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HealthCare System in Thailand: Past - Present and Where is the Future ? 1.

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Presentation on theme: "HealthCare System in Thailand: Past - Present and Where is the Future ? 1."— Presentation transcript:

1 HealthCare System in Thailand: Past - Present and Where is the Future ? 1

2 2 Thailand Population Census Population of Thailand Total Population63,891,00064,413,00064,623,000 - Male31,445,00031,683,00031,438,000 - Female32,446,00032,730,00033,185,000 Urban area23,078,00028,406,00029,662,000 Rural area40,813,00036,007,00034,961,000 Children (under 15 years)13,010,00012,892,00012,123,000 Labor force ( years)43,091,00043,410,00042,983,000 Elderly (60 years and over)7,790,0008,111,0009,517,000 School ages ( years)15,192,00015,092,00014,027,000 Women of reproductive ages( years)17,711,00017,712,00017,388,000 Crude birth rate (per 1,000 population) Crude death rate (per 1,000 population) Natural growth rate (percent) Infant mortality rate (per 1,000 live births) Child mortality rate (per 1,000 live births) Total fertility rate Source: Institute for Population and Social Research, Mahidol University

3 3 Thailand Population Census Estimated Population of Thailand in the Next 20 Years (2033) 65,759,000 - Male - Male31,633,000 - Female - Female34,126,000 Source: Institute for Population and Social Research, Mahidol University; Estimated Population at Midyear 2013 (1 st July)

4 4 Health statistics

5 Coverage of Health Insurance % Life Expectancy at birth (2010) 74 ( Male 71 (71.1), Female 77 (78.1) ) Crude birth rate (per 1,000) 12.4 (11.6) Crude death rate (per 1,000) 6.5 (7.7) IMR (per 1,000 live births) 6.6 (11.2) MMR (per 100,000 live births) 8.9 Source: Ministry of Public Health, Public Health Statistics 2011 ( ) = Institute for Population and Social Research, Mahidol University 5 Thailand Health Status

6 Aged Society Year 2553Year 2554Year 2555 Age Groupcountpercentagecountpercentagecountpercentage Ages ,672, ,496, ,241, Ages ,577, ,892, ,911, Ages 60 and Over 7,450, ,791, ,114, Total 63,701, ,181, ,266,36 5 Elderly = 12.63% of Total Population Aged Society 6 Source: Bureau of Policy and Strategy, Ministry of public health

7 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision Japan Korea China Thailand World 7 Proportion of elderly (>65 years old)

8 DiseaseYear 2011Year 2012 Infectious disease Non communicable diseases Circulatory diseases Accident Cancer Rate per 100,000 populationsMorbidity 8 Source: Bureau of Policy and Strategy, Ministry of public health

9 Disease Infectious disease Non communicable diseases Circulatory diseases Accident Cancer Rate per 100,000 populationsMortality 9 Source: Bureau of Policy and Strategy, Ministry of public health

10 Rate per 100,000 populationsMortality 10 Source: Bureau of Policy and Strategy, Ministry of public health

11 Source: Thailand Health Profile Major Causes of Death in Thailand,

12 Source: IHPP, Burden of disease, Thailand, 1999, 2004, and DALYs attributable to risk factors in Thailand 1999, 2004, and 2009

13 13 Evolution of health system in Thailand

14 King Rama 3 started the Western medicine Siriraj Hospital established Siriraj Hospital established MoPH Mandatory rural services HFA/ PHC policy UCS NHSO Department of Public Health, MoI /08/ Scaling up District Health System (DH + HC) Scaling up District Health System (DH + HC) Low Income Scheme 1980s CSMBS 1980 Health Card 1983 SSS s 1992 A decade of health center development 1992 A decade of health center development 1997 Constitution Economic crisis NHCO 1992 HSRI ThaiHealth LGs HAI EMIT 1946 First MoPH nursing college MoPH = Ministry of Public Health, HSRI = Health System Research Institute, LGs = local governments ThaiHealth = Thai Health Promotion Foundation, NHSO = National Health Security Office, NHCO = National Health Commission Office, EMIT = Emergency Medical Institute of Thailand, HAI = Hospital Accreditation Institute 1999 Local Health Funds Evolution of the Thai Health System

