Health system components to support UHC: Thai experience on pre-requisites for UHC

1. 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 Hotel 9 September 2013

2. 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.

3. Reduction of U5MR and MMR in Thailand, 1960-2008 Achieving UHC 3 http://ghlc.lshtm.ac.uk/ Source: Why and how did Thailand achieve good health at low cost? (2011)

4. Long march towards universal health coverage in Thailand Public policies to provide universal financial risk protectionGNI per capita, 1970-2009

5. 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,

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)

8. Selected health interventions for cardiovascular disease patients included in the UHC benefit package Basic health care services for individual beneficiaries Expansion of open heart surgery and PTCA • 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. Renal replacement therapy For ESRD patients (Pilot project in FY2007 and extend to the whole country in FY2009) Chronic NCDs (2nd prevention for DM/HT) (Pilot project in FY2009 and extend to the whole country in FY2010) Heart transplantation Commencement of the benefits 2004 2009 2012 2002 2010

9. NHSO allocation Capitation increase Item increase From: Bureau of policy and planning, NHSO

10. UHC scheme payment Capitation in OP, DRG with global budget in IP Basic health care Population/patient ARV drug Fee schedule & development plan UC fund Provider RRT Fee schedule & development plan Chronic (DM/HT) Point by no of pt Mental health (Medicine) Medicine supply & development plan

11. Development of Thai DRGs * Thai Modification for data entry only (not for new classification)

12. DRG evolution Thai DRGs ver. 4 Oct.2007 • Reclassification • Add group fromprevious other… • Bilateral , Multiple procedures • Special care • Unbundling • Coding: ICD-10-TM (diagnosis) ICD-9-CM 2005 with Extension (Procedure) Oct.2005 Thai DRGs Ver. 3.5 Apr.2005 Oct.2003 Thai DRGs Ver. 3.1 Feb.2001 Ver.3 • Reclassification • Recalibration Nov.1999 Ver.2 • Clean up library • Unbundling Additional lists Recalibration (Minor change) Ver.1

13. Increased utilization, low unmet needs Source: NSO 2009 Panel SES, application of OECD unmet need definitions

14. Increased access to expensive health interventions for heart disease patients among UHC beneficiaries, 2005-2012

15. Starting special 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 spendingOOP>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 Ambulatory care: concentration index

19. UHC achieved 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) 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

20. 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. District health systems: significant improvement • Well equipped building • Adequate supplies of medicines and diagnostics • Good working environment • Housing • Transportation • Recreation A standard team of HW and equipment list were planned in conjunction with infrastructure development

22. Ratio doctor density Between Bangkok to Northeastern region Rural development HFA/PHC Economic crisis Economic boom Economic recovery External brain drain 1965 1970 1975 1980 1985 1990 1995 2000 2005 1995 Collaborative Project to increase production of rural doctor 300-500 /year 2005 ODOD project (one district one doctor) 1974 Rural doctor program (Rural recruitment and hometown placement) 1979 Medical education reform (PHC base, rural training) Education strategies: increase production and rural recruitmentSource: 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. Ratio doctor density Between Bangkok to Northeastern region Rural development HFA/PHC Economic crisis Economic boom Economic recovery External brain drain 1965 1970 1975 1980 1985 1990 1995 2000 2005 2005 Special allowance >3 yrs work - 125 USD/mo Southern – 250 USD/mo 1995 Non-private practice allowance 250 USD/mo 1975 Hardship allowance 60-88 USD/mo 1997 Increase Hardship allowance Normal 55 USD/mo Remote 250 USD/mo Very remote 500 USD/mo Financial incentives

24. Four decades of infrastructure and workforce development The advent of district hospitals (1977) First batch of two-year technical nurses (1982) Now fully upgraded to RNs Public service mandate of new MDs (1972) Source: Health Resource Surveys (various years)

25. 46% (5.5) Regional H./General H. Community H. 1977 24% (2.9) Rural Health Centres 29% (3.5) 27% (11.0) Regional H./General H. 1987 35% (14.6) Community H. Rural Health Centres 38% (15.7) 18.2% (20.4) Regional H./General H. 35.7% (40.2) 2000 Community H. 46.1% (51.8) Rural Health Centres 12.6% (18.1) Regional H./General H. 33.4% (33.4) 2010 Community H. 54.0% (78.0) Rural Health Centres Change in the use of primary health care From reverse to upright triangle: PHC utilization

26. Primary health care development - Thailand The Decade of Health Center Development (1992-2001) Adopted Health For All Policy Starting Primary CareServices Wat Boat Project Universal Coverage Policy Health Centers Community Health Volunteers National HealthAct Economic Crisis Traditional Medicine 1964 1975 1978 1981 1992 1996 1997 1999 2001 2007 1932 1968 1985 2002 1950 1966 1974 Rural Doctors Movement Health Care Reform Project Thai Health Fund • Sarapee • Project • BanPai • Project Stating Rural Health Services Expanded Community Hospitals Decentralization Health Card Project Primary Care Development Lampang Project Samoeng Project Nonetai Project Tropical Diseases Control Programs Civil Society Movement Source: Komartra Chungsathiensarp, 2551

27. hospital accreditation status, 2005-2011 after Pay by quality based pay before Sources : Healthcare Accreditation Institute (Public Organization), 2011. adapted by Bureau of Service Quality Development, NHSO. หมายเหตุ ปี 2554 เป็นข้อมูล ณ ไตรมาส 2

28. Inputs & processes Outputs Outcomes Impact Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Improved health outcomes & equity Social and financial risk protection Responsiveness Infrastructure / ICT Health workforce Supply chain Information Financing Governance Population-based surveys Coverage, health status, equity, risk protection, responsiveness Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Clinical reporting systems Service readiness, quality, coverage, health status Vital registration Monitoring & Evaluation of health systems reform /strengthening A general framework Indicator domains Data sources Analysis & synthesis Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Communication & use Targeted and comprehensive reporting; Regular country review processes; Global reporting

29. Data availability for M&E system in Thailand 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

30. The principle of “Triangle that moves the mountain” Knowledge power & management Social and civic movement Political commitment/Policylinkages

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)