Iabe Paper 2010 Conferance

8/9/2019 Iabe Paper 2010 Conferance

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FINANCING STRATEGIES TO IMPROVE PRIMARY HEALTHCARE SERVICES AND POLICES INTHAILAND

Nenavath Sreenu, PhD Scholar, School Of Management Studies, University Of Hyderabad, A.P, INDIA,

500046, E-mail, ID : [email protected] , mobile no: +919966483998.

Dr. Somsaowanuch chamusri, associate dean, community nursing faculity of nursing, mahasarkham university

Thailand. Mail ID: [email protected] mobile no: 6643754356.

ABSTRACTPurpose: The purpose of this study is to assess the financing stragies to improve primary healthcareservices and policies in Thailand. Design/methodology/approach : This study has been developed based on literature review ofresearch in primary healthcare management. To improve the performance healthcare deliveryservices process and major step find the problems identification and formation the universalhealthcare coverage policyFindings: The study finds problems of the healthcare delivery services in Thailand 1) Problem ofprimary healthcare delivery system efficiency 2) Improved the delivery of quality healthcare services,accessibility and affordability. Research limitations/implications: This study is based on literature review, examining currentproblems in Thailand. Healthcare financing Contribution to research on primary healthcare deliveryby the development of a comprehensive instrument of provider-perceived healthcare delivery system

in Thailand. And lack of healthcare financing within the new decentralized systemPractical implications: The proposed model can be implemented in primary healthcare centreservices in order to improve primary healthcare performance. It may also be applied to other services.Provides a practical framework for stakeholders to develop an healthcare services performancemeasurement system to rationalize resource allocation process that enhances continuous primaryhealthcare financing stragies improvement. Originality/value: The study suggests the adoption of an approach of management practices indealing with Thailand healthcare services system problems and provides the quality healthcareservice at primary healthcare level.Key Words: financing, primary, healthcare, management, efficiency, delivery, services and health

system.FINANCING STRATEGIES TO IMPROVE PRIMARY HEALTHCARE SERVICES AND POLICES IN

THAILAND

1. Introduction: Thailand has a long history of primary health care (PHC) developmentwhich startedbefore the Declaration of Alma Ata in 1978. The National PHC programme was implemented nation-wide as part of the Fourth National Health Development Plan (19771981) focusing on the PHCmanagement of village health communicators and village health volunteers. Since then PHC hasevolved through many innovativehealth activities: community organization, community self-financingand management, the restructuring of the health system and multi-sectoral co-ordination. PHC hasbeen successful in Thailand because of community involvement in health, collaboration betweengovernment and non-government organizations, the integration of the PHC programme, newparadigm of National Health Service development focusing on improving healthcare equity had beenexperimented in Thailand for decades. Community involvements in healthcare in various forms wereimplemented. Based on the experiences gained and the global movement on primary healthcarefinancing (PHC). Thailand PHC program started with the new district hospitals and health centre andthe creation of community health workers i.e. village health communicators and village healthvolunteers to offset the main problem of health professional shortage. During the 5th National HealthDevelopment plan (1982-1987), many initiatives were implemented. To strengthen and sustaincommunity self-reliance, village health revolving funds were set up. Selected community leaders weretrained in planning and management and assigned to manage the so-called Self-managed PHCVillages and their skill and knowledge were transferred to other villages under the TechnicalCooperating among Developing Village (TCDV) Program. To increase inter-sectoral collaboration forPHC to be an integral part of the comprehensive national socioeconomic development strategies,Health for All agenda was shifted to Quality of Life (QOL). The Basic Minimum Needs (BMN)indicators were developed and placed under the shared responsibilities of all social Ministries.Healthcare policies typically focus on improving the populations health and preventing diseases andhealth hazards so that their entire population can aspire to a Healthy and happy life and thusproductively contributing to the prosperous development of the country and its economy. Theachievement of national health objectives is eventually achieved through the selection of an adequateand efficient combination of method of financing, organizational delivery structure for health services
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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and payment approach for health providers. The main methods of financing for health care include thenational health insurance system, general revenue, private insurance, community-based insuranceand out-of-pocket payments. The choice of method will impact on who bears the financial burden, theamount of resources available and who manages the allocation of resources. This study focuses onthe current primary healthcare financing method in Thailand priority in the field of health policies theachievement of universal health coverage and discusses various approaches towards this priority,

