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.

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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

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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)

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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

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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

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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

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Financial risk protection (1)Reducing incidence of catastrophic health spending

OOP>10% total consumption expenditure

Source: Analysis of Socio-economic Survey (SES)

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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

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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

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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.

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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)

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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

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The principle of“Triangle that moves the mountain”

Knowledge power &

management

Social and civic movement

Political commitment/

Policylinkages

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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)