HealthCare System in Thailand: Past - Present and Where is the Future ? Dr. Pradit Sintavanarong Minister of Ministry of Public Health, Thailand

Population of Thailand Thailand Population Census Population of Thailand 2011 2012 2013 Total Population 63,891,000 64,413,000 64,623,000    - Male 31,445,000 31,683,000 31,438,000    - Female 32,446,000 32,730,000 33,185,000 Urban area 23,078,000 28,406,000 29,662,000 Rural area 40,813,000 36,007,000 34,961,000 Children (under 15 years) 13,010,000 12,892,000 12,123,000 Labor force (15 - 59 years) 43,091,000 43,410,000 42,983,000 Elderly (60 years and over) 7,790,000 8,111,000 9,517,000 School ages (6 - 21 years) 15,192,000 15,092,000 14,027,000 Women of reproductive ages(15 - 49 years) 17,711,000 17,712,000 17,388,000 Crude birth rate (per 1,000 population) 12.4 12 11.6 Crude death rate (per 1,000 population) 6.9 7.1 7.7 Natural growth rate (percent) 0.6 0.5 0.4 Infant mortality rate (per 1,000 live births) 12.3 11.8 11.2 Child mortality rate (per 1,000 live births) 14.3 13.7 18.4 Total fertility rate 1.5 1.6 Source: Institute for Population and Social Research, Mahidol University

Estimated Population of Thailand in the Next 20 Years (2033) Thailand Population Census Estimated Population of Thailand in the Next 20 Years (2033) 65,759,000    - Male 31,633,000    - Female 34,126,000 Source: Institute for Population and Social Research, Mahidol University; Estimated Population at Midyear 2013 (1st July)

Health statistics

Thailand Health Status Coverage of Health Insurance 99.46 % 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 IMR = Infant Mortality Rate MMR = Maternal Mortality Rate CMR = Child Mortality Rate 5

Aged Society Aged Society Elderly = 12.63% of Total Population Year 2553 Year 2554 Year 2555 Age Group count percentage Ages 0-14 12,672,935 19.89 12,496,939 19.47 12,241,023 19.05 Ages15-59 43,577,838 68.41 43,892,616 68.39 43,911,198 68.33 Ages 60 and Over 7,450,930 11.70 7,791,446 12.14 8,114,144 12.63 Total 63,701,703   64,181,001 64,266,365 Elderly = 12.63% of Total Population Source: Bureau of Policy and Strategy, Ministry of public health

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

Morbidity Disease Year 2011 Year 2012 Infectious disease 2007.28 2044.77 Non communicable diseases Circulatory diseases Accident Cancer 1881.01 712.36 700.91 467.74 1970.27 724.18 762.75 483.34 Rate per 100,000 populations Source: Bureau of Policy and Strategy, Ministry of public health

Mortality Disease 2007 2008 2009 2010 2011 Infectious disease 60.6 61.2 60.7 64.9 64.6 Non communicable diseases Circulatory diseases Accident Cancer 208.25 55.2 68.1 84.9 209.73 56.0 66.1 87.6 209.67 88.3 215.79 61.9 62.7 91.2 227.32 68.8 63.4 95.2 Rate per 100,000 populations Source: Bureau of Policy and Strategy, Ministry of public health

Mortality Rate per 100,000 populations Source: Bureau of Policy and Strategy, Ministry of public health

Major Causes of Death in Thailand, 1967-2009 Source: Thailand Health Profile 2008 - 2010

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

Evolution of health system in Thailand

Mandatory rural services Evolution of the Thai Health System CSMBS 1980 Health Card 1983 SSS 1990 UCS NHSO Low Income Scheme 1997 Constitution Economic crisis 1980s 1968 1975 2001 2007/08/09 1828 1888 1918 1942 1990s 1946 1978 1999 2006 King Rama 3 started the Western medicine Department of Public Health, MoI Mandatory rural services HFA/ PHC policy 1992 HSRI Local Health Funds HAI LGs EMIT MoPH Scaling up District Health System (DH + HC) Scaling up district health system = expansion of district hospitals to cover all districts and expend health centers to cover all Tambols. A decade of health center development was a ten year plan for upgrading capacity of health centers. 1992 A decade of health center development ThaiHealth Siriraj Hospital established First MoPH nursing college NHCO 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

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.

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

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.