that are designed in a coherent manner for each population group through pluralistic methods offinancing and delivery systems while ensuring an efficient use of national resources and sufficientsolidarity across population groups. The government of Thai Health Promotion Fund has become anautonomous organization. The major development in this period is the launch of the universal healthcoverage scheme, so called 30 Baht scheme aiming at universal coverage (UC) for the entirepopulation by 2002. Although the PHC movement in Thailand encountered the time of ups and downsduring these 30 years of development, the nationwide network of village health volunteers issustained and found to be an extremely valuable health resources.

2.0 LITRATURE REVIEW

2.1 Conceptual Model of the Primary Healthcare in Thailand: Public policies specific governmentprograms may be formulated analyzed and evaluated without necessarily taking into account theactual organization. Interest group further strengthening of the basic health infrastructure to supportPHC. A system of family health facilities which will be the facility for each family and work with thecommunity and family to improve health related risks and addressing all new diseases. Ups, thisanalytical framework is based on two conceptual models of the implementation process (voradejchandarasorn 2002), The model hypothesizes that success of an implementation depends upon thecapacity of responsible implementing organizations the ability to implement policies, therefore, may behindered by the factors like inappropriate design of organization and work systems, inadequate andpoorly trained staff, the agencys inability to deploy the personnel to their appropriate place and underutilization of resources as well as the utilization of resources in the wrong direction. Apart from theafore mentioned model and theories, this study also benefits from review of related literature inparticular the primary healthcare development for rural villages require a new management approach.The approach stipulated that the basic healthcare services could be delivered most cost-effectively ifintegrated; demand for medical care services could be met, to a great extent, by up grading existinghealthcare personnel to be clinically competent Para physicians and also the need for healthcarepromotion and disease prevention services could be more broadly and effectively met throughcommunity participation. The approach proved to be a successful one. Under its guidance primaryhealthcare development and personnel development a number of innovations and modifications of theexisting healthcare system which constituted. Reorganization and strengthening of the primaryhealthcare services Infrastructure by integrated curative, disease prevention, and healthcare servicesby coordinating and administration them a single primary healthcare administration, Establishing adepartment of community healthcare within the primary healthcare hospital and Improvingmanagement and supervisory practices in part by developing a practical management healthcaresystem. Development of community healthcare from existing healthcare services personnel, to bedeployed to every district hospital and sub- district healthcare centre, Development of communityhealthcare volunteers in every village including training of a village healthcare volunteers in every

village, and Stimulating other community and private sector involvement by establishing healthcarecommittees in every village and at every administrative level, and by eliciting the interest and supportof other private sector group.

2.2 Strategies for Implementing Primary Health Care: In 1998 twenty years after the conference inalma-ata, WHO sponsored a follow up meeting in almaty, Kazakhstan to explore new strategies toachieve health for all in the 21 century. Participants described sustainable healthcare gains resultingfrom the implementation of primary healthcare in many regions, but inadequate progress in otherareas where there had been deterioration in health statues. They concluded that the PHCs approachhad resulted in considerable improvements in health outcomes. They recognized inconsistentimplementation as a key challenges, and identified the following prerequisites (WHO 2000b) foreffective primary healthcare

1. supportive national healthcare policies with long term commitments, decentralized

responsibility, accountability and acceptable conditions for health worker


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2. financing to assure access for the poor, continuous efforts to improve quality, communityempowerment and participation and sustainable partnerships

