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Health system components to support UHC: Thai experience on pre-requisites for UHC. Phusit Prakongsai , M.D. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the Exchange and Study Program on UHC Monitoring and Evaluation - PowerPoint PPT Presentation
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Health system components to support UHC:
Thai experience on pre-requisites for UHC
Phusit Prakongsai, M.D. Ph.D.International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
Presentation to the Exchange and Study Program on UHC Monitoring and Evaluation
VIC3 Bangkok Hotel9 September 2013
WHO’s framework for monitoring health system strengthening and outcomes
Source: WHO. Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007, Geneva, World Health Organization.
30
50100150200250300350400450
MMR
per 1
00,00
0 live
birth
s
Year
MMR 1960-2006: six sources of references
BPSBHPRAMOSTDRILancet 2010WHO
Reduction of U5MR and MMR in Thailand, 1960-2008
Achieving UHC
Source: Why and how did Thailand achieve good health at low cost? (2011) http://ghlc.lshtm.ac.uk/
Long march towards universal health coverage in Thailand
Public policies to provide universal financial risk protection
GNI per capita, 1970-2009
UHC policy objectives
• Improving health of all Thais by providing equitable access to quality health services in accordance with health need of the population,
• Preventing Thai households from being financially catastrophic when facing with high cost care,
5
6
Health care financing strategies of the UHC policy
• Removal of financial barriers to health services; • Risk sharing expand the UHC scheme to cover uninsured and
merge LIC and voluntary health card scheme, • Shift of the main source of HCF from OOPs to general tax; • Sustainable systems:
– Policy sustainability Law– Financial sustainability– Institutional sustainability
• Participatory process• Protect people right
7
UHC cube: what has been achieved in Thai UHC?
• X axis: – 99% pop overage by 3
schemes [UCS 75%, SHI 20%, CSMBS 5%]
• Y axis: – Free at point of services,
very minimum OOP, – Low incidence of
catastrophic health expenditure and health impoverishment
• Z axis: – Extensive and
comprehensive benefit package, very small exclusion list,
– Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines (Essential drug list)
Selected health interventions for cardiovascular disease patients included in the UHC benefit package
Basic health care services• OP• IP• High cost care including
open heart surgery and PTCA
• Accident and emergency, disease management
• Health promotion and disease prevention,
• Emergency medical services,
• etc.
Basic health care services for individual beneficiaries
Expansion of open heart surgery and PTCA
Renal replacement therapyFor ESRD patients
2002
Chronic NCDs (2nd prevention for DM/HT)
Heart transplantation
20122004 2009 2010
Commencement of the benefits
(Pilot project in FY2009 and extend to the whole country in FY2010)
(Pilot project in FY2007 and extend to the whole country in FY2009)
NHSO allocation
9
NHSO allocation 2003 2004 2005 2006 2007 2008 2009 2010 2011(A) OP averge cost 574.0 488.2 533.0 582.8 645.5 645.5 667.0 754.6 795.4 (B) IP average cost 303.0 418.3 435.0 460.4 514.0 845.1 837.1 885.9 954.7 (C) High cost 32.0 66.3 99.5 190.0 193.8 71.7 68.2 85.8 94.2 (D) Accident and emergency 25.0 19.7 24.7 52.1 51.0 44.6 70.9 72.5 76.5 (E) Special Denture - - - 2.3 - - - - 2.3 (F) Prevention and promotion 175.0 206.0 210.0 224.9 248.0 253.0 262.1 271.8 312.5 (G) Capital repleacement 83.4 85.0 76.8 129.3 142.6 143.7 148.7 148.7 148.7 (H) Emergency medical services 10.0 6.0 6.0 6.0 10.0 12.0 - - - (I) Rehabilitation/Disability 4.0 4.0 4.0 4.0 4.0 5.0 8.1 12.0 (J ) No-fault liability - 5.0 0.2 0.5 0.5 - 1.0 - 2.7 (K) Quality based pay 20.0 20.0 20.0 40.0 25.0 (L) Special medicine 5.0 6.7 4.7 (M) ARV 58.6 83.7 94.3 63.4 58.7 62.5 (N) RRT - - - 32.5 30.8 67.2 (O) Chronic - - - - 6.4 13.1 (P) Psychitry - - - - - 4.2 (Q) DMI 15.7 29.0 43.0 40.7 34.0 ( R) Special condition hospital 10.0 7.1 7.0 30.0 30.0 72.3 72.3 64.1 (S) Compensate for abolish copayment 24.1 (T) Compensate for health
