healthcare system in thailand: past - present and where is the future ? 1
TRANSCRIPT
HealthCare System in Thailand:Past - Present
and Where is the Future ?
1
Dr. Pradit SintavanarongMinister of Ministry of Public Health, Thailand
2
Thailand Population CensusPopulation of
Thailand 2011 2012 2013Total Population 63,891,000 64,413,000 64,623,000 - Male 31,445,000 31,683,000 31,438,000 - Female 32,446,000 32,730,000 33,185,000Urban area 23,078,000 28,406,000 29,662,000Rural area 40,813,000 36,007,000 34,961,000Children (under 15 years) 13,010,000 12,892,000 12,123,000Labor force (15 - 59 years) 43,091,000 43,410,000 42,983,000Elderly (60 years and over) 7,790,000 8,111,000 9,517,000School ages (6 - 21 years) 15,192,000 15,092,000 14,027,000Women of reproductive ages(15 - 49 years) 17,711,000 17,712,000 17,388,000Crude birth rate (per 1,000 population) 12.4 12 11.6Crude death rate (per 1,000 population) 6.9 7.1 7.7Natural growth rate (percent) 0.6 0.5 0.4Infant mortality rate (per 1,000 live births) 12.3 11.8 11.2Child mortality rate (per 1,000 live births) 14.3 13.7 18.4Total fertility rate 1.5 1.5 1.6
Source: Institute for Population and Social Research, Mahidol University
3
Thailand Population Census
Estimated Population of
Thailand in the Next 20 Years
(2033) 65,759,000
- Male 31,633,000
- Female 34,126,000Source: Institute for Population and Social Research, Mahidol University; Estimated Population at Midyear 2013 (1st July)
4
Health statistics
Coverage of Health Insurance 99.46 % Life Expectancy at birth (2010) 74 ( Male 71 (71.1),
Female 77 (78.1) )
Crude birth rate (per 1,000) 12.4 (11.6)
Crude death rate (per 1,000) 6.5 (7.7)
IMR (per 1,000 live births) 6.6 (11.2)
MMR (per 100,000 live births) 8.9
Source: Ministry of Public Health , Public Health Statistics 2011
( ) = Institute for Population and Social Research, Mahidol University
5
Thailand Health Status
Aged Society
Year 2553 Year 2554 Year 25550.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
19.89 19.47 19.05
68.41 68.39 68.33
11.70 12.14 12.63
Ages 0-14
Ages15-59
Ages60 and Over
Year 2553 Year 2554 Year 2555
Age Group count percentage count percentage count percentage
Ages 0-14
12,672,935 19.89
12,496,939 19.47
12,241,023 19.05
Ages15-59
43,577,838 68.41
43,892,616 68.39
43,911,198 68.33
Ages 60 and Over
7,450,930 11.70
7,791,446 12.14
8,114,144 12.63
Total
63,701,703
64,181,001
64,266,365
Elderly = 12.63% of Total Population
Aged Society
6Source: Bureau of Policy and Strategy, Ministry of public health
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision
Japan
Korea
China
Thailand
World
7
Proportion of elderly (>65 years old)
Disease Year 2011 Year 2012Infectious disease 2007.28 2044.77Non communicable diseases• Circulatory diseases• Accident• Cancer
1881.01712.36700.91467.74
1970.27724.18762.75483.34
Rate per 100,000 populations
Morbidity
8Source: Bureau of Policy and Strategy, Ministry of public health
Disease 2007 2008 2009 2010 2011
Infectious disease 60.6 61.2 60.7 64.9 64.6Non communicable diseases• Circulatory diseases• Accident• Cancer
208.2555.268.184.9
209.7356.066.187.6
209.6755.266.188.3
215.7961.962.791.2
227.3268.863.495.2
Rate per 100,000 populations
Mortality