These elements when combined in a continuous cycle of planning implementation and monitoring.Can be used to steer a health system towards better performance. A variety of additional strategieswill enhance the delivery of primary healthcare. They include community oriented primary healthcareand improving collaboration among stakeholders. Community oriented primary healthcare is a

systematic approach to improving primary healthcare services through integrating clinical medicinewith public health at the community level (kark 1998, Abramson 1998) this involves sequence ofrelated activities that include (1)defining a community by geographical, demographic or othercharacteristics,(2) determining the health needs of the community in systematic manager(3)identifying and prioritizing healthcare problems;(4) developing programme to address priorities withinthe context of primary healthcare(5) assessing outcomes, Uniting Stake holders through Partnership,Primary healthcare is also enhanced by sector wide approaches that unite key players. Such asdevelopment banks, donor organizations and government agencies, around shared goals andcollective responsibilities. The assumption underlying this approach ins that better use of availablefunds is likely to occur when healthcare services delivery policies are developed jointly amonginvolved parties and when those policies are then reflected in consistent resource allocations andinstitutional framework (cassels 2000).3. O Primary Healthcare financing Services in Thailand: The implementation of government

healthcare policies and health initiatives will only succeed when health care systems are rationallyfunded to achieve priority objectives. Apriority goal of primary healthcare is to provide easy access toessential healthcare services for all with as few financial barriers as possible. A limited number ofphysician payment options exist in any country or healthcare system. They include fee for services.Salaries, capitation payments, integrated capitation and combination payment systems. While theadvantage and disadvantages of each option may vary depending on social and culturalconsiderations particular to given country. Some generalizations about the main system of paymentcan be made. In healthcare system financed by free-for service payments, patients are usually notregistered with specification primary healthcare. In addition free-for-services payments may beassociated with relatively higher payments for diagnostic studies and medical procedures butrelatively lower reimbursement for cognitive services such as counseling and education whichcharacterize the practices of family doctors, healthcare system that principally use fee-for- servicespayment have experienced spiraling costs resulting from the unrestrained incentive to pay for any

services provided. Strategies to Improve Primary Healthcare Services (1)provide sufficient funding tosupport a strong primary healthcare infrastructure(2) minimize financial barriers to essentialhealthcare services(3) provide financial and other incentives to attract family doctors to increases ofgreatest need (4) use a combination of payment methods to support and reward high qualitycomprehensive, equitable primary healthcare services(5) measure performance and provide incentivefor targeted services such as prevention,3.1 Health Care Financing: The health care system reflects the entrepreneurial, market-drivennature of its economy. It is a cross- over system of public-sector and private-sector interfacing in bothhealthcare financing and provision. Recently, the overall resources allocated to health care increasedmarkedly. The total health expenditure did rise steadily, at a higher rate than the growth of the grossdomestic product (GDP). In 2003, the total health expenditure equalled 3.3% of the GDP, of which ahigher proportion (61.6%) was covered by the public sector than by the private sector (38.4%). Theachievement of national health objectives is eventually achieved through the selection of an adequate

method of financing as well as through the choice of an effective and efficient organizational deliverystructure for health services and payment approach for health providers. The method of financingconsists of the way in which financial resources are mobilized and how they are utilized. It is multi-faceted as it relates to different factors including: (1) The approach to mobilize financial resources;the institutional organization delivery structure; and the allocation of resources; (2) The remunerationand incentive method for health providers; and others. The approaches to mobilize resourcestypically include a mixture of general taxation and contributions to public health systems and privatehealth insurance schemes. The main methods of financing for health care include the national healthinsurance system, general revenue, private insurance, community-based insurance and out-of-pocketpayments.3.2 Financing Policies to Achieve Universal Health Care: The national objective for health careduring the period 2006 to 2010, as set by the WHO is: To renovate and improve quality of peopleshealth protection and care to meet the requirement in the human development strategy. Thedocument also specified tasks related to health financing, emphasizing increases in Governmentbudgets for the grass-roots-level health-care system and preventive health care as well as support for