Healthcare financing

General government Revenue and Expenditure 2003-2011 This slide shows general government revenue as compared with GDP and government expenditure as % of GDP. Percentage of government budgets spending on education, health care, and military Revenue is cash receipts from taxes, social contributions, and other revenues such as fines, fees, rent, and income from property or sales. Grants are also considered as revenue but are excluded here. Expense is cash payments for operating activities of the government in providing goods and services. It includes compensation of employees (such as wages and salaries), interest and subsidies, grants, social benefits, and other expenses such as rent and dividends. General government final consumption expenditure (formerly general government consumption) includes all government current expenditures for purchases of goods and services (including compensation of employees). It also includes most expenditures on national defense and security, but excludes government military expenditures that are part of government capital formation. Note: Revenue excluding grants, GGCE = general government consumption expenditure, GGE = General government expenditure Source: Thailand Data; http://data.worldbank.org/country/thailand

Total Health Expenditure 1994 - 2010: ↑ government spending, ↓ out-of-pocket payment, but maintain the level of spending to GDP UHC achieved There was rapid increase in total health expenditure prior to the 1997 economic crisis, 15-19% per annum. Total health expenditure was increased by 19% in 2002 according to the introduction of UCS. Average annual growth was around 8-10% since then and went up to 17% in 2008. Mark increase in the amount and proportion of government spending on health care was also observed in opposite to the declining of proportion of out-of-pocket spending. However, the level of spending in relation to the economy of the country was quite stable or just slightly increased, only 4% of GDP. Economic crisis Source: NHA 1994-2010

CSMBS expenditure, 1994 – 2012 rapid cost escalation in opposite to declining of beneficiaries Per capita expense ≈ 12,000/ year CSMBS expense on OP service increased sharply following the introduction of direct disbursement for OP services together with the Fee-for-service payment on OP services, average annual growth was 20 – 40% while expense on IP was much better controlled. Price control by DRG and limited available beds in public hospitals best explain the relatively well control of IP expenditure. From 2009 onward, there have been various intensive supply side interventions which decelerated the increase rate. 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

SSS expenditure 1994 – 2010 Per capita expense 2010 = 2,750 Baht 1404 1284 1250 1100 900 800 700 Increase in SSS expenditure was driven by two main factors, increase in the number of beneficiaries and increase in the capitation rate. xxx capitation Source: expenses from NHA 1994-2010 excluding expense on administration Number of beneficiaries at the end of each year from SSO

งบกองทุนหลักประกันสุขภาพแห่งชาติ ปีงบประมาณ เป้าหมายประชากรสิทธิ UC (ล้านคน) อัตราค่าเหมาจ่ายรายหัว (บาท/คน/ปี) งบเหมาจ่ายรายหัวรวมเงินเดือน (ล้านบาท) % เปลี่ยนแปลง ปี 2545 45.000 1,202.40 51,407.71 ปี 2546 46.000 56,091.23 9.1% ปี 2547 46.820 1,308.50 61,212.39 ปี 2548 47.000 1,396.30 67,582.60 10.4% ปี 2549 47.750 1,659.20 82,023.00 21.4% ปี 2550 46.066 1,899.69 91,369.05 11.4% ปี 2551 46.477 2,100.00 101,984.10 11.6% ปี 2552 47.026 2,202.00 108,065.09 6.0% ปี 2553 47.240 2,401.33 117,969.00 9.2% ปี 2554 47.997 2,546.48 129,280.89 9.6% ปี 2555 48.333 2,755.60 140,609.40 8.8% ปี 2556 48.445 141,539.75 0.7% ปี 2557 48.852 2,895.09 154,257.98 8.9% Mark increase in the per capita budget of UCS was observed in 2006-2008, increased by 19, 15, and 11% respectively and increased by 5-9% after that. Increase in the per capita budget of UCS came from two main factors, utilization rate and unit cost. The sharp increase in 2006 was partly due to the recognition of under financed of the scheme at the beginning. Increase in utilization and laobur cost best explained the increase in the later phase. Comparing ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

Number of use persons, OP visits, and IP admissions of UCS, 2003-2012 Approximately 78% of UCS beneficiaries (37 million persons) used benefits from the scheme. OP visits increased from 111.9 million visits in 2003 to 163.8 visits in 2012, this resulted in increase in utilization rate from 2.45 visits/ person/ year to 3.37 visits/person/year. IP admission increased from 4.3 million admissions in 2003 to 5.6 million admissions in 2012, this resulted in increase in utilization rate from 0.94 to 1.15 admissions/person/year 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

