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Assessment of National Health Plans

The case study of Thailand

Phusit Prakongsai, MD. Ph.D.Viroj Tangcharoensathien, MD. Ph.D.

Walaiporn Patcharanarumol, MSc. Ph.D.

International Health Policy Program (IHPP)Bureau of Policy and Strategy, Ministry of Public Health,

Thailand

Presentation to the Regional Consultation on Strengthening ofNational Health Planning

Bali, Indonesia4-6 August 2010

Background

• The first National Health Plan (NHP) was developed in 1961, as part of the National Economic and Social Development plan (NESDP)

• The first NHP and NESDP covered six years from 1961 to 1966, but subsequently five year duration.

• Currently, Thailand is in the period of the 10th NHP operating from 2007 to 2011.

• NHP guided public investment and development of the Thai health system, and its focus changed from time to time, depending on the national health priorities and challenges.

Key features and achievements of the NHP (1)

Plan/ year Key features of NHP Achievements of the NHP

1st Plan(1961-1966)

• Expansion of health infrastructure coverage, particularly provincial hospitals and health centers

• Provincial hospitals in all provinces

2nd Plan (1967-1971)

• Compulsory government health services for new medical graduates

• District health facilities increased from 42.3% to 54.9% of all districts in five years of the 2nd plan

3rd Plan(1972-1976)

• Emphasis on MCH and family planning,• The policy on free medical services for the low income households

• Public services by all medical graduates started in 1972 (2515 B.E.) for the first batch of signing agreement in 1965

4th Plan(1977-1981)

• The policy on Health for All by 2000 was adopted using PHC strategies,• National EPI Program launched in 1977

• Basic immunization programme began in 1977-78 gradually and consistently scaled up,• Village health volunteers (VHV) was launched in response to community participation principles of PHC

5th Plan(1982-1986)

• Expansion of district hospitals in all districts, • upgrading all midwifery stations to be health centers

• Coverage of district hospital was 85.2%, and health center coverage was 97.9%

Key features and achievements of the NHP (2)

Plan/ year Key features of NHP Achievements of the NHP

6th Plan(1987-1991)

• Expansion of health facilities, campaigns against HIV/AIDS epidemics, • Legislation of the 1990 Social Security Act

• Improving life expectancy at birth, and significantly decreasing MMR and IMR,• Universal coverage of health facilities at all districts and sub-districts

7th Plan (1992-1996)

• Strengthening health centers as a major PHC contact point, • improvement in service quality, and tackle problems of internal brain drain

• Comprehensive coverage of health facilities at all levels, but shortage of doctors from rapid growth of private hospitals and internal brain drain,• Child immunization coverage over 80%

8th Plan(1997-2001)

• Emphasis on development of human potential in health, and expansion of financial risk protection

• Much improved Overall health status,• Health insurance coverage rose to 71% in 2001 prior to UC,

9th Plan(2002-2006)

• Emphasis on holistic health system development; Universal coverage of health care by all citizens; • Development of health service quality improvement accreditation body

• Universal health coverage was expanded to cover> 96% of population,• Further strengthening primary care at the district and sub-district levels.

10th Plan(2007-2011)

• Aims to achieve health development in a holistic way by incorporating physical, mental, social, and spiritual aspects with social mobilization for health promotion.

• Further strengthening universal health insurance coverage to rare disease and high cost medical care, • Expansion of health insurance coverage to stateless people and migrant workers.

1945

2000

2002

Informal user fee exemption

1980

1970

User fees

1-3rd NHP1962-76Provincial hospitals

Health Infrastructure extension--wide geographical coverage

Evolution of achieving universal coverage in Thailand:

Infrastructure development + financial protection extension

1975LIC

1990

Establishment of prepayment schemes

1983CBHI

1980CSMBS

1990SSS

Universal Coverage

CSMBS

2002 full achieve

Universal Coverage

SSS

LIC MWS 1994Pub VHI

CSMBS

SSS

Expansion consolidation of prepayment schemes

4th -5th NHP (1977-86) District hospitalsHealth centers

Immunization coverage and prevalence of

vaccine preventable

disease

Vaccine preventable cases report, 1971-2007

0

1,000

2,000

3,000

4,000

5,000

6,000

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

DiphtheriaPertussisTet Neonate

Child mortality in Thailand from various sources of surveys, 1970-

2005

Source: Hill et al. Int J Epidemiol 2007 (with updates)

0

10

20

30

40

50

60

70

80

90

100

1970 1975 1980 1985 1990 1995 2000 2005

Un

der

5 m

ort

alit

y ra

te (

per

1,0

00)

Vital registration DHS 1987 - direct Census 1990 - indirect Census 2000 - indirect

SPC 1985 - direct SPC 1985 - indirect SPC 1995 - direct SPC 1995 - indirect

SPC 2005 - indirect SPC 2005 - direct Predicted

Incidence of catastrophic health expenditure in Thailand 2000-2006

Incidence of catastrophic health expenditure 2000 to 2006, Thailand, exceed 10% of total household income