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access to health services by social policy beneficiaries, the poor and low-income groups. In parallel,with revision of the user-fee policy in the principle of identifying full costs of health care, theGovernment would support user fees for the poor and social policy beneficiaries,Public Health Careand Protection Strategy in the 2001-2010 In order to achieve the objective of universal health-careprovision, the following resolution on health financing was introduced in the Strategy for the People'sHealth care Protection.(1) State investment for the health-care service shall take the lead in revenues

for the health sector. Efforts will be made to allow higher regular expenditures for health service fromthe total State budget. Priority shall be given to poor, mountainous and remote areas, focusing onpreventive services, traditional health services, maternal and child health care and primary healthcare in local medical units, providing health services to the poor and priority targets. (2) Hospital feesshall be adapted in accordance with costs incurred, level of investment and affordability of the public.4.0 Universal Health Care Coverage Policy (30-baht Policy): The fragmented funding andprovision of health care made it difficult to provide equitable services, and contributed to inefficienciesand variable levels of quality of care. The implications of reform of the Thai health care system weretaken into consideration by the government in 2001, with regard to financing, delivery of services, andconsumer rights. The main objectives and characteristics of the Universal Health Care Policy are:universal coverage, single standard, and sustainable system. To ensure the effectiveness of thesystem, strong emphasis has been placed on both resource and technology efficiencies, underpinnedby adequate and stable budget allocation to secure the systems financial affordability. Legislation

was initiated so as to ensure policy sustainability. The government drafted a pertinent law, theNational Health Security Act, which was duly enacted in November 2002, to ensure sustainability interms of policy, financing, and institutional support.4.1 Beneficiaries of the UC Scheme: The Medical Welfare Scheme was the public health financingscheme for the poor, the UC Scheme has relatively higher proportion of the poor more than twoschemes. Beneficiaries in income quintile 1 and 2 in the UC Scheme are more than half while in theSSS and the CSMBS account for 6.9% and 16.1% respectively. Success of the UC Scheme andharmonization of the UC Scheme with the others would strongly affect equity improvement for thepoor.(1) Improving access to healthcare From 2002-2007, utilization rate of ambulatory serviceincreased 4.2% annually, while hospital admission rate increased 2.2% annually. Health serviceutilization has changed to focus more on primary healthcare. When rural healthcare infrastructureswere extensively developed. Share of health service utilization at district hospital increased(2)Prevention of medical impoverishment The UC Scheme could reduce household expenditure on

health including catastrophic healthcare expenditure. It was fond that incidence of catastrophicexpenditure (health expenditure more than 10% of household expenditure) reduced from 5.4% in2000 to 3.3-2.8% in 2002-2004. As a result of this, it was estimated that the poverty headcounts dueto out of pocket payments dropped from 2.1% in 2000 to 0.8-0.5% in 2002-2004.(3) Promoting equityin health Many features of the UC Scheme promote equity in health. For its source of healthcarefinance,4.2 Challenges and strategies Universal coverage for health care: Aligning pluralistic publichealth protection system although there was consensus among every stek holders that Thailandshould have Universal coverage for health care.(1) Appropriate payment mechanismExperience inThailand clearly that public health care providers are also response to different payment mechanismin similar way with private ones.(2) Long-term financial sustainability The UCS now depends ongeneral revenue financing through annual budgeting process, (3) Improve equity, quality andefficiencyThailand still retains a fragmented health insurance system and single fund management is

not politically feasible at the moment.5. ANALYSIS: (1)PHC has been successful in Thailand because of community involvement in health,collaboration between government and non-government organizations, the integration of the PHCprogramme, the decentralization of planning and management, inter-sectors collaboration atoperationallevels, resource allocation in favour of PHC, the management and continuous supervisionof the PHC programme from the national down to the district level, .(2) To strengthen and sustaincommunity self-reliance, village health revolving funds were set up. Selected community leaders weretrained in planning and management and assigned to manage the villages the need for healthcarepromotion and disease prevention services could be more broadly and effectively met throughcommunity participation. Under its guidance primary healthcare development and personneldevelopment a number of innovations and modifications of the existing healthcare system (3) theeffectiveness and equity of healthcare system correlated with their orientation towards primaryhealthcare. This correlation was demonstrated in a study that measured the healthcare out comes of

the industrialized nation in relation to the characteristics of their healthcare system policies andpractices that reflect primary healthcare.(4) The main methods of financing for health care include the


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national health insurance system, general revenue, private insurance, community-based insuranceand out-of-pocket payments. The choice of method will impact on who bears the financial burden, theamount of resources available and who manages the allocation of resources.(5) The budget under theUniversal Coverage Policy was allocated to provinces according to the registered population. Thepayment mechanism was applied to both public-sector and private-sector facilities. Highest prioritywas given to channeling allocations to the primary care units based on the registered population.