personnel's work relate injury 0.4 0.4 0.9 0.8 1.0 (U) Thai traditional medicine 1.0 1.0 2.0 6.0 (V) Promote primary care 10.6 11.2 (W) Support special tertiary care 0.8 1.5
Total 1,202.4 1,308.5 1,396.3 1,717.8 1,983.4 2,194.3 2,298.0 2,497.2 2,693.5
From: Bureau of policy and planning, NHSO
Capitation increase
Item
incr
ease
UHC scheme payment
10
UC fund
Basic health care
Mental health(Medicine)
Chronic (DM/HT)
RRT
ARV drug
Population/patientProvider
Medicine supply & development plan
Point by no of pt
Fee schedule & development plan
Fee schedule & development plan
Capitation in OP, DRG with global budget in IP
Version Refined Diagnosis code
Procedure code
Groups Implement
1No ICD-10 (WHO)
1992ICD-9-CM
2000511 Nov 1998
2No ICD-10 (WHO)
1992ICD-9-CM
2000511 Feb 2001
35 levels ICD-10 (WHO)
1992ICD-9-CM
20001,283 Oct 2003
4
5 levels ICD-10 (WHO) 2007
+ ICD-10-TM*
ICD-9-CM 2007
with extension
1,920 Oct 2007
5
5 levels ICD-10 (WHO)2010
ICD-9-CM2010
with extensionHoNOS
Barthel index
DRG 2,450 TMHCC 54
SNAP 41
Expectedon Oct 2011
Development of Thai DRGs
* Thai Modification for data entry only (not for new classification) 11
Thai DRGs ver. 4
• Reclassification–Add group from previous other…–Bilateral , Multiple procedures–Special care
• Unbundling• Coding: ICD-10-TM (diagnosis)
ICD-9-CM 2005 with Extension
(Procedure)
12
Thai DRGs
Ver. 3.5
Nov.1999
Feb.2001
Oct.2003Thai DRGs
Ver. 3.1
Apr.2005
Oct.2005
Oct.2007
Clean up library Unbundling Additional lists
Recalibration
(Minor change)
Reclassification Recalibration
Ver.1
Ver.2
Ver.3
DRG evolution
13
Increased utilization, low unmet needs
Prevalence of unmet need OP IP
National average 1.44% 0.4%Civil Servant Medical Benefit Scheme (CSMBS) 0.8% 0.26%Social Security Scheme (SSS) 0.98% 0.2%Universal Health Coverage Scheme (UCS) 1.61% 0.45%
Source: NSO 2009 Panel SES, application of OECD unmet need definitions
Inte
rnat
iona
l Hea
lth P
olic
y Pr
ogra
m -T
haila
ndIn
tern
atio
nal H
ealth
Pol
icy P
rogr
am -
Thai
land
Increased access to expensive health interventions for heart disease patients among UHC beneficiaries, 2005-
2012
14
48 49 50 51 52 53 54* 14.00 14.50 15.00 15.50 16.00 16.50 17.00 17.50 18.00 18.50
17.43 17.77 16.95
17.87
16.68 16.42 15.58
Case Fatality rate ST-elevation MI (%)
Case Fatality rate ST-elevation MI (%)
48 49 50 51 52 53 54*0.005.00
10.0015.0020.0025.0030.0035.0040.00
0.49 1.71 5.389.88
17.41
32.1536.88
Injection or infusion rate of thrombolytic agent in ST-elevation MI (%)
Injection or infusion rate of thrombolytic agent in ST-elevation MI (%)
Startingspecial pay
*54 = estimation from Aug. 2010 – Jul.2011 Source : IP individual record 2005- 2011 , NHSO
16
Financial risk protection (1)Reducing incidence of catastrophic health spending
OOP>10% total consumption expenditure
Source: Analysis of Socio-economic Survey (SES)
17
UHC achieved
Financial risk protection (2)Protection Thai HH against health impoverishment
18
UHC scheme improved equity in service use
-0.50
-0.40
-0.30
-0.20
-0.10
0.00
0.10
0.20
0.30
0.40
0.50
2001 2003
2004 2005
2001 -0.294 -0.271 -0.037 0.431 -0.090
2003 -0.365 -0.315 -0.080 0.348 -0.139
2004 -0.345 -0.285 -0.119 0.389 -0.163