9Source: Bureau of Policy and Strategy, Ministry of public health
•Rate per 100,000 populations
2007 2008 2009 2010 20110
50
100
150
200
250
60.6 61.2 60.7 64.9 64.6
208.25 209.73 209.67215.79
227.320000000001
Infectious diseaseNon communicable diseases• Circulatory diseases• Accident• Cancer
Mortality
10Source: Bureau of Policy and Strategy, Ministry of public health
Source: Thailand Health Profile 2008 - 2010 11
Major Causes of Death in Thailand, 1967-2009
Source: IHPP, Burden of disease, Thailand, 1999, 2004, and 2009 12
DALYs attributable to risk factors in Thailand 1999, 2004, and 2009
13
Evolution of health system in Thailand
18881828
King Rama 3started the Western medicine
Siriraj Hospitalestablished
MoPH
Mandatory rural services
HFA/ PHC
policy
UCSNHSO
Department of Public Health, MoI
1918 19681942 2007/08/091978 20011975
Scaling up District Health System
(DH + HC)
Low Income Scheme
1980s
CSMBS 1980Health Card 1983SSS 1990
1990s
1992 A decade of
health center development
1997 ConstitutionEconomic crisis
NHCO
1992HSRI
ThaiHealth
LGs
HAI
EMIT
1946
First MoPH nursing college
MoPH = Ministry of Public Health, HSRI = Health System Research Institute, LGs = local governmentsThaiHealth = Thai Health Promotion Foundation, NHSO = National Health Security Office, NHCO = National Health Commission Office, EMIT = Emergency Medical Institute of Thailand, HAI = Hospital Accreditation Institute
1999Local
Health Funds
2006
14
Evolution of the Thai Health System
Principles of organizing healthcare system in Thailand
The 1997 Constitution was adopted as principle legal framework for moving toward welfare state by providing Universal Health Coverage,
• ‘access to needed health services is a basic right of the Thai population’
The UHC policy in Thailand aims to enable access to needed services to all Thai people and protecting them from catastrophic health expenditure
• Put emphasis on ensuring access for all at an affordable cost rather than providing the best to some
Health service delivery system has been organized as multi-level system to ensure geographical equity while maintain efficiency of the system.
15
Area
GovernorMOPH
Local Authorities
Tumbon health fund
Output/ Outcome/ Impact
PPP
NHCO
NHSO
ThaiHealth
EMIT
HAI
Ministry of Public Health
Emergency Medical Institute of Thailand
National Health Security Office
Health Accreditation Institute
Public Private Partnership
National Health Commission
Health System Research Institute HSRI
Thai Health Promotion Foundation
16
Multiple Actors in Health
17
Governance of the health system
MoPH had been sole actor in the health system for six decades; however, following various reforms, there are various actors involving in governing the health system.• Decentralization: various public health functions have been transferred to
local governments• Establishment of NHSO separation of purchasing and providing functions • ThaiHealth dealing with social determinants of health• NHCO -> citizen empowerment in health • EMIT pre-hospital care system• HAI hospital accreditation
Following various reforms, there has been brain drain from MoPH to those new autonomous agencies and resulted in weakening MoPH’s role in directive the health system.
