1. International Health Policy Program -Thailand Reviews of the Thai health care systems and knowledge gaps for health system research Phusit Prakongsai Somsak Chunharas International Health Policy Program (IHPP) Thai National Health Foundation (TNHF) Presentation to the meeting on Health System Research Collaboration Pan Pacific Hotel, Bangkok 10 July 2009

2. International Health Policy Program -Thailand What are we trying to do? Build up (institutionalize) groups of researchers doing “health (services) system research” in Thailand Ensure continuous funding for research in areas of high priority Build network of researchers, users and funders Many groups already exist and work with certain degree of coordination and support => addressing high priority issues, linking to policy and decision making, involving the public, ensuring continuous funding and capacity building 2

3. International Health Policy Program -Thailand What are we talking about today? Health system research vs health services research? Health services “system” (design and organization/governance) vs health services/care (delivery). Health services system components (6 components as proposed by WHO) Implications (utilization of research results) – Policy development (financing, governance, HRH, technology, HIS) – Health services delivery practices (model, technology use, – Health services management ( HR management, IT management) 3

4. International Health Policy Program -Thailand Outline of presentation The past decades of health system development and current context – The extension of social protection – Burden of disease (BOD) in 1999 and 2004 – Economic crisis and pandemic of new emerging diseases Health system building blocks framework – Health service delivery – Health workforce – Health information system – Medical products & technologies – Health care financing – Equity and efficiency Conclusions on knowledge gaps of health system research

5. International Health Policy Program -Thailand Health system development and the extension of social protection Almost three decades of the long march through piecemeal social protection extensions: – 1975 Low income scheme  1990s social welfare + elderly, children <12, disabled – tax financed supply side subsidies. – 1980 CSMBS for public sector employee + dependants—tax financed non-contributory – 1983 CBHI  1994 voluntary public subsidies insurance, 50/50 – 1991 SHI for private employee—pay roll tax financed tripartite, capitation contract model – By 2001, 30% of 60m population still uninsured – By April 2002, fully achieved universal coverage All residual population--non-SHI and non-CSMBS were covered 5

6. 1945 2000 2002 Informal user fee exemption 1980 1970 User fees 1-3 rd NHP 1962-76 Provincial hospitals Health Infrastructure extension--wide geographical coverage Historical evolution: 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 (1977-86) District hospitals Health centers

7. International Health Policy Program -Thailand Current context Good news: – Achieving universal coverage with improved financial risk protection and health equity, – Achieving all MDG targets, – Establishment of a number of autonomous organizations regarding health sector reform: HSRI, NHSO, THPF, NHCO, HISRO, HITAP, etc. Bad news: – Economic crisis and decrease in GDP of the country, – Political instability, – The pandemic of new emerging infectious diseases e.g. SARS, H5N1, H1N1, – Unsuccessful containment of tuberculosis, – Poor governance of the health sector as well as other sectors, Lack of leadership since UC reform, MOPH leaders strongly resist to reform, totally loss financial command to NHSO Lack of strong units in PS Office/ Departments to generate evidence Lack of vision and no systematic training of new cadres of qualified managers in long term

8. % of Total 52.6 42.8 Top ten DALY loss among Thais in 2004 Note – The number of total DALY loss increased from 9.5 million DALY loss in 1999 to 9.9 million DALY loss in 2004 Source: Thai BOD Study 2004

9. Year of DALY loss of Thais in 1999 and 2004 by risk factor

10. Profile of DALY loss, Thailand 2004

11. Prevalence of smoking by educational level, 2001-2006

12. Prevalence of smoking by income quintile, 2001-2006

13. Prevalence of drinking alcohol by educational level 2001-2006

14. Prevalence of drinking alcohol by income quintile, 2001-2006

15. International Health Policy Program -Thailand System building blocks of a health system: its aims and desirable attributes Source: WHO. Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007, Geneva, World Health Organization.

