thailand: universal health care coverage through pluralistic approaches
DESCRIPTION
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. Contents. Introduction Health Care Delivery in Thailand - PowerPoint PPT PresentationTRANSCRIPT
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THAILAND:Universal Health Care Coverage Through
PLURALISTIC APPROACHES30 August 2012
Dr. Thaworn SakunphanitMD., FRCPT, BA (Econ), MSc. (Social Policy Financing)
Deputy Director, Health Insurance System Research Office
1
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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• Introduction• Health Care Delivery in Thailand• Social Health Protection • Performance of Health Care System• Is Thai UC sustain?• Enabling Factors for UCS• Future challenges
2
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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)
3
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earc
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tePopulation: Elderly Society
0
200
400
600
800
1000
1200
1400
0 20 40 60 80 100 Age
Popul
ation
(x 1
,000
)
Pop 2007 POP 2020
Source: Health Care Reform Project (2008)
Population - 67 millionTotal fertility rate: 1.6 (2009)
Life expectancy at birth: 74 Years
Under 5 Mortality: 14/ 1000 live births
Maternal mortality: 48/100,000 live births
4
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Source: IHPP (2007)
Total Disability adjusted life years (DALY) loss 9.17 million years
0
200
400
600
800
1,000
1,200
1,400
1,600
0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+
Males Females
Dis
abili
ty A
dju
sted
life
Yea
r L
ost
('
000
s)
Group III Injuries
Group II Non-communicable diseases
Group I Infections, maternal, perinatal and nutritional cond
Burden of Disease: Thailand (2004)
5
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Health Care Delivery
Nation-wide coverage by Pubic Providers
6
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
Hea
lth In
sura
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Syst
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esea
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Offi
ceH
ealth
Sys
tem
Res
earc
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te • 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
Health Care Delivery Development
7
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Coverage of health facilitiesMainly under Ministry of Public Health (MOPH)
• Provinces (76) exclude Bangkok– General/Regional hospitals 100%
• Districts – Community hospitals nearly 100%
• Subdistrict or Tambon – Municipal health centres (214)– Tambon Health centres (9,738) nearly 100%
Health Care Delivery Development
8
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Syst
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Offi
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Sys
tem
Res
earc
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teQuality:
Hospital Accreditation Voluntary program which
is conducted by the Institute of Hospital Quality Improvement and Accreditation
This Thai accreditation
process is demanding from both public and private hospitals
Accredited Hospitals
0
50
100
150
200
250
1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Numb
er of
hosp
ital
Hospitals
9
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Social Health Protection
Public Managed Schemes
10
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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earc
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teThailand:
Path to Universal Coverage
Source: National Statistic Office, the Health and Welfare Surveys in 1991, 1996, 2001 and 2003.
11
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earc
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teServices cover under
National Health Security Act• Promotive and preventive cares;• Diagnosis;• Ante-natal care; • Curative care;• Medicine, medical supplies, organ substitutes, and medical e
quipments;• 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.
12
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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tem
Res
earc
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teCurrent
Social Health Protection Schemes
Major
Schemes
Civil Servant Medical Benefit Scheme
(CSMBS)
Social Security Scheme
(SSS)
Universal Coverage
(UCS)
Introduced in 1960s 1990s 2002
Target beneficiaries Govt employees & dependents, retirees
Private sector employees:
To whom which not covered by CSMBS
nor SHI,
Pop Coverage 7% 13% 80%
Funding Govt budget Payroll contribution, Tripartite
Govt budget
Payment to health facilities
Fee-for-service for OP, and DRG for IP
Capitation
(use DRG in risk adjusted part)
Capitation
+ DRG
Social health protection schemes have covered all Thai citizen since 2002
13
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Differences in utilization and expenditures across the schemes
Current Social Health Protection Schemes
Source: HISRO (2010) calculate from database for the three schemes
1 US$ = 34 Baht in 2009
14
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Performance of Health Care System
after 10 years of the UC
15
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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0
1
2
3
4
5
6
7
8
9
Decile
1
Decile
2
Decile
3
Decile
4
Decile
5
Decile
6
Decile
7
Decile
8
Decile
9
Decile
10
Income Deciles
% in
com
e sp
ent
on h
ealt
h
19922000200220042006
Dec
linin
g of
gap
Poorest Richest
EQUITY: Income Spending on Health by Income Groups
Before UC
After UC
Source: Socio-Economic Survey 1992 - 2006 conducted by NSO.16
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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teImpacts of Universal Coverage
17
Distribution of Patients by Treatment Outcome
0%
20%
40%
60%
80%
100%
2003-4 2008-9 2003-4 2008-9 2003-4 2008-9
Hypertension Diabetic Hypercholesterol
No diag No trearment Uncontrol Control
DecreasePoverty from Health Care Spending
ImproveHealth Outcome
Source: National Health Examination Survey 2003-2004 and 2008-2009
Source: Limwattananon (2010): analysis of Socioeconomic Survey (various years)
2000280,000
Households
200888,000
Households
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Source: HISRO (2008)
• Increase utilization of out-patient and in-patient
18
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Enabling Factors for UCS
19
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
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Res
earc
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teEnabling 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
20
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Source: HISRO (2012) Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010).