18
Healthcare financing
Source: Thailand Data; http://data.worldbank.org/country/thailand
Note: Revenue excluding grants, GGCE = general government consumption expenditure, GGE = General government expenditure
19
General government Revenue and Expenditure 2003-2011
UHC achieved
Source: NHA 1994-2010
Economic crisis
20
Total Health Expenditure 1994 - 2010: ↑ government spending, ↓ out-of-pocket payment, but
maintain the level of spending to GDP
21
Source: Comptroller’s General Department, MOFNote: direct disbursement of OP services started in 2004 for chronic conditions, 2006 extended to pensioners, and 2009 extended to cover all CSMBS members
Per capita expense ≈ 12,000/ year
22
CSMBS expenditure, 1994 – 2012rapid cost escalation in opposite to declining of beneficiaries
Source: expenses from NHA 1994-2010 excluding expense on administration Number of beneficiaries at the end of each year from SSO
700 80
0
900 11
00
1250
1284
1404
xxx capitation
23
SSS expenditure 1994 – 2010 Per capita expense 2010 = 2,750 Baht
ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ� 24
งบกองที่�นัหลักประกนัสำ�ขภาพแห�งชาติ�ปี�งบปีระมาณ เปี�าหมายปีระชากรสิ�ทธิ�
UC (ล้�านคน)
อั�ตราค�าเหมาจ่�ายรายห�ว
(บาท/คน/ปี�)
งบเหมาจ่�ายรายห�วรวมเง�นเดื อัน (ล้�าน
บาท)
% เปีล้!"ยนแปีล้ง
ปี� 2545 45.000 1,202.40 51,407.71
ปี� 2546 46.000 1,202.40 56,091.23 9.1%
ปี� 2547 46.820 1,308.50 61,212.39 9.1%
ปี� 2548 47.000 1,396.30 67,582.60 10.4%
ปี� 2549 47.750 1,659.20 82,023.00 21.4%
ปี� 2550 46.066 1,899.69 91,369.05 11.4%
ปี� 2551 46.477 2,100.00 101,984.10 11.6%
ปี� 2552 47.026 2,202.00 108,065.09 6.0%
ปี� 2553 47.240 2,401.33 117,969.00 9.2%
ปี� 2554 47.997 2,546.48 129,280.89 9.6%
ปี� 2555 48.333 2,755.60 140,609.40 8.8%
ปี� 2556 48.445 2,755.60 141,539.75 0.7%
ปี� 2557 48.852 2,895.09 154,257.98 8.9%
25
Data from NHSO: 78% of UCS members used benefits, OP visits increased from 2.45 to 3.37 visits/person/year, IP admissions increased from 0.94 to 1.15 admissions/person/year 26
Number of use persons, OP visits, and IP admissions of UCS, 2003-2012
27
รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2553 – 2555 สำ�ที่ธิ� UC
ปี� จ่$านวนคน จ่$านวน Visit
2553 27,098,157 144,809,385
2554 29,671,976 166,184,132
2555 32,352,507 167,790,950
ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ�
28
รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2555 UCVisit count group Visit count Patient count Accumulative
patient count
1 - 3 1 10,123,016 10,123,016
1 - 3 2 5,618,033 15,741,049
1 - 3 3 3,615,457 19,356,506
4 - 6 4 2,634,825 21,991,331
4 - 6 5 2,037,527 24,028,858
4 - 6 6 1,620,063 25,648,921
7 - 9 7 1,293,477 26,942,398
7 - 9 8 1,047,112 27,989,510
7 - 9 9 846,614 28,836,124
10 - 12 10 688,628 29,524,752
10 - 12 11 561,665 30,086,417
10 - 12 12 455,115 30,541,532
13 ขึ้&'นไปี 13 ขึ้&'นไปี 2,140,938 32,682,470
ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ�
29
รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2555 UCVisit count group Visit count Patient count Accumulative
patient count
13 – 15 13 369,525 30,911,057
13 – 15 14 297,834 31,208,891
13 – 15 15 241,517 31,450,408
16 – 18 16 196,252 31,646660
16 – 18 17 160,178 31,806,838
16 – 18 18 131,145 31,937,983
19 – 21 19 108,554 32,046,537
19 – 21 20 89,594 32,136,131
19 – 21 21 73,962 32,210,093
22 – 24 22 61,340 32,271,433
22 – 24 23 51,668 32,323,101
22 – 24 24 43,466 32,366,567
25 ขึ้&'นไปี 25 ขึ้&'นไปี 315,903 32,682,470
ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ�
• On average, salary of hospital staffs increased by 6-10% per annum
• Non-salary labor cost of district hospitals increased sharply by 50% in 2009, and it increased by 30-40% for general and regional hospitals in 2009 and 2010
• All type of hospitals had a declined rate of expense on drugs