รายงานสรุปจำนวนการใช้บริการ OP ปี 2553 – 2555 สิทธิ UC จำนวนคน จำนวน Visit 2553 27,098,157 144,809,385 2554 29,671,976 166,184,132 2555 32,352,507 167,790,950 Mark increase in the per capita budget of UCS was observed in 2006-2008, increased by 19, 15, and 11% respectively and increased by 5-9% after that. Increase in the per capita budget of UCS came from two main factors, utilization rate and unit cost. The sharp increase in 2006 was partly due to the recognition of under financed of the scheme at the beginning. Increase in utilization and laobur cost best explained the increase in the later phase. Comparing ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

รายงานสรุปจำนวนการใช้บริการ OP ปี 2555 UC Accumulative patient count Visit count group Visit count Patient count Accumulative patient count 1 - 3 1 10,123,016 2 5,618,033 15,741,049 3 3,615,457 19,356,506 4 - 6 4 2,634,825 21,991,331 5 2,037,527 24,028,858 6 1,620,063 25,648,921 7 - 9 7 1,293,477 26,942,398 8 1,047,112 27,989,510 9 846,614 28,836,124 10 - 12 10 688,628 29,524,752 11 561,665 30,086,417 12 455,115 30,541,532 13 ขึ้นไป 2,140,938 32,682,470 Mark increase in the per capita budget of UCS was observed in 2006-2008, increased by 19, 15, and 11% respectively and increased by 5-9% after that. Increase in the per capita budget of UCS came from two main factors, utilization rate and unit cost. The sharp increase in 2006 was partly due to the recognition of under financed of the scheme at the beginning. Increase in utilization and laobur cost best explained the increase in the later phase. Comparing ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

รายงานสรุปจำนวนการใช้บริการ OP ปี 2555 UC Accumulative patient count Visit count group Visit count Patient count Accumulative patient count 13 – 15 13 369,525 30,911,057 14 297,834 31,208,891 15 241,517 31,450,408 16 – 18 16 196,252 31,646660 17 160,178 31,806,838 18 131,145 31,937,983 19 – 21 19 108,554 32,046,537 20 89,594 32,136,131 21 73,962 32,210,093 22 – 24 22 61,340 32,271,433 23 51,668 32,323,101 24 43,466 32,366,567 25 ขึ้นไป 315,903 32,682,470 Mark increase in the per capita budget of UCS was observed in 2006-2008, increased by 19, 15, and 11% respectively and increased by 5-9% after that. Increase in the per capita budget of UCS came from two main factors, utilization rate and unit cost. The sharp increase in 2006 was partly due to the recognition of under financed of the scheme at the beginning. Increase in utilization and laobur cost best explained the increase in the later phase. Comparing ที่มา : สำนักงานหลักประกันสุขภาพแห่งชาติ

Increase in cost of MoPH hospitals, 2009-2011 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

Traffic Accident Insurance Losses incurred varied from 40-50% of collected revenues Source: Office of Insurance Commission http://www.oic.or.th/en/home/index.php

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

Other public hospitals 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 Health service delivery system in Thailand is a public-private mix. MoPH facilities are backbone of the Thai health care system, they are organized as a multi-level system. At the grass root level, there are health centers, and there are district hospital at the district level, provincial and regional hospital at the provincial level; moreover, there are specialized hospitals providing tertiary care. Health facilities of other public agencies are not organized in a systematic way and have specific purpose, i.e military, interior, education, etc. Many municipalities have medical health centers locating in town area. Private facilities include private clinics, pharmacies, and private hospitals, they are usually located in big cities and urban settings. Source: 1. Thailand Health Profile 2008-2010 2. Bureau of Policy and Strategy, MoPH, http://hrm.moph.go.th/res53/res-rep2553.html

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 Source: Bureau of Policy and Strategy, Bureau of Sanatorium and Art of Healing, Food And Drug Administration; Ministry of public health

Health Facilities in the Public Sector (2010) Administrative Level Health 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 Source : Bureau of Health Administration; Ministry of public health

Human resources

Population to provider ratios, 1979 - 2009 Source: Thailand Health Profile 2008 - 2010

Disparities of population/healthcare provider ratios for Bangkok and the Northeast, 2001 - 2009 There was mark reduction in the disparities of population to health care provider ratios for Bangkok and the Northeast during 2001-2009 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 Source: Thailand Health Profile 2008 - 2010

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

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) 40

Pharmaceutical industry

Pharmaceutical industry in Thailand During the period 1992 - 2006, 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 2010 Source: Drug Control Bureau, Food and Drug Administration, MoPH

Use of drugs outside national ED list in 31 hospitals 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 Expense on drugs accounted for 83% of total OP expenses. 34 big hospitals shared 35% of total OP visits of CSMBS members but shared 60% of the reimbursements. Prescribing of drugs outside the national essential drug list and original products was major cause of the high expense among these hospitals. Reimbursements of NED drugs accounted for 50-80% of total reimbursements among these hospitals.

