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Ekachai Piensriwatchara, MD.
Walaiporn Patcharanarumol, PhD.
17 July 2017
Yokohama, Japan
Universal Health Coverage:
Thailand experience
2
ASEAN-Japan 15 July 2017
Statement of the Minister of Public Health, Thailand
1. With strong political commitment, UHC can be started and
achieved at low level of income
2. Peace and sustained economic growth mobilized ‘more
money for health’
3. Universal access to good quality essential health services is
the real goal
4. Strong capacity on health system and policy research
5. Participatory governance systems ensures real ownership
3
1. UHC can be started and achieved
at low to middle income level
29% 42% 53% 70% 100%Population coverage
4
2. Peace and sustained economic growth
mobilized ‘more money for health’
5
13.5
*Security
22.6
16.1
13.113.7
13.2
24.7
*Debt serv.
8.2
5.0 5.3
9.112.5
24.4
17.9
*Education
16.9
25.8
23.5
21.8
8.1
4.34.14.25.1
4.43.23.4
2.9
*Health
4.4
7.6 7.87.1
0
5
10
15
20
25
30
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
From security and debt service budget to healthP
erce
nta
ge
Year
Source: Bureau of Budget; Dr.Suwit’s presentation 30 Sept 2011
6
More budget to health
1972
1990
2004
Government budget Budget for health
29,000 mil. ฿
986.6 mil. ฿(3.4%)
16,225.1 mil. ฿(4.8%)
335,000 mil ฿
77,720.7 mil. ฿ (78x) (8.1%)
1,028,000 mil ฿
(35x)
2011 Budget
for health rose
to 13% of
government
budget
7
1,659
1,899
2,1002,202
2,4012,546
3,0283,109
1,3961,308
1,202 1,202
2,7552,895
-
500
1,000
1,500
2,000
2,500
3,000
3,500
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Continued political commitment to UC Scheme:
Budget, Baht per capita, by Regime 2002-20178 governments, 13 Health Ministers, 11 Permanent Secretaries
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
G 1 G 2 G 3 G 4, 5 G 6 G 6, 7 G 7 G 7, 8 G 8
M 1 M 2 M 3 M 4 M 5-7 M 8 M 9 M 9 M 10 M 11 M 12 M 12 M 13 M 13
8
3. Universal access to good quality essential
health services is the real goal
• Free but inaccessible health services and/or poor
quality is not UHC.
• Thai’s UHC focuses on Primary Health Care.
• Evolution of rural health systems since before UHC
– 780 district hospitals: one district hospital per district
– 9,777 health centers: one health center per rural commune
• Rapid increase in HRH training, i.e., doctors, nurses,
voluntary health volunteers, etc, through “rural
recruitment, local training and hometown placement”
and compulsory public work for graduates with
adequate motivation and incentives;
9
District health system: hub for pro-poor outcomesThe Lancet 2013;381:2118-33.