15 Principles of organizing healthcare system in Thailand The 1997 Constitution was adopted as principle legal framework for moving toward welfare state by providing Universal Health Coverage, ‘access to needed health services is a basic right of the Thai population’ The UHC policy in Thailand aims to enable access to needed services to all Thai people and protecting them from catastrophic health expenditure Put emphasis on ensuring access for all at an affordable cost rather than providing the best to some Health service delivery system has been organized as multi-level system to ensure geographical equity while maintain efficiency of the system. 15

16 Area Governor MOPH Local Authorities Tumbon health fund Output/ Outcome/ Impact PPP NHCO NHSO ThaiHealth EMIT HAI Ministry of Public Health Emergency Medical Institute of Thailand National Health Security Office Health Accreditation Institute Public Private Partnership National Health Commission Health System Research Institute HSRI Thai Health Promotion Foundation 16 Multiple Actors in Health

17 17 Governance of the health system MoPH had been sole actor in the health system for six decades; however, following various reforms, there are various actors involving in governing the health system. Decentralization: various public health functions have been transferred to local governments Establishment of NHSO  separation of purchasing and providing functions ThaiHealth dealing with social determinants of health NHCO -> citizen empowerment in health EMIT  pre-hospital care system HAI  hospital accreditation Following various reforms, there has been brain drain from MoPH to those new autonomous agencies and resulted in weakening MoPH’s role in directive the health system.

18 18 Healthcare financing

19 Source: Thailand Data; Note: Revenue excluding grants, GGCE = general government consumption expenditure, GGE = General government expenditure 19 General government Revenue and Expenditure

20 UHC achieved Source: NHA Economic crisis 20 Total Health Expenditure : ↑ government spending, ↓ out-of-pocket payment, but maintain the level of spending to GDP

21 21

22 Source: Comptroller’s General Department, MOF Note: direct disbursement of OP services started in 2004 for chronic conditions, 2006 extended to pensioners, and 2009 extended to cover all CSMBS members Per capita expense ≈ 12,000/ year 22 CSMBS expenditure, 1994 – 2012 rapid cost escalation in opposite to declining of beneficiaries

23 Source: expenses from NHA excluding expense on administration Number of beneficiaries at the end of each year from SSO xxx capitation 23 SSS expenditure 1994 – 2010 Per capita expense 2010 = 2,750 Baht

24 ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ 24งบกองทุนหลักประกันสุขภาพแห่งชาติ ปีงบประมาณเป้าหมายประชากร สิทธิ UC (ล้านคน) อัตราค่าเหมาจ่าย รายหัว (บาท/คน/ปี) งบเหมาจ่ายรายหัว รวมเงินเดือน (ล้านบาท) % เปลี่ยนแปลง ปี , , ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , % ปี , , %

25 25

26 Data from NHSO: 78% of UCS members used benefits, OP visits increased from 2.45 to 3.37 visits/person/year, IP admissions increased from 0.94 to 1.15 admissions/person/year 26 Number of use persons, OP visits, and IP admissions of UCS,

27 27 รายงานสรุปจำนวนการใช้บริการ OP ปี 2553 – 2555 สิทธิ UC ปีจำนวนคนจำนวน Visit ,098,157144,809, ,671,976166,184, ,352,507167,790,950 ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

28 28 รายงานสรุปจำนวนการใช้บริการ OP ปี 2555 UC Visit count groupVisit countPatient countAccumulative patient count ,123, ,618,03315,741, ,615,45719,356, ,634,82521,991, ,037,52724,028, ,620,06325,648, ,293,47726,942, ,047,11227,989, ,61428,836, ,62829,524, ,66530,086, ,11530,541, ขึ้นไป 2,140,93832,682,470 ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

29 29 รายงานสรุปจำนวนการใช้บริการ OP ปี 2555 UC Visit count groupVisit countPatient countAccumulative patient count 13 – ,52530,911, – ,83431,208, – ,51731,450, – ,25231, – ,17831,806, – ,14531,937, – ,55432,046, – ,59432,136, – ,96232,210, – ,34032,271, – ,66832,323, – ,46632,366, ขึ้นไป 315,90332,682,470 ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

30 On average, salary of hospital staffs increased by 6-10% per annum Non-salary labor cost of district hospitals increased sharply by 50% in 2009, and it increased by 30-40% for general and regional hospitals in 2009 and 2010 All type of hospitals had a declined rate of expense on drugs Source: Health Insurance System Research Office; analysis of financial report of MoPH hospitals 30 Increase in cost of MoPH hospitals,

