,000
 ANC & hospital delivery 99-100 (2009)
•
Total Health Expenditure
 US$300 per capita, 6% GDP
 Half from public , 14% of National
National Health Security Office – NHSO – www.nhso.go.th
Thailand: country profiles
budget
 Less than 40% out of pocket
2
National Health Security Office – NHSO – www.nhso.go.th
UHC can be started and achieved at low level of income
US $
4,000
GDP/capita
1997: Asian
financial crisis
2,700
The children n
elderly
3,000
2001: 29% of
population are
uninsured
1,900
71%
2,000
2002 Universal
Coverage for entire
population achieved
1980 CSMBS
introduced
1990 SHI
introduced
760
20%
1,000
1490
29%
390
710
1975 Low Income
scheme introduced
100%
53%
1983 CBHI
introduced
42%
Suwit Wibulpolprasert, MoPH, Thailand
year
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
0
3
CSMBS
7.69%
(4.97 Millions)
None 0.95%
(0.65Millions)
Other 0.10%
0.07Millions
SSS 15.99%
(10.33Millions)
UC 1 ประกันสุขภาพถ ้วนหน ้า
SSS 2social
ประกันsecurity
สงั คม
CSMBS
servant
medical
benefit
3 ขcivil
้าราชการ/รั
ฐวิสาหกิ
จ
Others
ิ ธิอน
4 สท
ื่ ๆ *
UC 75.27%
(48.62Millions)
National Health Security Office – NHSO – www.nhso.go.th
Health Insurance Schemes
None5 ผู ้ยังไม่ลงทะเบียนสท
ิ ธิ
4
1.Ensure Healthcare for all and poverty reduction
2.The Development of benefit package
3.The Transparency and participatory mechanism.
4.The Strategic purchasing under fiscal constraint
5. The Preliminary assistance for damage or injury
caused by any services
6.The 24 hr services of the call center
National Health Security Office – NHSO – www.nhso.go.th
Ethical point
5
4
3.68
Fast tracking rural health
Budget (billion Bahts)
3.5
2.9
3
2.4
1.5
1.88
2.23
2.15
2.04
3.15
3.1
2.73
2.64
2.5
2
3
3.01
2.27
2.43
No investment in urban areas for 5 yrs.
1.68
1
0.5
0
1982
Provincial
1983
District
1984
1985
1986
1987
1988
1989
National Health Security Office – NHSO – www.nhso.go.th
1. Ensure availability of quality health care for all
Year
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand
6
Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population
Extensive production of
appropriate cadres and
motivated health
personnel with
mandatory public works
and adequate support
are essential.
Rural community hospital with 2-8
doctors cover 30-80,000 population
National Health Security Office – NHSO – www.nhso.go.th
Adequate and appropriately manned rural health
facilities
7
For more complex service, secondary
and tertiary hospitals with specialized
personnel , highly diagnostic and
treatment technology are available .
Referral system was set up .
Medical school hospital
General hospital in every province
National Health Security Office – NHSO – www.nhso.go.th
Seamless Health Service Networks
Regional hospital in every region
8
1977
1987
2000
2010
(
46%
(5.5)
24%
(2.9)
29%
(3.5)
27%
(11.0)
35%
(14.6)
38%
(15.7)
18.2%
(20.4)
35.7%
(40.2)
46.1%
(51.8)
12.6%
(18.1)
33.4%
(33.4)
54.0%
(78.0)
) : Number of OPD visits (millions)
Regional H./General H.
District Hospital
Rural Health Centres
Regional H./General H.
District Hospital
Rural Health Centres
Regional H./General H.
District Hospital
Rural Health Centres
Regional H./General H.
National Health Security Office – NHSO – www.nhso.go.th
1. Healthcare for all : Changes in out-patient utilization:
District Hospital
Rural Health Centres
Source: Rural Health Division, MoPH
9
UHC achieved
Source: Viroj Tangcharoensathien
Suwit Wibulpolprasert, MoPH, Thailand
National Health Security Office – NHSO – www.nhso.go.th
UHC is effective for poverty reduction
10