Secondary and tertiary hospitals were funded from the budget of and through primary care units forinpatient care.6. Conclusion: (1) Thailand has implemented the UC Scheme for six years with some successesespecially in improving access to healthcare for the poor and financial protection for catastrophicillness. These successes happen as a result of well-designed systems based on knowledge learntfrom health system development in the past. (2) Health service provision based on primary care anddistrict health system, and a tax based financing system. Universal approach and a tax basedfinancing system share a common characteristic of administrative simplicity and, therefore, can beeasily implemented in developing countries where administrative capacity is limited.(3) It should benoted that vertical equity of a tax based financing system depends on a country specific tax structureand higher share of income tax would result in more vertical equity. Health service provision based onprimary care would ensure access to healthcare for the poor and improvement of system efficiency.(4) PHCs are the well designed organizational structure and management system. The establishment

of a coordinating mechanism for primary healthcare evaluation. at district level the strength is thestructure of the district coordinating committee (5) The implementation of government healthcarepolicies and health initiatives will only succeed when health care systems are rationally funded toachieve priority objectives. Apriority goal of primary healthcare is to provide easy access to essentialhealthcare services for all with as few financial barriers as possible.(6) Further strengthening of thebasic health infrastructure to support PHC. A system of family health facilities which will be thefacility for each family and work with the community and family to improve health related risks andaddressing all new diseases.REFERENCE

1. Dayl Donaldson, supasit, and viroj (2008), healthcare management and financing project inThailand; ADB NO: 2997 THA, management science for health 165 MA02130-2400 USAcopy rights management science for health

2. hiroshi nishiura, sujan barua, saranath lawpoolsri and chatporn (2004) healthcare inequalities

in thailand and distribution of medical supplies in the provinces; DTM & h epidemiologycommittee, bangkok school of tropica medicine, faculity of tropica medicine, mahidoluniversity, bangkok, thailand, vol 35 no 3

3. voradej chandarasorn(2000): implementation of primary healthcare policy in thailand : ananalysis of strengths and weaknesses in the management system, thai journal of evelopmentadministration vol 30. no 3

4. boonkla(2002) a study on public healthcare implementation of tambon administrationorganization: a study of mamoh district, lampang provinc, chonburi: central training andprimary healthcare development centre

5. WHO reports (2008) Health System Strengthening using Primary Health Care Approach andhealthcare financing Regional on Revitalizing Primary Health Care Jakarta, Indonesia, 6-8August 2008 SEA/RPHC/2008/12

6. Thailand healthcare report (2002) healthcare strategy and policy in Thailand, ministry of

public health, Thailand7. Thaworn Sakunphanit(2006) Universal Health Care Coverage Through Pluralistic

Approaches: Experience from Thailand; Health Care Reform Project, National Health SecurityOffice, Thailand

8. Worawan Chandoevwit(2005): Financing Universal Health-care Coverage TDRI andLecturer at the Faculty of Management Science, Khon Kaen University Vol. 20 No. 3

9. Sara Bennett Lucy Gilson(2001) Health financing: designing and implementing pro-poorpolicies; Copyright: 2001 by HSRC Image credits: Cover photo: People walking into ruralclinic. (C) enjamin Lozare, JHU/CCP M/MC Photoshare, www.jhuccp.org/mmcDesigned by:Adkins Design Printed by: Fretwells

10. Anne Drouin(2007) Methods of financing health care A rational use of financing mechanismsto achieve universal coverage; International Financial and Actuarial Service Social SecurityDepartment Social Protection Sector, International Social Security Association, 2008.
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11. charles boelen, Cynthia haq (2004): primary healthcare strategies and policies; Europe aidco-operative officie, community health centre, university of Miami school of medicine, netLucy Gilson

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Iabe Paper 2010 Conferance