2005 -0.380 -0.300 -0.100 0.372 -0.177
Health centre Community hosp Provincial hosp Private hosp Overall
Ambulatory care: concentration index
19
Increasing share of public spending on health with less share of out-of-pocket payments after
achieving UHC(Total health expenditure and THE as % of GDP 1994-2010)
Thailand THE 1994-2010
0
100,000
200,000
300,000
400,000
500,00019
94
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
Mil
Baht
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
% G
DP
Government spending non-government spending THE, %GDP
UHC achieved
Total health expenditure during 2003-2009 ranged from
3.49 to 4.0% of GDP, THE per capita in 2010 = 194 USD
Capitation payment for UC beneficiary in 2010 = 80 USD per capita
Inte
rnat
iona
l Hea
lth P
olic
y Pr
ogra
m -T
haila
ndIn
tern
atio
nal H
ealth
Pol
icy P
rogr
am -
Thai
land
Key contributing factors•Development of health systems:
–First strand: expansion of strong district health systems both infrastructure and workforces
• More resource allocation to district and provincial levels,
• Government bonding “mandatory public health services” by all health-related graduates.
• The MOPH high level production capacity of nursing and other health-related personnel contributed significantly to the functioning of rural health services.
20
21
• Good working environment• Housing• Transportation• Recreation
• Well equipped building• Adequate supplies of medicines
and diagnostics
District health systems: significant improvement
A standard team of HW and equipment list were planned in conjunction with infrastructure development
22
1965 1970 1975 1980 1985 1990 1995 2000 2005
Externalbrain drain
Ruraldevelopment
HFA/PHCEconomic
boomEconomic
crisis
Ratio doctor density Between Bangkok to Northeastern region
Economicrecovery
1974 Rural doctor program(Rural recruitment and hometown placement) 1979
Medical education reform(PHC base, rural training)
1995 Collaborative Project to
increase production of rural doctor 300-500 /year
2005 ODOD project
(one district one doctor)
Education strategies: increase production and rural recruitment
Source: Noree & Pagaiya, 2011
3 year mandatory rural services to all graduates, non-compliance are liable to pay a fine of US$ 10,000 to 50,000 (for ODOD)
23
1965 1970 1975 1980 1985 1990 1995 2000 2005
Externalbrain drain
Ruraldevelopment
HFA/PHCEconomic
boomEconomic
crisis
Ratio doctor density Between Bangkok to Northeastern region
Economicrecovery
1975 Hardship allowance
60-88 USD/mo
1995Non-private practice
allowance 250 USD/mo
1997 Increase Hardship allowance
Normal 55 USD/moRemote 250 USD/mo
Very remote 500 USD/mo
2005 Special allowance
>3 yrs work - 125 USD/moSouthern – 250 USD/mo
Financial incentives
Source: Health Resource Surveys (various years)
Four decades of infrastructure and workforce development
0100200300400500600700800900
1, 0001, 1001, 2001, 3001, 400
1965 1970 1975 1980 1985 1990 1995 2000 2005
All Dist r ict O t her public Pr ivat e
Hospitals
0
10, 000
20, 000
30, 000
40, 000
50, 000
60, 000
70, 000
80, 000
90, 000
100, 000
110, 000
120, 000
1965 1970 1975 1980 1985 1990 1995 2000 2005
Doct ors Nurses
Doctors and nurses
400
500
600
700
800
900
1, 000
1, 100
1, 200
1, 300
1, 400
1965 1970 1975 1980 1985 1990 1995 2000 2005
Population per bed
1, 000
2, 000
3, 000
4, 000
5, 000
6, 000
7, 000
8, 000
9, 000
10, 000
1965 1970 1975 1980 1985 1990 1995 2000 2005
Doct or Nurse
Population per doctor and nurse
The advent of district hospitals (1977)
Public service mandate of new MDs (1972)
First batch of two-year technical nurses (1982)
Now fully upgraded to RNs
46%(5.5)
29%(3.5)
24%(2.9)1977
Regional H./General H.