Source: Health Insurance System Research Office; analysis of financial report of MoPH hospitals 30
Increase in cost of MoPH hospitals, 2009-2011
31Source: Office of Insurance Commission http://www.oic.or.th/en/home/index.php
Losses incurred varied from 40-50% of collected revenues
Traffic Accident Insurance
Ministry of Public Health
Permanent Secretary
Technical DepartmentsDirector-General
Ministry of Interior
Permanent Secretary
Office of the Permanent Secretary
Province
Governor
Provincial Public Health Offices (76)
Provincial Chief Medical Officers
Regional & General Hospital
Community Hospitals Districts
Governors
District Health OfficesPrimary Care Unit
Tambol Health Promoting Hospitals Tambol Administration Offices
Municipalities
Provincial Administration
Offices
32
Provincial Health Administration
33
Health service delivery system in Thailand
Health centers9,768
Municipality Medical
Centers 365
District hospitals776
Provincial hospitals 68
Pharmacy 11,154
Private clinics 17,671
Other public
hospitals 120
Private hospitals
323
Regional hospitals 28
University hospitals 17
Other MoPH hospitals 55
MOPH facilities
Sub-district
District
Province
Source: 1. Thailand Health Profile 2008-20102. Bureau of Policy and Strategy, MoPH, http://hrm.moph.go.th/res53/res-rep2553.html
Private Hospital Clinics (2013)Private Hospitals• Bangkok 98, Other provinces 224• Total 322
Medical clinics• Bangkok 3,970 , Other provinces 14,533 • Total 18,503
Drugstores• Bangkok 4,912 , Other provinces 11,780 • Total 16,692
Traditional medicine Drugstores• Bangkok 443 , Other provinces 1,615 • Total 2,058
Private Hospital Clinics (2013)
34Source: Bureau of Policy and Strategy, Bureau of Sanatorium and Art of Healing, Food And Drug Administration; Ministry of public health
Health Facilities in the Public Sector (2010)
Source : Bureau of Health Administration; Ministry of public health
Administrative Level Health facility
Bangkok • 5 medical school hospitals• 26 general hospitals• 13 specialized hospitals/institutions• 68 community health care centers
Regional level • 6 medical school hospitals• 33 regional hospitals• 48 specialized hospitals
Provincial level • 83 general hospitals
District level • 774 community hospitals• 284 municipal health centers
Sub-district level • 9,768 health promoting hospitals
Village level • 198 community health posts• 48,049 rural community primary health care centers• 3,108 urban community primary health care centers• 1,055,000 Village Health Volunteers
Health Facilities in the Public Sector (2010)
35
36
Human resources
37Source: Thailand Health Profile 2008 - 2010
Population to provider ratios, 1979 - 2009
• There was mark reduction in the disparities of population to health care provider ratios for Bangkok and the Northeast during 2001-2009
• Population to doctor ratio of the Northeast remained 5 time of Bangkok while the ratios of other professions were 1.5 – 2 times of Bangkok
38Source: Thailand Health Profile 2008 - 2010
Disparities of population/healthcare provider ratios for Bangkok and the Northeast, 2001 - 2009
39Source: Kanchanachitr et al (2011)
Thailand has relatively low numbers of doctor and nurse to 1,000 populations compared with countries at the same level of economy
Doctor and nurse to 1,000 population among ASEAN countries
40 40
Limited production capacityCurrently, annual production increases to 2,500 for doctor and 9,000 for nurse; however, the production capacity remains lower than other countries.
Source: Kanchanachitr et al (2011)
41
Pharmaceutical industry
• During the period 1992 - 2006, with a high economic growth and new drug marketing monopolies under the Drug Act, the value and proportion of imported drugs was rising rapidly.