31 31 Source: Office of Insurance Commission Losses incurred varied from 40-50% of collected revenues Traffic Accident Insurance

32 Ministry of Public Health Permanent Secretary Technical Departments Director-General Ministry of Interior Permanent Secretary Office of the Permanent Secretary Province Governor Provincial Public Health Offices (76) Provincial Chief Medical Officers Regional & General Hospital Community Hospitals Districts Governors District Health Offices Primary Care Unit Tambol Health Promoting Hospitals Tambol Administration Offices Municipalities Provincial Administration Offices 32 Provincial Health Administration

33 33 Health service delivery system in Thailand Health centers 9,768 Municipality Medical Centers 365 District hospitals 776 Provincial hospitals 68 Pharmacy 11,154 Private clinics 17,671 Other public hospitals 120 Private hospitals 323 Regional hospitals 28 University hospitals 17 Other MoPH hospitals 55 MOPH facilities Sub-district District Province Source: 1. Thailand Health Profile Bureau of Policy and Strategy, MoPH,

34 Private Hospital Clinics (2013) Private Hospitals Bangkok 98, Other provinces 224 Total 322 Medical clinics Bangkok 3,970, Other provinces 14,533 Total 18,503 Drugstores Bangkok 4,912, Other provinces 11,780 Total 16,692 Traditional medicine Drugstores Bangkok 443, Other provinces 1,615 Total 2,058 Private Hospital Clinics (2013) 34 Source: Bureau of Policy and Strategy, Bureau of Sanatorium and Art of Healing, Food And Drug Administration; Ministry of public health

35 Health Facilities in the Public Sector (2010) Source : Bureau of Health Administration; Ministry of public health Administrative LevelHealth facility Bangkok 5 medical school hospitals 26 general hospitals 13 specialized hospitals/institutions 68 community health care centers Regional level 6 medical school hospitals 33 regional hospitals 48 specialized hospitals Provincial level 83 general hospitals District level 774 community hospitals 284 municipal health centers Sub-district level 9,768 health promoting hospitals Village level 198 community health posts 48,049 rural community primary health care centers 3,108 urban community primary health care centers 1,055,000 Village Health Volunteers Health Facilities in the Public Sector (2010) 35

36 36 Human resources

37 37 Source: Thailand Health Profile Population to provider ratios,

38 There was mark reduction in the disparities of population to health care provider ratios for Bangkok and the Northeast during Population to doctor ratio of the Northeast remained 5 time of Bangkok while the ratios of other professions were 1.5 – 2 times of Bangkok 38 Source: Thailand Health Profile Disparities of population/healthcare provider ratios for Bangkok and the Northeast,

39 39 Source: Kanchanachitr et al (2011) Thailand has relatively low numbers of doctor and nurse to 1,000 populations compared with countries at the same level of economy Doctor and nurse to 1,000 population among ASEAN countries among ASEAN countries

40 40 Limited production capacity Currently, annual production increases to 2,500 for doctor and 9,000 for nurse; however, the production capacity remains lower than other countries. Source: Kanchanachitr et al (2011)

41 41 Pharmaceutical industry

42 During the period , with a high economic growth and new drug marketing monopolies under the Drug Act, the value and proportion of imported drugs was rising rapidly. The proportion of imported drugs was rising steadily to 56.3% in 2005, 64.5% in 2009, and 68% in Source: Drug Control Bureau, Food and Drug Administration, MoPH Pharmaceutical industry in Thailand

43 Percentage of prescribed items Percentage of reimbursements Use of drugs outside national ED list in 31 hospitals University hosp MoPH hosp Other public hosp Data error Bubble size represents amount of reimbursement Type of hospital 43

44 In Thailand, important antibiotic resistant bacteria are – Enterobacteriaceae (Quinolone resistance, <20% in community, 30-70% in hospital), – Staphylococcus aureus (Penicillin resistant 1% in community, 30-70% in hospital) – Pseudomonas aeruginosa (Carbapenam resistance 10-30%) – Acinetobacter baumanni. (Carbapenem resistance 60-85% for hospital infection) Antibiotic use, low / middle income countriesOP penicillin use and resistance Source: Werner C. (2004) Source: report of workshop on antimicrobial drug resistance, Bangkok, 6-10 August 2012 Antimicrobial drug resistance (1) 44