16. Health service delivery: Better coverage of essential vaccines, ARV and condom use Compulsory licensing Include ART in UC package Generic production of triple ART Percentage of female sex worker consistently use condom when having sex with general client in the past 1 month, 1995 – 2007

17. Current situation and challenges of human resources for health in Thailand Thailand Source: World Development Indicator 2002 and World Health Report 2006

18. Inequity in geographical distribution of Health workforce in 2007 Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 Pharmacists 4,600-8,432 8,433-12,274 12,275-16,115 16,116-19,956 Nurses 280 - 652 653 - 904 905 - 1,156 1,157 – 1,408 Dentists 5,500-15,143 15,144-25,767 25,768-36,390 36,391-47,011

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

20. International Health Policy Program -Thailand Comparison between broad causes of death from vital registration (VR) and verbal autopsy (VA)

21. Health care finance and service provision of Thailand after achieving universal coverage (UC) General tax General tax Standard Benefit package Tripartite contributions Payroll taxes Risk related contributions Capitation Capitation & global Co-payment budget with DRG for IP Services Fee for services Fee for services - OP Population Patients Ministry of Finance - CSMBS (6 million beneficiaries) National Health Insurance Office The UC scheme (47 millions of pop.) Social Security Office - SSS (9 millions of formal employees) Voluntary private insurance Public & Private Contractor networks

22. International Health Policy Program -Thailand Scheme beneficiaries by income quintiles, 2004

23. The incidence of catastrophic health payments from 2000 to 2007 20002002200420062007 Q1 (poorest) 4.0%1.7%1.6%0.9%1.9% Q5 (richest) 5.6%5.0%4.3%3.3%2.8% All quintiles5.4%3.3%2.8%2.0%2.2% Note: Catastrophic health expenditure refers to household out-of-pocket payments for health exceed 10% of household consumption expenditure

24. Total health expenditure 1994-2005 Total health expenditure during 2003-2005 ranged from 3.49 to 3.55% of GDP, THE per capita approx 100 USD

25. International Health Policy Program -Thailand Real term growth GDP versus THE, 1994-2005 25

26. Trend of financing sources NHA 1994-2005

27. International Health Policy Program -Thailand Health care expenditure in Thailand by function in 2001 and 2005

28. International Health Policy Program -Thailand Household OOP for health, % income 1992-2004

29. Household consumption: tobacco, alcohol and health Median household expenditure per month Sources: Analyses from 2006 SES

30. The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities 2001 2003 Concentration index Type of health facilities20012003 Health centers - 0.2944- 0.3650 Community hospitals- 0.2698- 0.3200 Provincial and regional hospitals- 0.0366- 0.0802 Private hospitals0.43130.3484 Source: Prakongsai P et al. Assessing the impact of a policy on universal coverage on financial risk protection, health care finance, and benefit incidence of the Thai health care system. Presentation to the 6th IHEA World Congress, July 2007, Copenhagen

31. International Health Policy Program -Thailand Equity in utilization: Concentration Index OP service by levels: 2001 to 2007 Facility levels200120032004200520062007 Health centers-0.294-0.365 -0.345-0.380-0.267-0.292 District hospitals-0.270-0.320 -0.285-0.300-0.256-0.246 Provincial and regional hospitals-0.037-0.080 -0.119-0.1000.0280.013 Private hospitals0.4310.348 0.3890.3720.5160.528 Overall-0.090-0.139 -0.163-0.177-0.054-0.041 31 Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).

32. International Health Policy Program -Thailand Equity in utilization: Concentration Index IP service by levels: 2001 to 2007 Types of health facilities200120032004200520062007 Community hospitals-0.316-0.293 -0.294-0.266-0.242-0.293 Provincial and regional hospitals -0.069-0.138 -0.114-0.156-0.049-0.114 Private hospitals0.3200.309 0.2540.3660.3980.464 Overall-0.079-0.121-0.127-0.114-0.051-0.080 32

33. International Health Policy Program -Thailand Equity in budget subsidies: BIA, 2001 and 2003 Note: -Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were 80,678 million Baht (in 2001-value) - The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123

