Health System Research Institute
Health Insurance System Research Office
THAILAND:
Universal Health Care Coverage Through
PLURALISTIC APPROACHES
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
• Introduction
• Health Care Delivery in Thailand
• Social Health Protection
• 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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Population - 67 million
Total fertility rate: 1.6 (2009)
1400
P opulation (x 1,000)
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Population: Elderly Society
1200
1000
Life expectancy at birth:
74 Years
800
600
400
Under 5 Mortality:
14/ 1000 live births
200
0
0
20
40
60
Pop 2007
80
100
POP 2020
Source: Health Care Reform Project (2008)
Age
Maternal mortality:
48/100,000 live births
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Total Disability adjusted life years (DALY) loss 9.17 million years
1,600
Disability Adjusted life Year Lost ('000s)
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Burden of Disease: Thailand
(2004)
Group III Injuries
1,400
Group II Non-communicable diseases
1,200
Group I Infections, maternal, perinatal and nutritional cond
1,000
800
600
400
200
0
0-4
5-14
15-29
30-44
45-59
Males
Source: IHPP (2007)
60-69
70-79
80+
0-4
5-14
15-29
30-44
45-59
60-69
70-79
Females
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80+
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Health Care Delivery
Nation-wide coverage by
Pubic Providers
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Health Care Delivery Development
• Successful centralized (Public) health care
coverage plan for distribution of health care
infrastructure nationwide 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
• Maldistribution of health care providers among
rural and urban areas
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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
•
Districts
– Community hospitals
•
100%
nearly 100%
Subdistrict or Tambon
– Municipal health centres (214)
– Tambon Health centres (9,738)
nearly 100%
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Hospital Accreditation
Voluntary program which
is conducted by the
Institute of Hospital
Quality Improvement
and Accreditation
Accredited Hospitals
Number of hospital
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Quality:
250
200
150
100
50
0
1999
2000
2001
2002
2003
Year
Hospitals
2004
2005
2006
2007
This Thai accreditation
process is demanding
from both public and
private hospitals
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Social Health Protection
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.
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Services cover under
National 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.
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Current
Social Health Protection Schemes
Social health protection schemes have covered all Thai citizen since 2002
Major
Schemes
Introduced in
Target beneficiaries
Pop Coverage
Funding
Payment to health
facilities
Civil Servant Medical
Benefit Scheme
(CSMBS)
Social Security Scheme
(SSS)
Universal Coverage
(UCS)
1960s
1990s
2002
Govt employees &
dependents, retirees
Private sector
employees:
To whom which not
covered by CSMBS
nor SHI,
7%
13%
80%
Govt budget
Payroll contribution,
Tripartite
Govt budget
Fee-for-service for
OP, and DRG for IP
Capitation
Capitation
+ DRG
(use DRG in risk
adjusted part)
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Current
Social Health Protection Schemes
Differences in utilization and expenditures across the schemes
1 US$ = 34 Baht in 2009
Source: HISRO (2010) calculate from database for the three schemes
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Performance of
Health Care System
after 10 years of the UC
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Income Spending on Health by Income Groups
% income spent on health
9
Declining of gap
8
7
1992
2000
2002
2004
2006
6
5
Before UC
4
3
2
1
After UC
Poorest
Source: Socio-Economic Survey 1992 - 2006 conducted by NSO.
10
ile
9
D
ec
ile
8
Income Deciles
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
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EQUITY:
Richest
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Impacts of Universal Coverage
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Decrease
Poverty
from
Health Care
Spending
2000
280,000
Households
2008
88,000
Households
Source: Limwattananon (2010): analysis of Socioeconomic Survey (various years)
Dis tribution of Patients by Treatment Outcome
100%
80%
Improve
Health
Outcome
60%
40%
20%
0%
2003-4
2008-9
Hypertension
2003-4
2008-9
Diabetic
No diag
No trearment
2003-4
2008-9
Hypercholesterol
Uncontrol
Control
Source: National Health Examination Survey 2003-2004 and 2008-2009
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Accessibility
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• Increase utilization of out-patient and inpatient
Source: HISRO (2008)
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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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State Commitment to health
Developing Country
Source: HISRO (2012) Thailand’s Universal Coverage Scheme: Achievements and Challenges. An
independent assessment of the first 10 years (2001-2010).
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Centralized (Public) health care coverage
Developing Country
Developing Country
Decade of hosp 1977- 1986
Decade of health centre
Developing Country
1992-2001
Developing Country
Source: Patcharanarumol W et al (2011). Why and how did Thailand achieve good health at low cost?10
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Centralized (Public) health care coverage
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Regional disparities: Improve but Still Exist
Developing
Country
Developing
Country
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)
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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, noprivate practice allowances, Pay for performance
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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
Accumulation of Knowledge
Health
Reform
Social Movement
Political Linkage
Source: Dr. Prewase Wasi
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Technical Process
Political Process
1996
1997
1998
1999
2000
2001
2002
Pilot Information and
financing
model in 6 provinces
Process
1995
the Policy
1994
Development
1993
Policy Research
1992
Technical Input for
1991
Movements of Civic
Groups
Creation of Critical
Mass Inside MOPH
1990
Field Model Development
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Chronological Events of UC Policy
Development Process
First Draft of NHA
First National Forum on HCR
Network of Civic Groups were organized and supported
Draft NHA by Civic Groups was submitted to the Parliament
Draft NHA Approved by the Parliament
Source: NHSO (2009)
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Is Thai UCS Sustain?
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Financial Sustainability
Political Sustainability
Social Sustainability
Source: Saltman et al (2004). Social health insurance systems in western
Europe. European Observatory on Health Systems and Policies Series
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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 Relatively 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
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Political Sustainability:
Commitment of Political Parties
Gov Health Exp as % Gov Spending
16.0%
14.0%
Gov Health Exp as % of Gov Spending
12.0%
10.0%
8.0%
6.0%
GDP Growth (Norminal)
4.0%
2.0%
0.0%
-2.0%
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GDP Growth (Nominal)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
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Social Sustainability:
Legitimacy, People Satisfaction
Solidarity?
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Challenges
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Harmonized
Social Protection Scheme
• Multiple schemes using the same
payment mechanism
• Harmonized life serving and high cost
care among three schemes
• Try to identify basic health care package
• Services more than basic package are
depended on Schemes or People
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Harmonized
Social Protection Scheme:
System Governance at national Level
Prime Minister
National
health
assembly
Net work of
Civil societies
Net work of
technocrats
Net work of
medias
Parliaments
National Health
Commission
Cabinet
System governance and Harmonisation
- “Tax (Contribution)”
- Benefits
- Administration
Minister of Health
Minister of Labour
National Heath
Security Office
Social
Security
Office
Minister of Finance
Civil
Servant
Medical
Benefit
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Harmonized
Social Protection Scheme:
Proposed Functions at national Level
Reports & Analysis
-Cross-section
-Time series
Macroeconomic data
Modeling
National
Financial
Monitoring
Demographic data
UC
Scheme
Indices
SSS
Scheme
CSMBS
Scheme
Other
Schemes
Design &
Costing for
Benefit
Package
National
Clearing House
MoPH
Hospitals
Other
Ministries
Hospitals
Private
Hospitals
Coding Standard
Payment Method
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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
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Self care, Acute, Subacute, Chronic and Long Term Care
1400
Population (x 1,000)
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Mitigating and Coping of Aging Society:
New Continuum of Care
1200
1000
800
600
400
200
0
0
20
40
60
Pop 2007
Source: Health Care Reform Project (2008).
80
100
Age
POP 2020
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THANK YOU
Questions?
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