Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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)
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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.
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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.
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
19
Thank you
for your
attentio
n