0.9%

4.0%

3.3%

5.4%

2.0%

0%

1%

2%

3%

4%

5%

6%

2000 2002 2004 2006

Q1 (poorest) Q5 (richest) All quintiles

Source: Analysis from the SES 2000-2006, NSO

The distribution of government subsidies for health:

Benefit incidence analysis, 2001-2007

28%

31%

28%

29%

20%

22%

26%

24%

17%

15%

20%

20%

17%

16%

14%

14%

18%

15%

11%

12%

0% 20% 40% 60% 80% 100%

OP&IP

OP&IP

OP&IP

OP&IP

2544

2546

2549

2550

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Distribution of health infrastructure and human resources for health in Thailand

Figure 3 Population per Health w orkforce in 1987, 1997 and 2006

14,800

3,6491,073

5,595

36,516

1,743

17,711

10,178

2,965

7,3407,862

617

0

5000

10000

15000

20000

25000

30000

35000

40000

Phy sicians Dentists Pharmacists Nurses

Nu

mb

er

1987 1997 2006

Physicians800-3,3053,306-6,2746,245-9,2729,243-12,300

Nurses280 - 652653 - 904905 - 1,1561,157 – 1,408

Participatory process in the NHP formulation

• MOPH is the prime responsible agency for the NHP formulation Bureau of Policy and Strategy is the national focal point.

• Set up of the task force comprising key stakeholders in and outside the MOPH to develop the 10th NHP.

• A wide range of multi-sectoral and regional consultation to ensure involvement and ownership and down stream effective program implementation: – For policy formulation at the technical level,– Public hearing on the draft NHP.

• However, there is a need for developing joint

assessment and M&E of the plan among many key stakeholders.

Monitoring & Evaluation of health systems reform /strengtheningA general framework

Data sources

Indicatordomains

Analysis & synthesis

Communication & use

Administrative sourcesFinancial tracking system; NHADatabases and records: HR, infrastructure, medicines etc.Policy data

Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness

Clinical reporting systemsService readiness, quality, coverage, health status

Vital registration

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

Improved health outcomes

& equity

Social and financial risk protection

Responsiveness

Fina

ncin

gInfrastructure

/ ICT

Health workforce

Supply chain

Information

Interventionaccess & services

readiness

Interventionquality, safety and efficiency

Coverage of interventions

Prevalence risk behaviours &

factors

Gov

erna

nce

Inputs & processes Outputs Outcomes Impact

Evidence-based national health planning in Thailand (1)Evidence-based national health planning in Thailand (1)

Input Output Outcome Impact

HCF HRH

Infra struct

ure

Gover

nance

Med/Health tech

HIS access

quality

safety

efficienc

y

Interven

coverage

Risk factor

s

H outco

me

Responsive

Equity

Finan prote

ction

Civil registration and vital statistics

Biennial SES

Biennial HWS

Census / SPC

NHES

MICS

Reproductive H survey

NHA

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

Evidence-based national health planning in Thailand (2)Evidence-based national health planning in Thailand (2)

Input Output Outcome Impact

HCF

HRH Infra structu

re

Gover

nance

Med/Health

tech

HIS access

quality

safety

efficiency

Interven coverage

Risk factors

H outco

me

Responsive

Equity Finan protect

ion

Facility-based report

H resource survey

HIS electronic IP database

Dis surveillance

Behavioral H survey

Sero-sentinelSurvey

Specific dis registration

Quality assurance (HA)

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Health Information System Networking in Thailand

MOPH

Thai Health Promotion Foundation

Health System Research Institute (HSRI)

Health Information System DevelopmentPlan and Networking

NHSO NESDB

Civil societies

NGOs

Professionals

NSO

Academics

Data owners

Steering committee

Management office

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M&E of the 10th NHP

• Despite M&E activities were clearly stated in the 10th NHP, there was neither appointment of the M&E committee nor launch of the mid-term review report from the MOPH.

• The M&E activities tend to be low priority of the MOPH because the plan was rarely mentioned by the Health Minister and the high level officers of MOPH.

• A few people in MOPH are concerned about what has been achieved and what has been unachieved in the 10th NHP.

• Poor participation from the policy-makers in the policy formulation process tends to be the key factor.

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Lessons learnt from the case study of Thailand

• Long-term capacity building of – data producing (NSO) – data analysis (IHPP, MOPH, NESDB)– Implementation and M&E (MOPH)

• Genuine collaboration and relationship between data producers (NSO) and data users (MOPH, IHPP, NESDB, IPSR, etc.)

• Strong health information system from long-term investment by the government and other public sectors (THPF).

• Gradual evolving culture among policy makers in using evidence for decision making.

Key challenges in national health planning in Thailand

• Very weak M&E of the current NHP neither activity nor implementation of the M&E activity in the 10th NHP

• Policy-makers, particularly politicians are not concerned with the NHP, having their own policies and priorities,

• Fragmented institutes and organizations for M&E in Thailand, particularly data analysis,

• Low capacity of MOPH in directing and monitoring the 10th NHP.

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19

Thank you

for your

attentio

n