Rural Health Centres
Community H.
27%(11.0)35%
(14.6)38%
(15.7)
1987Regional H./General H.
Community H.
Rural Health Centres
200046.1%(51.8)
35.7%(40.2)
18.2%(20.4) Regional H./General H.
Community H.
Rural Health Centres
201054.0%(78.0)
33.4%(33.4)
12.6%(18.1) Regional H./General H.
Community H.
Rural Health Centres
Change in the use of primary health care From reverse to upright triangle: PHC utilization
TraditionalMedicine
1932
1950
1964
1966
1968
1974
1975 1978 1981 1992 1996 1997 1999 20022001 2007
Stating Rural Health Services
TropicalDiseasesControl
Programs
Wat BoatProject
- Sarapee
Project-
BanPai Project
Health Centers
Lampang Project Samoeng Project Nonetai Project
ExpandedCommunityHospitals
AdoptedHealth For All
Policy
Rural Doctors Movement
Community Health Volunteers
Health CardProject
The Decade of Health Center Development(1992-2001)
1985
Health Care ReformProject
EconomicCrisis
Civil Society Movement
Universal Coverage
Policy
Thai Health Fund
Starting Primary Care Services
National Health Act
Primary Care Development
Source: Komartra Chungsathiensarp, 2551
Decentralization
after Pay by quality based paybefore
หมายเหต ุ ปี 2554 เป็นขอ้มูล ณ ไตรมาส 2Sources : Healthcare Accreditation Institute (Public Organization), 2011. adapted by Bureau of Service Quality Development, NHSO.
HOSPITAL ACCREDITATION STATUS, 2005-2011
Monitoring & Evaluation of health systems reform /strengtheningA general framework
Data sources
Indicatordomains
Analysis & synthesis
Communication & use
Administrative sourcesFinancial tracking system; NHA
Databases 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
Gove
rnan
ce
Inputs & processes Outputs Outcomes Impact
Data availability for M&E system in ThailandInput 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
Inte
rnat
iona
l Hea
lth P
olic
y Pr
ogra
m -T
haila
ndIn
tern
atio
nal H
ealth
Pol
icy P
rogr
am -
Thai
land
30
The principle of“Triangle that moves the mountain”
Knowledge power &
management
Social and civic movement
Political commitment/
Policylinkages
Inte
rnat
iona
l Hea
lth P
olic
y Pr
ogra
m -T
haila
ndIn
tern
atio
nal H
ealth
Pol
icy P
rogr
am -
Thai
land
31
Acknowledgements• Ministry of Public Health (MOPH) of Thailand,• National Statistical Office (NSO) of Thailand, • National Health Security Office (NHSO) of Thailand,• Health Systems Research Institute (HSRI), • World Health Organization (WHO)