community
temple
school
Local authority
private sector
Rural
Health facilities
Rural health centers with 3-6 nurses and
paramedics cover 2,000-5,000 population
Rural community hospitals with 2-8
doctors cover 30-80,000 population
1. Health promotion
2. Disease control
3. Health care
4. Rehabilitation
5. Consumer protection Pri
ma
ry h
ea
lth
ca
re
10
Huge increase in access to primary care
46%(5.5)
29%(3.5)
24%(2.9)1977
Regional / General Hospital
Rural Health Centres
District Hospital
27%(11.0)
35%(14.6)
38%(15.7)
1987
200046.1%(51.8)
35.7%(40.2)
18.2%(20.4)
201054.0%(78.0)
33.4%(33.4)
12.6%(18.1)
Regional / General Hospital
Rural Health Centres
District Hospital
Regional / General Hospital
Rural Health Centres
District Hospital
Regional / General Hospital
Rural Health Centres
District Hospital
Note: (number of OP visits in million)
Source: Suwit’s presentation on 30 Sep 2011 and updated 2010 data
11
4. Strong capacity on health system and policy research
• Home grown technical capacities
– Designing and implementing UC scheme
• Provider payment methods: capitation, DRGs, fee schedule
• IT to support UHC
• Medical audit
– Priority setting using many tools, including health technology
assessment, budget impacts, supply side readiness,
– Monitoring progress of UHC
• Population coverage using citizen ID of CRVS; everyone is count
• Service coverage -> effective coverage of 6 conditions: HIV, TB,
cervical cancer, DM, Hypertension, cerebrovascular disease
• Financial risk protection: catastrophic and medical impoverishment
12
UC Scheme achievements
• Some key achievements
• Improved equity in financing healthcare;• Health Research Policy and Systems 2013;11:25
• Increased access to care by beneficiaries; • Journal of Public Economics 2015;121:79-94
• Pro-poor utilization and benefit incidence; • BMC Public Health 2012; 12(suppl 1): S6
• Preventing non-poor households become poor from medical bills; • Bulletin of the World Health Organization 2007; 85: 600–6
• Gaining efficiency and cost containment;• Economic & Political Weekly 2012; 47: 53-7
• UCS flourishes despite eight rival governments, six elections, two
coup d’etat, thirteen health ministers, between 2001-2015
• UCS gradually owned by the people, not political party who initiated it.
13
New interventions assessed for service coverage Contribution by IHPP and HITAP
Interventions (Indication)
Cost-effectiveness Budget impact
UC Scheme coverage
Lamivudine
(Chronic hepatitis B)
Cost-saving Low Yes
Cyclophosphamide + azathioprine
(Severe lupus nephritis)
Cost-saving Low Yes
Peg-interferon alpha 2a + ribavirin
(Chronic hepatitis C)
Cost-effective
(ICER=86,600*)
High No
Adult diapers
(Urinary and fecal incontinence)
Cost-effective
(ICER=54,000* )
High No
Anti IgE (Severe asthma) Cost-ineffective High No
Implant dentures Cost-effective
(ICER= 5,147*)
Low No
Note: * Threshold: ICER = 160,000 ThaiBaht per QALY
Source: UC Benefit package project
14
Incidence of catastrophic health spending >10% of household expenditure, before and after UC Scheme in 2002
Health Research Policy and Systems 2013;11:25
15
Sub-national health impoverishment 1996 to 2008
16
5. Participatory governance systems ensures real ownership
• Voices of people
– Board of UC scheme: 5 seats from civil society (out of 30),
chaired by the Minister of Health
– satisfaction survey of providers and patients
– Call Center 1330 of UC Scheme
– Annual public hearing at the national level, regional level and
now extend to provincial level
Call Center 1330 of UC Scheme Public hearing of UC Scheme
17
(%)
Satisfaction of UC beneficiaries & health care providers
Source: NHSO
83 83.483.284.083.188.389.389.8
92.890.895.596.62
45.639.3
47.750.9
56.550.7
60.3
78.8
66.968.567.6 64.4
0
10
20
30
40
50
60
70
80
90
1002003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
UC people
provider
18
• UHC is context specific – learn from others and adapt but not copied
• Political and financial commitment is the key factors – on both health systems development and financial protection
• Ensuring equitable access to and good quality of health care services is as important as the financial protection
• The success of UHC depends much on the spirit of committed health workers not only money
• National capacity for evidence based policy is really needed
Summary
19
Situations that lead to reform
Triangle that moves the mountain
1997 Constitution
Politics(Window of opportunity)
2001 general election
Social mobilization
A civil proposal on
UC
1993, 1996,1997
HCF workshops
Evidences& capacity
HSRI 1992
HCRP (EU)1998-2000
SIP (WB)1999-2001
UC working group 2000
Experiences SSS & HCS
IHPPHITAP
HISRO
20
Thank you for your attention
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