Evidence base transparent n participatory processes
Life saving non cost-effective treatments but high
impoverishment tendency w low budget impact
Increase access at affordable budget by using mix
payment methods to control cost and also stimulate
demand and services
The use of quality generic medicines, TRIPs flexibilities,
and the promotion of rational drug use
National Health Security Office – NHSO – www.nhso.go.th
2. The Ethic in the benefit packages development
11
25,000
bottles
20,000
CL
CL
15,000
UC Scheme
10,000
5,000
0
Suwit Wibulpolprasert, MoPH, Thailand
National Health Security Office – NHSO – www.nhso.go.th
Use of Lopinavir/Ritonavir (200/50mg)
12
 By







law National Health Security board consists of
Minister of Health chair the Board,
8 Government Ex-officio
4 Local Government Representatives,
5 representatives selected from 9 NGO constituencies
4 representatives from four Professional Councils,
1 representative from Private Hospital Association,
7 experts appointed by Cabinet [insurance, medical and
public health, traditional medicines, alternative medicines,
financing, lawyer and social science],
 Secretary General serves as secretary of the Board
 Public
hearing from provider, people every year
 Annual accounting audit
 Satisfaction survey every year
National Health Security Office – NHSO – www.nhso.go.th
3.The Transparency and participatory mechanism
13
Percent
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
83.0
45.6
2003
83.4
39.3
2004
83.2
47.7
84.0
50.9
83.1 88.3
56.5 50.7
89.3
89.8
60.3
78.8
92.8
66.9
Expand
financial
incentives
2005
2006
2007
UC People
2008
2009
2010
2011
National Health Security Office – NHSO – www.nhso.go.th
Satisfaction: UC members and providers
provider
Source: Satisfaction survey NHSO & ABAC University in various years
14
 Close
end capitation based budget with mixed
payment mechanisms mainly on capitation (OP) and
Case Mix (IP) and some FFS and PC as gate keeper
 Involvement
of the private providers, e.g, providing
primary care in the urban areas, emergency medical
services, and some specific tertiary care, e.g., cardiac
surgery
 Central
bargaining and purchasing with VMI (Vendor
Managed Inventory)
National Health Security Office – NHSO – www.nhso.go.th
4.Strategic purchasing : Better Value for Money
15
US$
Numbers
3,000,000
800
700
2,500,000
600
2,000,000
500
1,500,000
400
300
1,000,000
200
500,000
100
0
0
2004
2005
2006
2007
US$ compensate
From: NHSO data 2011
2008
2009
2010
2011
National Health Security Office – NHSO – www.nhso.go.th
5.The Preliminary assistance for damage or
injury caused by any service
Cases
16
(1)
Complaint – quality care
4,386 (0.51%)
96.18%
Complete cases
in 30 days
(2)
Complaint - general
5,758 (0.75%)
96,45%
Complete cases
in 30 day
Total call
743,744
(3) Information
729,320 (98.35%)
(4)
Inpatient bed finding
4,280 (0.39%)
From : NHSO data 2011
National Health Security Office – NHSO – www.nhso.go.th
6.The 24 hrs services of the call center 1330
17
 UHC
is the accesses to health services without
financial barrier, not merely financial protection. It is
can be achieved at low level of income and it is
effective for poverty reduction
 Fiscal
spaces and innovative financing are possible
with political leadership - resources must be used
cost-effectively thru Health Technology Assessment
and strategic purchasing
 Mechanisms to assure sustainable financing and
meeting the emerging challenges are needed and
should be developed thru evidence based health
systems researches
Suwit Wibulpolprasert, MoPH, Thailand
18
National Health Security Office – NHSO – www.nhso.go.th
Three key take home messages
National Health Security Office – NHSO – www.nhso.go.th
Thank you

TRIPS stands for Trade-Related Aspects of
Intellectual Property Rights agreed in DOHA , 2001
20



Flexibilities : special mechanism is allowed for
developing countries to gain access to essential
drugs and or to protect health system
Such as to import some generic drugs aiming to
lower ARV cost for HIV patients
The example of flexibilities is CL in ARV drug
Thailand,
National Health Security Office – NHSO – www.nhso.go.th
TRIPS flexibilities

The first goal is : Eradicating extreme poverty and
hunger
21

The Millennium Development Goals (MDGs)
are eight international development goals that were
officially established following the Millennium
Summit of the United Nations in 2000, following the
adoption of the United Nations Millennium
Declaration. All 193 United Nations member
states and at least 23 international
organizations have agreed to achieve these goals
by the year 2015.
National Health Security Office – NHSO – www.nhso.go.th
MDG 1