45 Aim to ensure security of drug supply and to maintain price level of necessary pharmaceutical supplies to ensure accessibility for all Thais Production Stocking distribution Trade of between national security and promoting local pharmaceutical industry (push and pull) Competing with local pharmaceutical firms in producing generic drugs Production of vaccines Role of Government Pharmaceutical organization (GPO) 45

46 Time line of Health Sector Reform 46

47 47 Time line of Health Sector Reform Scaling up district health system Health volunteer Community- based health insurance (health card) PHC era Introduction of Universal Health Coverage Expansion to cover high cost services i.e. ARV, RRT Universal Coverage Population aging Increase demand for health care Increase burden of chronic care Use of original & NED drugs Demand drive by Advance medical technology Increasing health expenditure Sustainability doubted Control of health care expenditure Harmonization of health insurance schemes Regional health service plan Health sector reform 1 Sustainability Healthcare expenditure Quality and safety Management Health sector reform 2

48 48 Current issues of concern Downsizing public sector policy of various governments put pressure on public health sector Increased workload according to universal coverage policy Limited public hospital capacity in recruitment and retain health professions, especially professional nurse Major incentive for working in public hospital with greater workload and lower salary is being a civil servant Disparities in financial compensation level for different health professions in the public sector

49 49 Health Sector Reform: issues for debate Whether Thailand will move towards full welfare state, particularly for health care Wealth & Health Balancing of revenue and expenditure; how to generate additional revenue for health care Equal basic benefits to all or comprehensive benefits Explicit cost sharing policy to prevent unnecessary use, especially high cost medicines Long-term financial sustainability

50 Burden Of Disease and old aged dependency challenges Burden Of Disease and old aged dependency challenges Governance of the health system Governance of the health system – Role of MoPH and other partners and their relationship Government fiscal space and long term financial sustainability Government fiscal space and long term financial sustainability Harmonization of the three main schemes Harmonization of the three main schemes Health systems capacity to cope with Health systems capacity to cope with – Increased demand within very strained health workforces – Decentralization context –threats and opportunities – Public private dialogues, better trust and collaboration 50 Challenges for further reforms

51 ช่วงอายุ 0 – 5 ปี เด็กเกิดจากมารดาซึ่งมี ANC ครบถ้วนในช่วงระยะเวลาที่ เหมาะสม และคลอดในห้องคลอด เด็กได้รับน้ำนมมารดาและอาหารเสริมในระยะเวลาที่เหมาะสม เด็กได้รับวัคซีนที่จำเป็นต่างๆครบถ้วน การได้รับการรักษาทางการแพทย์ที่พอเพียง เด็กได้รับการเตรียมตัวสำหรับการพัฒนาในช่วงวัยต่อไปอย่าง เหมาะสมผ่านศูนย์ดูแลเด็กเล็กและโรงเรียนอนุบาล การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่ง ตามช่วงวัย 51

52 ช่วงอายุ 6 – 19 ปี การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่ง ตามช่วงวัย 52 การบริการทางการแพทย์ที่พอเพียง เด็กและเยาวชนได้รับวัคซีนที่จำเป็น และวัคซีนกระตุ้นครบถ้วน เด็กและเยาวชนได้รับการพัฒนาทักษะเพื่อการเข้าสู่ช่วงวัย ทำงานต่อไปอย่างเหมาะสมกับสถานการณ์และปัญหาด้าน สาธารณสุข เช่น ยาเสพติด สุรา บุหรี่ การตั้งครรภ์ไม่พร้อม โรคติดต่อทางเพศสัมพันธ์ รวมทั้ง HIV/AIDS ปัญหาอุบัติเหตุ ปัญหาทางการโภชนาการ โดยเฉพาะ โรคอ้วน การออกกำลังกาย ปัญหาการติดการพนันและเกมส์ การมี E.Q. ที่เหมาะสม ความรับผิดชอบต่อสังคม

53 ช่วงอายุ 20 – 59 ปี การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่ง ตามช่วงวัย 53 ได้รับการดูแลส่งเสริมสุขภาพและการคัดกรอง โดยมีการ กระตุ้นเตือนให้ความรู้ผ่านช่องทางต่างๆอย่างเหมาะสม ได้รับบริการด้านสุขภาพที่พอเพียงในกรณีที่เจ็บป่วย ได้รับการเตรียมตัวที่จะเข้าสู่ช่วงอายุวัยชราต่อไป ช่วงอายุ > 60 ปี ได้รับการซ่อมแซมสุขภาพในกรณีที่จำเป็น ได้รับการส่งเสริมให้มีสุขภาพที่แข็งแรงจนถึงช่วงสุดท้ายของ วัย ได้รับการดูแลจากลูกหลานและชุมชนอย่างอบอุ่น