State Commitment to health
21
Developing Country
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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ealth
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teCentralized (Public) health care coverage
Source: Patcharanarumol W et al (2011). Why and how did Thailand achieve good health at low cost?10
Developing Country
Developing Country Developing Country
Developing Country
Decade of hosp 1977- 1986Decade of health centre 1992-2001
22
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Regional disparities: Improve but Still Exist
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)
Centralized (Public) health care coverage
DevelopingCountry
DevelopingCountry
23
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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ealth
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tem
Res
earc
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teCentralized (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
24
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
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em R
esea
rch
Offi
ceH
ealth
Sys
tem
Res
earc
h In
stitu
tePlanning 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, no-private practice allowances, Pay for performance
25
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
Syst
em R
esea
rch
Offi
ceH
ealth
Sys
tem
Res
earc
h In
stitu
teImprovement 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
26
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
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em R
esea
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ceH
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Sys
tem
Res
earc
h In
stitu
teImprovement 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.
27
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
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esea
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ceH
ealth
Sys
tem
Res
earc
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stitu
teCollaboration Among Health Care
Professional, Civil Societies and Politicians:Triangle that moves mountain
Health Reform
Social Movement
Accumulation of Knowledge
Political Linkage
Source: Dr. Prewase Wasi
28
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
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em R
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Sys
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Res
earc
h In
stitu
te
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Political ProcessTechnical Process
First Draft of NHA
Fie
ld M
odel
Dev
elop
men
t
Pol
icy
Res
earc
h
Mov
emen
ts o
f Civ
ic
Gro
ups
Cre
atio
n o
f Cri
tica
l M
ass
Insi
de M
OPH
Draft NHA Approved by the ParliamentTech
nic
al In
put
for
the
Polic
y D
evel
opm
ent
Proc
ess
Draft NHA by Civic Groups was submitted to the Parliament
First National Forum on HCR
Network of Civic Groups were organized and supported
Chronological Events of UC Policy Development Process
Source: NHSO (2009)Pilot Information and financing model in 6 provinces
29
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Is Thai UCS Sustain?
30
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Source: Saltman et al (2004). Social health insurance systems in western Europe. European Observatory on Health Systems and Policies Series
Political SustainabilityFinancial Sustainability
Social Sustainability
31
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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nce
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esea
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ceH
ealth
Sys
tem
Res
earc
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teShare 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)
32
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
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esea
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ceH
ealth
Sys
tem
Res
earc
h In
stitu
teThailand 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)
33
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
nce
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em R
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ealth
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tem
Res
earc
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stitu
teProjection 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 researchreport. Nonthaburi, National Health Security Office, 201234
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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ealth
Sys
tem
Res
earc
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tePolitical Sustainability:
Commitment of Political Parties
GDP Growth (Norminal)
Gov Health Exp as % of Gov Spending
35
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
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nce
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em R
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Offi
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ealth
Sys
tem
Res
earc
h In
stitu
teSocial Sustainability:
Legitimacy, People SatisfactionSolidarity?
36
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Challenges
37
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Offi
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ealth
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Res
earc
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teHarmonized
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
38
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Syst
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Offi
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National Health Commission Cabinet
Net work of technocrats
Net work of medias
Net work of Civil societies
Prime Minister
National Heath Security Office
CivilServantMedicalBenefit
National health
assembly
SocialSecurityOffice
Minister of Health Minister of Labour Minister of Finance
Parliaments
System governance and Harmonisation - “Tax (Contribution)” - Benefits - Administration
Harmonized Social Protection Scheme:
System Governance at national Level
39
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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Syst
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Offi
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Sys
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Res
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IndicesReports & Analysis-Cross-section-Time series
Modeling
Demographic data
Macroeconomic data
CSMBSScheme
PrivateHospitals
MoPHHospitals
OtherMinistriesHospitals
National Clearing House
SSSScheme
UCScheme
OtherSchemes
National Financial
Monitoring
Coding StandardPayment Method
Design &Costing forBenefit Package
Harmonized Social Protection Scheme:
Proposed Functions at national Level
40
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
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Syst
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Offi
ceH
ealth
Sys
tem
Res
earc
h In
stitu
teMore 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
41
สำ��นั�กง�นัวิจั�ยเพื่��อก�รพื่�ฒนั�หลั�กประก�นัสำ�ขภ�พื่ไทย
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lth In
sura
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Syst
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esea
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Offi
ceH
ealth
Sys
tem
Res
earc
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teMitigating and Coping of Aging Society:
New Continuum of Care Self care, Acute, Subacute, Chronic and Long Term Care
0
200
400
600
800
1000
1200
1400
0 20 40 60 80 100 Age
Po
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(x
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00)
Pop 2007 POP 2020
Source: Health Care Reform Project (2008).42
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Offi
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Res
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THANK YOU
Questions?
43