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
Good morning everyone. First of all, I would like to thank the CAP UHC program for inviting me to share Thai experiences in the pre-requisite of health system components prior to achieving UHC.

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 , Geneva, World Health Organization.

3. Reduction of U5MR and MMR in Thailand, 1960-2008
If we look at the progress of reduction in under five and maternal mortality in Thailand, there are considerable achievements from 1960 until present. Under five mortality reduced from almost 100 per 1000 live births in 1970 to around 10 per 1000 live births in 2008, and maternal mortality reduced from 421 per 100,000 live births in 1960 to less than 40 per 100,000 live births in 2009.
Achieving UHC 3
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 protection GNI per capita,
The historical milestone is described against the economic capacity of the country measured in term of Gross National Income per capita between 1970 and 2009
Our experiences showed that even we were low income country, in 1975 we introduced low income scheme when the GNI per capita was 390 US Dollar. Community based health insurance scheme was introduced in 1983 when GNI was 760 US dollar,
Thailand had proved that universal coverage can be achieved despite the GNI per capita of less than 2000 US Dollar. While the USA whose income was 13 times richer than Thailand, they still cannot reach UC. I would say, reaching UC is the real political and financial commitment

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)
A brief description on how far Thailand had achieved to date on the UC Cube.
By 2012 population coverage was 99% by 3 schemes, UC Scheme covers the largest population, 75% of total
Services by all 3 schemes were literally free,
Benefit package is comprehensive, range from the low cost such as outpatient services to high cost care such as chemotherapy, hemodialysis and open heart surgeries,
All services cover medicines,
This results in a very minimum level of catastrophic health expenditure and prevent non-poor people become poor from medical bills.
These achievements are outstanding.

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)
Since achieving UHC in 2002, a number of health interventions related to cardiovascular and heart disease have been provided by the UHC scheme. We included open heart surgery and PTCA for coronary heart disease patients into the UHC benefit package since 2002, RRT for ESRD patients in 2009, secondary prevention for diabetic and hypertensive patients in 2010, and recently heart transplantation in 2012.
Heart
transplantation
Commencement of the benefits
2002
2004
2009
2010
2012

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

10. UHC scheme payment Basic health care ARV drug Population/patient
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
Version
Refined
Diagnosis code
Procedure code
Groups
Implement 1 No
ICD-10 (WHO) 1992
ICD-9-CM 2000
511
Nov 1998 2
Feb 2001 3
5 levels
1,283
Oct 2003 4
ICD-10 (WHO) 2007
+ ICD-10-TM*
ICD-9-CM 2007
with extension
1,920
Oct 2007 5
ICD-10 (WHO)
2010
ICD-9-CM
HoNOS
Barthel index
DRG 2,450
TMHCC 54
SNAP 41
Expected
on Oct 2011
* Thai Modification for data entry only (not for new classification)

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

13. 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%
Evidence from national HH surveys and routine reporting system shows improved utilization both outpatient and inpatient services.
OP utilization rate increased from 2.4 visits per person per year in 2003 to 3.6 in 2011.
Also, hospitalization rate increased significantly from admissions per year to admissions per capita per year.
Another key evidence is on the unmet needs. When we applied OECD standard questionnaire in the panel HH surveys, the unmet needs of Thai people was low, 1.4% of OP and 0.4% of IP, which is similar to good performing OECD countries.
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,
This slide shows the increased access to expensive health interventions for heart disease patients which include open heart surgery, PTCA for IHD, and primary PCI for ST-elevated myocardial infarction. You can see the increasing number of patients access to these expensive cardiac interventions, especially poor people in the rural areas of Thailand.

15. Starting
special pay
When we assess the impact of special payment for injection of thrombolytic agent in ST-elevation myocardial infarction, we found a significant increase in the infusion rate of thrombolytic agent with reduction in case fatality rate of ST-elevation Myocardial infarction.
*54 = estimation from Aug – Jul Source : IP individual record , NHSO

16. Financial risk protection (1) Reducing incidence of catastrophic health spending OOP>10% total consumption expenditure
Since the benefit package of the UHC scheme is quite generous and comprehensive, data from national household surveys show that there was a significant reduction in households facing catastrophic health expenditure, particularly among poor households, when we define catastrophic health expenditure as HH out-of-pocket payments for health exceeding 10% of total household expenditure.
Source: Analysis of Socio-economic Survey (SES)

17. Financial risk protection (2) Protection Thai HH against health impoverishment
UHC achieved
From the analysis of national household surveys, it is clear that in 2009, seven years after we achieved UHC, the UHC policy protected almost 70,000 households from health impoverishment caused by medical care costs.
It is clear that the more high cost benefits we cover, the higher reduction of health impoverishment and equitable access to expensive health services. For example, universal access to open heart surgery and PTCA in 2002, and free services for Renal Replacement Therapy (RRT) for ESRD patients in 2006 have clearly further reduce the poverty and household catastrophic health spending.