Antimicrobial drug resistance (1) Antibiotic use, low / middle income countries OP penicillin use and resistance 1990-2000 Source: Werner C. (2004) 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) Source: report of workshop on antimicrobial drug resistance, Bangkok, 6-10 August 2012

Role of Government Pharmaceutical organization (GPO) 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

Time line of Health Sector Reform

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

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

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

Challenges for further reforms 1 Burden Of Disease and old aged dependency challenges Governance of the health system Role of MoPH and other partners and their relationship Government fiscal space and long term financial sustainability Harmonization of the three main schemes 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 2 3 4 5

การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่งตามช่วงวัย ช่วงอายุ 0 – 5 ปี เด็กเกิดจากมารดาซึ่งมี ANC ครบถ้วนในช่วงระยะเวลาที่เหมาะสม และคลอดในห้องคลอด เด็กได้รับน้ำนมมารดาและอาหารเสริมในระยะเวลาที่เหมาะสม เด็กได้รับวัคซีนที่จำเป็นต่างๆครบถ้วน การได้รับการรักษาทางการแพทย์ที่พอเพียง เด็กได้รับการเตรียมตัวสำหรับการพัฒนาในช่วงวัยต่อไปอย่างเหมาะสมผ่านศูนย์ดูแลเด็กเล็กและโรงเรียนอนุบาล

การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่งตามช่วงวัย ช่วงอายุ 6 – 19 ปี การบริการทางการแพทย์ที่พอเพียง เด็กและเยาวชนได้รับวัคซีนที่จำเป็น และวัคซีนกระตุ้นครบถ้วน เด็กและเยาวชนได้รับการพัฒนาทักษะเพื่อการเข้าสู่ช่วงวัยทำงานต่อไปอย่างเหมาะสมกับสถานการณ์และปัญหาด้านสาธารณสุข เช่น ยาเสพติด สุรา บุหรี่ การตั้งครรภ์ไม่พร้อม โรคติดต่อทางเพศสัมพันธ์ รวมทั้ง HIV/AIDS ปัญหาอุบัติเหตุ ปัญหาทางการโภชนาการ โดยเฉพาะ โรคอ้วน การออกกำลังกาย ปัญหาการติดการพนันและเกมส์ การมี E.Q. ที่เหมาะสม ความรับผิดชอบต่อสังคม

การดูแลและพัฒนาคุณภาพชีวิตของประชาชนที่แบ่งตามช่วงวัย ช่วงอายุ 20 – 59 ปี ได้รับการดูแลส่งเสริมสุขภาพและการคัดกรอง โดยมีการกระตุ้นเตือนให้ความรู้ผ่านช่องทางต่างๆอย่างเหมาะสม ได้รับบริการด้านสุขภาพที่พอเพียงในกรณีที่เจ็บป่วย ได้รับการเตรียมตัวที่จะเข้าสู่ช่วงอายุวัยชราต่อไป ช่วงอายุ > 60 ปี ได้รับการซ่อมแซมสุขภาพในกรณีที่จำเป็น ได้รับการส่งเสริมให้มีสุขภาพที่แข็งแรงจนถึงช่วงสุดท้ายของวัย ได้รับการดูแลจากลูกหลานและชุมชนอย่างอบอุ่น

Reform direction

Reform direction Restructuring health sector Separation regulatory role and service provision role in the MoPH Strengthening 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

Reform direction Regional health service commissioning 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

Reform direction Financing reform 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

Reform direction Harmonization of current health insurance schemes National Clearing House National Information center Harmonization of benefit package and payment system Accident and Emergency services Anti-Retro Viral Therapy Cancer

National Health Authority โครงสร้างการทำงานระบบสาธารณสุขประเทศไทย National Health Authority Regulator Provider Purchaser Supplement / Agent สปสช. สวรส. สช. สพฉ.

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

Health services use by non-Thais 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

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

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

Inspiration

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

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

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

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

ระยะทางจากโลกถึงดวงจันทร์ 1/4 ล้าน ไมล์ ระยะทาง 3 กม. แรก ใช้พลังงานไป 50 % ของทั้งหมด

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

Thank you