International Health Policy Program -Thailand 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 of National Health Planning Bali, Indonesia 4-6 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 10 th NHP operating from 2007 to 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/ yearKey features of NHPAchievements of the NHP 1 st Plan ( ) Expansion of health infrastructure coverage, particularly provincial hospitals and health centers Provincial hospitals in all provinces 2 nd Plan ( ) 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 3 rd Plan ( ) 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 th Plan ( ) The policy on Health for All by 2000 was adopted using PHC strategies, National EPI Program launched in 1977 Basic immunization programme began in gradually and consistently scaled up, Village health volunteers (VHV) was launched in response to community participation principles of PHC 5 th Plan ( ) 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/ yearKey features of NHPAchievements of the NHP 6 th Plan ( ) 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 7 th Plan ( ) 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% 8 th Plan ( ) 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, 9 th Plan ( ) 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. 10 th Plan ( ) 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.

Informal user fee exemption User fees 1-3 rd NHP Provincial hospitals Health Infrastructure extension--wide geographical coverage Evolution of achieving universal coverage in Thailand: Infrastructure development + financial protection extension 1975 LIC 1990 Establishment of prepaymentschemes 1983 CBHI 1980 CSMBS 1990 SSS UniversalCoverage CSMBS 2002 full achieve Universal Coverage SSS LIC  MWS 1994 Pub VHI CSMBS SSS Expansion consolidationof prepayment schemes 4 th -5 th NHP ( ) District hospitals Health centers

Immunization coverage and prevalence of vaccine preventable disease

Child mortality in Thailand from various sources of surveys, Source: Hill et al. Int J Epidemiol 2007 (with updates)

Incidence of catastrophic health expenditure in Thailand Source: Analysis from the SES , NSO

The distribution of government subsidies for health: Benefit incidence analysis,

Distribution of health infrastructure and human resources for health in Thailand Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 Nurses ,156 1,157 – 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 10 th 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 /strengthening A general framework Data sources Indicator domains Analysis & synthesis Communication & use Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Population-based surveys Coverage, health status, equity, risk protection, responsiveness Clinical reporting systems Service 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 Financing Infrastructure / ICT Health workforce Supply chain Information Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Governance Inputs & processesOutputsOutcomesImpact

Evidence-based national health planning in Thailand (1) InputOutputOutcomeImpact HCFHR H Infra struct ure Gov er nan ce Med/ Healt h tech HISacc ess qual ity safe ty effic ienc y Interve n coverag e Risk factor s H outco me Re sp on siv e Equit y Finan prote ct ion 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) InputOutputOutcomeImpact HC F HRHInfra structu re Gove r nanc e Med/ Health tech HISacc ess quali ty safet y effici ency Interven coverage Risk factors H outco me Res pon sive EquityFinan protect ion Facility-based report H resource survey HIS electronic IP database Dis surveillance Behavioral H survey Sero-sentinel Survey Specific dis registration Quality assurance (HA)

International Health Policy Program -Thailand Health Information System Networking in Thailand MOPH Thai Health Promotion Foundation Health System Research Institute (HSRI) Health Information System Development Plan and Networking NHSO NESDB Civil societies NGOs Professionals NSO Academics Data owners Steering committee Management office

International Health Policy Program -Thailand M&E of the 10th NHP Despite M&E activities were clearly stated in the 10 th 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 10 th NHP. Poor participation from the policy-makers in the policy formulation process tends to be the key factor.

International Health Policy Program -Thailand 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 10 th 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 10 th NHP.

International Health Policy Program -Thailand 19 Thank you for your attention