18. UHC scheme improved equity in service use
Ambulatory care:
concentration index

19. 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 )
UHC achieved
Data from the National Health Accounts of Thailand show that after achieving UHC in 2002, the share of public financing for health increased from 56% in 2001 to 75% in Total health expenditure during which is shown as the line graph ranged from 3.49 to 4% of GDP, and THE per capita in 2010 was 194 USD. Health expenditure for UHC beneficiaries in 2010 was approximately 80 USD per capita.
Total health expenditure during 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.
We can say that one of the key contributing factors in achieving UHC is the long-term development of health system. The expansion of strong district health systems both infrastructure and health workforces during the past decades contribute significantly to the achievements of UHC policy in Thailand. 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. Education strategies: increase production and rural recruitment Source: Noree & Pagaiya, 2011
1965
1970
1975
1980
1985
1990
1995
2000
2005
External
brain drain
Rural
development HFA/PHC
Economic
boom
crisis
Ratio doctor density
Between Bangkok to
Northeastern region
recovery
1974
Rural doctor program
(Rural recruitment and
hometown placement)
1979
Medical education reform
(PHC base, rural training)
Collaborative Project to
increase production
of rural doctor /year
ODOD project
(one district one doctor)
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. Financial incentives Ratio doctor density Between Bangkok to
1965
1970
1975
1980
1985
1990
1995
2000
2005
External
brain drain
Rural
development HFA/PHC
Economic
boom
crisis
Ratio doctor density
Between Bangkok to
Northeastern region
recovery
Hardship allowance
60-88 USD/mo
Non-private practice
allowance 250 USD/mo
1997
Increase Hardship allowance
Normal 55 USD/mo
Remote 250 USD/mo
Very remote 500 USD/mo
Special allowance
>3 yrs work USD/mo
Southern – 250 USD/mo

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)
The four decades of health infrastructure and health workforce development greatly contribute to distribution of good quality health services throughout the country. This includes the advent of district hospitals in 1977, mandatory public services of new graduated medical doctors in 1972, and first batch of two year technical nurses in 1982.
Source: Health Resource Surveys (various years)

25. Change in the use of primary health care
From reverse to upright triangle: PHC utilization
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)
1987
2000
46.1%
(51.8)
35.7%
(40.2)
18.2%
(20.4)
2010
54.0%
(78.0)
33.4%
(33.4)
12.6%
(18.1)
Evidence shows gradual improvement of utilization by level of care, reverse the dominant tertiary care to primary care. By 2010, 54% of OP services were provided by rural health centres, and one thirds by district hospitals.

26. The Decade of Health Center Development
Primary health care development - Thailand
Adopted
Health For All
Policy
The Decade of Health Center Development
( )
Starting Primary Care Services
Wat Boat
Project
Universal Coverage Policy
Health Centers
Community Health Volunteers
National Health Act
Economic
Crisis
Traditional
Medicine
1932
1964
1968
1975
1978
1981
1985
1992
1996
1997
1999
2001
2002
2007
1950
1966
1974
Rural Doctors Movement
Health Care Reform
Project
Thai Health Fund
Stating Rural Health Services
Sarapee
Project
BanPai
Expanded
Community
Hospitals
Decentralization
Health Card
Project
Primary Care Development
Tropical
Diseases
Control
Programs
Lampang Project
Samoeng Project
Nonetai Project
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 เป็นข้อมูล ณ ไตรมาส 2

28. Monitoring & Evaluation of health systems reform /strengthening
A general framework
Inputs & processes
Outputs
Outcomes
Impact
Improved
health outcomes
& equity
Social and financial risk protection
Responsiveness
Financing
Infrastructure / ICT
Health workforce
Supply chain
Information
Intervention
access & services readiness
quality, safety and efficiency
Coverage of interventions
Prevalence risk behaviours & factors
Governance
Indicator
domains
Data
sources
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
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 28 28

29. Data availability for M&E system in Thailand
Input
Output
Outcome
Impact
HCF
HRH
Infra structure
Gover
nance
Med/
Health tech
HIS
access
quality
safety
efficiency
Interven coverage
Risk factors H
outcome
Responsive
Equity
Finan protect
ion
Civil registration and vital statistics 
Biennial SES
Biennial HWS
Census / SPC
NHES
MICS
Reproductive H survey
NHA
From M&E framework, the reviews on existing reports and facility-based data in Thailand show that Thailand has a wide range of household survey data and routine information from many institutes and organizations to assess almost all areas of health system capacity and its performance, except governance and health system responsiveness. These data are conducted by different institutes and organizations in Thailand which require coordination and networking. These data are useful for assessment of health reform policies 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
In conclusion, it took us 25 years to achieve UHC based on a gradual and incremental movements. Our successes depend on the inter-connectedness of three important powers, the policy or political power, the social power and the power of wisdom. This concept has been called the strategy of ‘The triangle that moves the mountain’, and has been applied to solve many difficult social problems in Thailand.
Political commitment/ Policy linkages

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)