34. International Health Policy Program -Thailand Kakwani index of health care finance from 2000 to 2006 2000200220042006 Out of Pocket-0.1502-0.0755-0.0764-0.0450 Direct tax0.39130.41590.44240.3617 Indirect tax-0.0964-0.0691-0.0435-0.0831 Premium Insurance-0.3623-0.3906-0.3233na Social health Insurance Contribution0.16500.11210.1046na Premium Insurance+SHI Contributionna -0.0491 34

35. RR = 2.8 (95% CI 2.5-3.0) RR = 1.8 (95% CI 1.6-2.0) 55% (39%-68%) reduction Error bars are 95% CIs Equity in health: Child mortality by economic status Source: Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez AD, Lim SS. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369:850-855

36. Inefficiency of the Thai health care system: CSBMS expenditure from 1989 to 2008, current year price Note: Expenditure for 2008 is extrapolated from 6 months actual spending Source: Ministry of Finance, Comptroller Generals Department, various years

37. Inequity in quality and patterns of health service provision: Percentage of caesarian section to total deliveries by health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

38. Inequity in quality and patterns of health service provision: Propensity of receiving single source antiplatelets clopidogrel, cilostazol: 6 regional hospitals

39. International Health Policy Program -Thailand Discussion – Key concerns in HSD (1) An increasing disease burden from chronic NCD and the situation of aging society, => what needs to be changed wrt financing model and service delivery model/practices? (F, D) Inequitable health risk distribution among different SE groups, => alternative model for financing, resource allocation and service purchasing (F) Inefficiency and inequitable access to good quality of health services among beneficiaries of different health insurance schemes, => should we have a single system with multiple fund manager? How else could be improve inefficiency, inequitable access and quality/safety? (G, D) Poor governance of health systems in Thailand, => what roles and functions and relationship should be like between 4 major organizations in health system (MOPH, NHSO, NHCO, HPF) (G) 39

40. International Health Policy Program -Thailand Discussion – Key concerns in HSD (2) The unknown impact of current economic crisis on health of the population (F, G, D) The internationalization of health care seeking => should Thailand develop itself as medical hub for international patients? (G, F, HRH) The pandemic of new emerging infectious disease and unsuccessful control of tuberculosis and HIV/AIDS, => does it have to do with financing model, HRH quantity and quality, or management capacity? (D, G, HRH) Maldistribution and internal brain drain of HRH. => what policy options should be adopted, separating HRH payment from service purchasing package? (HRH) Complex and inefficient HIS (multiple purchasers and MOPH line of command) => standardization will help? What else should be done? Humanware? (HIS) Access to & more efficient use of (new) technology => CL and R&D investment for local production of health tech, and R&D for national health priority? (Technology) => the future role of HiTap? (G) how to influence cost-effective use of technology (D) 40

41. International Health Policy Program -Thailand Potential areas for research collaboration between Thai partners and AHSPR (1) Effective health and non-health interventions towards NCD which is an increasing BOD in Thailand and many developing countries, – Policy recommendations for the Thai government through the 10 th national Development Plan, Reorientation of public resources towards health promotion and disease prevention of disease burden priorities e.g. – HIV/AIDS, – road traffic injuries, – Obesity / overweight and inadequate activity and exercise, – tobacco and alcohol consumption, Social determinants of health (SDH)

42. International Health Policy Program -Thailand Potential areas for research collaboration between Thai partners and AHSPR (2) Improving equitable quality and patterns of health service provision among beneficiaries of different health insurance schemes  provider payment reform, Harmonization of benefit package and provider payment methods among three public health insurance schemes, Effective health interventions to tackle mal-distribution and internal brain drain of HRH, Economic impact on health of the population, Sustainability of health care finance in Thailand, Improving efficiency and rational drug use of the Thai health care system, Improving health information system in Thailand, Enhancing regulatory capacity and governance of the Thai health care system.

43. International Health Policy Program -Thailand Your ideas/suggestion Which area/issues are of high priority? How should we go about doing it? – Potential researchers – Needs for new capacity in research – Funding for research – Institutional backup => what should be the role of IHPP, HFRO,HISO, HRO, CHEM, other faculties in universities? International collaboration – Research conduct (technical collaboration) – Capacity building – Research funding – how should we go about? 43

44. International Health Policy Program -Thailand Thank you for your attention