• The proportion of imported drugs was rising steadily to 56.3% in 2005, 64.5% in 2009, and 68% in 2010
42Source: Drug Control Bureau, Food and Drug Administration, MoPH
Pharmaceutical industry in Thailand
Percentage of prescribed items
Perc
enta
ge o
f rei
mbu
rsem
ents
Use of drugs outside national ED list in 31
hospitals
University hosp
MoPH hosp
Other public hosp
Data error
Bubble size represents amount of reimbursement
Type of hospital
43
• In Thailand, important antibiotic resistant bacteria are – Enterobacteriaceae (Quinolone resistance, <20% in community, 30-70% in hospital), – Staphylococcus aureus (Penicillin resistant 1% in community, 30-70% in hospital) – Pseudomonas aeruginosa (Carbapenam resistance 10-30%)– Acinetobacter baumanni. (Carbapenem resistance 60-85% for hospital infection)
Antibiotic use, low / middle income countries OP penicillin use and resistance 1990-2000
Source: Werner C. (2004)
Source: report of workshop on antimicrobial drug resistance, Bangkok, 6-10 August 2012
Antimicrobial drug resistance (1)
44
Aim to ensure security of drug supply and to maintain price level of necessary pharmaceutical supplies to ensure accessibility for all Thais
• Production• Stocking• distribution
Trade of between national security and promoting local pharmaceutical industry (push and pull)
• Competing with local pharmaceutical firms in producing generic drugs
• Production of vaccines
Role of Government Pharmaceutical organization (GPO)
45
Time line of Health Sector Reform
46
47
Time line of Health Sector Reform
• Scaling up district health system• Health
volunteer• Community-
based health insurance (health card)
PHC era
• Introduction of Universal Health Coverage • Expansion to
cover high cost services i.e. ARV, RRT
Universal Coverage
• Population aging• Increase
demand for health care• Increase
burden of chronic care• Use of original
& NED drugs• Demand drive
by Advance medical technology
Increasing health
expenditure
• Sustainability doubted• Control of
health care expenditure• Harmonization
of health insurance schemes• Regional health
service plan
Health sector reform 1
• Sustainability
• Healthcare expenditure
• Quality and safety
• Management
Health sector reform 2
48
Current issues of concern
Downsizing public sector policy of various governments put pressure on public health sector
• Increased workload according to universal coverage policy• Limited public hospital capacity in recruitment and retain health
professions, especially professional nurse• Major incentive for working in public hospital with greater
workload and lower salary is being a civil servant
Disparities in financial compensation level for different health professions in the public sector
49
Health Sector Reform: issues for debate
Whether Thailand will move towards full welfare state, particularly for health care
• Wealth & Health• Balancing of revenue and expenditure; how to
generate additional revenue for health care• Equal basic benefits to all or comprehensive benefits• Explicit cost sharing policy to prevent unnecessary
use , especially high cost medicines• Long-term financial sustainability
• Burden Of Disease and old aged dependency challenges • Governance of the health system
– Role of MoPH and other partners and their relationship
• Government fiscal space and long term financial sustainability
• Harmonization of the three main schemes
• Health systems capacity to cope with – Increased demand within very strained health workforces – Decentralization context –threats and opportunities– Public private dialogues, better trust and collaboration
50
Challenges for further reforms
1
2
3
4
5
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54
Reform direction
1. Restructuring health sector
55
Reform direction
Separation regulatory role and service provision role in the MoPH• Policy, direction, and guidelines on financing • Policy on human resources• Regulation and supervision• Monitoring and evaluation• Implementing cost accounting system in hospitals
Strengthening MoPH functions as National Health Authority
Reorganize relationships between MoPH and various main actors
2. Regional health service commissioning
56
Reform direction
Decentralize administration of service provision to 12 regional MoPH areas (service plan)
• Improve efficiency of resources use by sharing resources• Improve capacity of service provision within the regions• Better referral system• Greater accountability by setting KPIs
Greater cooperation between purchaser and providers in planning, purchasing, and service provision
3. Financing reform
57
Reform direction
Expansion of health protection coverage by compulsory contributory insurance• Migrant workers and dependents• Foreign visitors• Foreign residents
Reform Traffic Accident Insurance to improve effectiveness and efficiency of the system
Pharmaceutical cost control of CSMBS and reform payment system for better cost control
Reform payment system to support MoPH service plan
57
4. Harmonization of current health insurance schemes
58
Reform direction
National Clearing House
• Accident and Emergency services • Anti-Retro Viral Therapy• Cancer
National Information center
Harmonization of benefit package and payment system
Provider
National Health
Authority
Purchase
r
Regulator
Supplement /
Agent- สำปสำช.- สำวรสำ.- สำช.- สำพฉ.