54 54 Reform direction

55 1.Restructuring health sector 55 Reform direction Separation regulatory role and service provision role in the MoPHStrengthening MoPH functions as National Health Authority Policy, direction, and guidelines on financing Policy on human resources Regulation and supervision Monitoring and evaluation Implementing cost accounting system in hospitals Reorganize relationships between MoPH and various main actors

56 2.Regional health service commissioning 56 Reform direction Decentralize administration of service provision to 12 regional MoPH areas (service plan) Improve efficiency of resources use by sharing resources Improve capacity of service provision within the regions Better referral system Greater accountability by setting KPIs Greater cooperation between purchaser and providers in planning, purchasing, and service provision

57 3.Financing reform 57 Reform direction Expansion of health protection coverage by compulsory contributory insurance Migrant workers and dependents Foreign visitors Foreign residents Reform Traffic Accident Insurance to improve effectiveness and efficiency of the system Pharmaceutical cost control of CSMBS and reform payment system for better cost control Reform payment system to support MoPH service plan 57

58 4.Harmonization of current health insurance schemes 58 Reform direction National Clearing HouseNational Information centerHarmonization of benefit package and payment system Accident and Emergency services Anti-Retro Viral Therapy Cancer

59 Provide r National Health Authority Purch aser Regul ator Supplement / Agent - สปสช. - สวรส. - สช. - สพฉ.โครงสร้างการทำงานระบบสาธารณสุขประเทศไทย 59

60 MOPH hospitals at border areas provide unpaid care around 250 million Baht a year Walk in across border for medical visit Illegal migrants & dependents, both registered and non- registered ≈ 3 mil. Legal skilled migrants & dependents ≈ 1 mil. (attracted by 2 mm public project on infrastructure) Immigrant workers ≈ 800,000/year, not much affected by AEC Medical Hub Increase demand for health care 60

61 Illegal migrant workers & dependents ≈ 3 m, share 15-20% of OP visits and 20-35% of IP admissions in provinces with high density of migrant workers. Non-Thais patients shared ≈ 30% of OP services and 35-50% of IP services in hospitals at west-border of Thailand There are ≈ 1 million foreign patients under the medical hub Health services use by non-Thais 61

62 Policies response to increase demand for healthcare of Non-Thais At the border; Supporting capacity building of health facilities in nearby countries at border areas Supporting governments of neighborhood countries in moving towards UHC Providing health protection to Non-Thais and generate additional source of finance by compulsory contributory insurance Migrant workers and dependents Foreign visitors 62

63 63

64 64

65 Policies response to increase demand for healthcare of Non-Thais (2) Medical hub (academic training and conference, medical care, dental care, spa and Thai traditional medicine) Promoting Thailand as center of medical education, academic training, and conferences) Loosening professional barrier in importing foreign professions Reduce income gap between public and private sector in order to prevent brain drain 65

66 Inspiration 66

67 ชายคนแรกตอบ “ ผมกำลังทำงานหาเงินเพื่อเลี้ยงชีพอยู่ ” คนที่สองตอบว่า “ ผมกำลังฝึกหัดเพื่อเป็นนักแกะสลักหินชั้นยอด ” ชายคนที่สามตอบ “ ผมกำลังสร้างวิหารอยู่ครับ เป็นวิหารที่จะอยู่เป็นร้อยๆ ปีและเป็นแรงบันดาลดลใจให้คนรุ่นหลังอีกหลายชั่วอายุ คนหลังจากผมตายไปแล้ว ” 67

68 Bamboo seeding ( water for 4 yrs ) After off from land : grow 60 fts in 9 m 68

69 Bamboo seeding ( water for 4 yrs ) After off from land grow 60 fts in 9 m 69

70 A journey of a thousand miles begins with a single step. Chinese proverb 70

71 ระยะทางจากโลกถึงดวงจันทร์ 1/4 ล้านไมล์ ระยะทาง 3 กม. แรก ใช้พลังงานไป 50 % ของทั้งหมด 71

72 Attitude is a little thing that makes a big difference Winston Churchill 72

73 73

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