โครงสิร�างการท$างานระบบสิาธิารณสิ7ขึ้ปีระเทศูไทย
59
Walk in across border for medical visit
• MOPH hospitals at border areas provide unpaid care around 250 million Baht a year
Immigrant workers
• Illegal migrants & dependents, both registered and non-registered ≈ 3 mil.• Legal skilled migrants & dependents ≈ 1 mil. (attracted by 2 mm public
project on infrastructure)
Medical Hub
• ≈ 800,000/year, not much affected by AEC
Increase demand for health care
60
• Illegal migrant workers & dependents ≈ 3 m, share 15-20% of OP visits and 20-35% of IP admissions in provinces with high density of migrant workers.
• Non-Thais patients shared ≈ 30% of OP services and 35-50% of IP services in hospitals at west-border of Thailand
• There are ≈ 1 million foreign patients under the medical hub2008 2009 2010 2011
-
400,000
800,000
1,200,000
1,600,000
1,363,29
5
695,779 935,035 942,107
Number of Medical hub services
Health services use by non-Thais
61
Policies response to increase demand for healthcare of Non-Thais
At the border;
• Supporting capacity building of health facilities in nearby countries at border areas
• Supporting governments of neighborhood countries in moving towards UHC
Providing health protection to Non-Thais and generate additional source of finance by compulsory contributory insurance
• Migrant workers and dependents• Foreign visitors
62
63
64
Policies response to increase demand for healthcare of Non-Thais (2)
Medical hub (academic training and conference, medical care, dental care, spa and Thai traditional medicine)
• Promoting Thailand as center of medical education, academic training, and conferences)
• Loosening professional barrier in importing foreign professions
• Reduce income gap between public and private sector in order to prevent brain drain
65
Inspiration
66
ชายคนแรกตอับ “ผ่มก$าล้�งท$างานหาเง�นเพ "อัเล้!'ยงช!พอัย5�”
คนท!"สิอังตอับว�า “ผ่มก$าล้�งฝึ>กห�ดืเพ "อัเปี-นน�กแกะสิล้�กห�นช�'นยอัดื”
ชายคนท!"สิามตอับ “ผ่มก$าล้�งสิร�างว�หารอัย5�คร�บ เปี-นว�หารท!"จ่ะอัย5�เปี-นร�อัยๆ ปี�แล้ะเปี-นแรงบ�นดืาล้ดืล้ใจ่ให�คนร7 �นหล้�งอั!กหล้ายช�"วอัาย7คนหล้�งจ่ากผ่มตายไปีแล้�ว”
67
Bamboo seeding ( water for 4 yrs )
After off from land : grow 60 fts in 9 m 68
Bamboo seeding ( water for 4 yrs )
After off from land
grow 60 fts in 9 m
69
A journey of a thousand miles begins with
a single step.
Chinese proverb
70
ระยะที่างจำากโลักถึ'งดวงจำนัที่ร)1/4 ลั!านัไมลั)
ระยะที่าง 3 กม. แรก ใช!พลังงานัไป 50 % ของที่+งหมด 71
Attitude is a little thing that
makes a big difference
Winston Churchill
72
73
THANK YOU