Transcript Slide 1

-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
Healthcare Financing in Thailand:
an update in 2007
Updated by
International Health Policy Program (IHPP)
Ministry of Public Health,
Thailand
1
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Outline presentation
I. Background information on burden of disease and health care
finance
IA. Burden of Disease in 2004 & national health expenditure,
1994 – 2005
IB. Healthcare financing performance
• Fairness in financial contribution – EQUITAP results
• Incidence of catastrophic and impoverishment from
OOPs
• Equity in utilization & benefit incidence analysis (BIA)
II. Ongoing major works
IIA. Universal offer of VCT
IIB. Major program review of cervical cancer control
IIC. Review of DCP2 and its application in chronic
diseases management
IID. Annual hospital report
III. Future challenges: Renal replacement therapy, financial
sustainability, and potential moral hazards, etc.
2
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IA. Background information:
BOD and financing healthcare
3
-Thailand
Profile: top 10 mortality, Thailand 2004
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Total deaths 390,285
Top 10 deaths share 63% of total national deaths
4
Profile: top 10 YLL,
Thailand 2004
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Total YLL 6.07 million years
Top 10 YLL shares 63 % of total national YLL
5
Profile: top 10 YLD,
Thailand 2004
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Total YLD 3.1 million years
Top 10 YLD shares 71% of total national YLD
6
Profile: top 10 DALY loss,
Thailand 2004
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Total DALY loss 9.17 million years
Top 10 DALY shares 52% of total national DALY loss
7
DALY loss by age group and gender,
-Thailand
Thailand 2004
DALY s Los t by age and s ex and dis as e categorie s , Thailand 2004
Disability Adjusted life Year Lost ('000s)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
1,600
Group III Injuries
1,400
Group II Non-communicable diseases
1,200
Group I Infections, maternal, perinatal and nutritional cond
1,000
800
600
400
200
0
0-4
5-14
15-29
30-44
45-59
Males
60-69 70-79
80+
0-4
5-14
15-29
30-44
45-59
60-69 70-79
80+
Females
8
DALYs per 1,000 population, ranked 22
categories
Other
Infectious diseases
Intentional injuries
Chronic respiratory diseases
Cardiovascular diseases
HIV/AIDS
Cancer
Mental disorders
Unintentional injuries
DALYs per 1,000 population
350
300
250
200
150
100
50
-
0-4
5-14
15-29
30-44
45-59
60-69
70-79
80+
males
DALYs per 1,000 population
700
Other
Chronic respiratory diseases
Unintentional injuries
Sense disorders
Diabetes
HIV/AIDS
Mental disorders
Cardiovascular diseases
Cancer
600
500
400
300
200
100
-
0-4
5-14
15-29
30-44
45-59
females
60-69
70-79
80+
Top 15 risk factors,
Burden of Risk Factors in Male, Thailand 2004
-Thailand
Malnutrition-Thai
Malnutrition-Inter
Non-Seatbelt
WSH
Physical Inactivity
Risk Factors
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
men Thailand 2004
*Air Pollution
Illicit Drugs
Fruit&Vegetable
Cholesterol
BMI
Blood pressure
Non-Helmet
Tobacco
Unsafe Sex
Alcohol
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
DALYs (x100,000)
10
Top 15 risk factors,
Burden of Risk Factors in Female, Thailand 2004
-Thailand
Non-Seatbelt
Malnutrition-Thai
Malnutrition-Inter
Illicit Drugs
WSH
Risk Factors
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
women, Thailand 2004
Alcohol
Fruit&Vegetable
*Air Pollution
Physical Inactivity
Tobacco
Non-Helmet
Cholesterol
Blood pressure
BMI
Unsafe Sex
0
0.5
1
1.5
2
2.5
3
3.5
4
DALYs (x100,000)
11
Total Health Expenditure,
Amount of THE and ratio of THE to GDP, current prices, 1994-2001
3.47%
3.49%
6.00%
3.84% 4.00%
170,000 3.52%
3.53%
3.40% 3.32%
3.74%
3.50%
4.00%
120,000
2.00%
THE% GDP
3.68% 3.55%
220,000
Mln.Baht
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
NHA 1994 – 2005
70,000
20,000
0.00%
1994
1995
1996
1997
1998
1999 2000
2001
2002
2003
2004
year
2005
investment
Operating health expenditures
Ratio of THE to GDP (%)
12
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Real term growth GDP versus THE, 1994-2005
20.0%
15.6%
15.6%
15.0%
10.0%
9.5%
8.3%
6.3%
4.6%
5.0%
3.6%
-0.1%
0.0%
1994
1995
1996
1997
1998
1999
-0.6%
2000
2001
2002
2003
2004
-5.0%
-10.0%
-11.4%
-15.0%
-13.4%
THE
GDP
13
THE, Baht per capita
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
NHA 1994-2005
current and constant price (2003)
4,500
3,669 3,793
4,000
3,500
3,000
2,947
3,208
3,323
3,233 3,335
1995 1996 1997
1998 1999 2000
3,609
3,881
2,867 2,855 2,819
2,500
2,000
1,500
1,000
500
0
1994
Current
2001 2002 2003
2004 2005
Constant
14
Trend of financing sources
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
NHA 1994-2005
million baht
250,000
200,000
150,000
53
100,000
50,000
55
45
46
37
45
45
44
37
36
36
44
53
47
47
54
55
55
56
56
63
63
64
64
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Government
NON Government
15
Trends of financing agents,
NHA1994-2005
50%
42.8%
44.5%
38.4%
41.7%
41.6%
33.4%
40%
39.2%
30%
20%
30.5%
27.6%
33.1%
33.3%
27.3%
26.4%
10%
0%
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Central Gov.-ส่วนกลาง
Local Gov.- ส่วนท้ องถิน่
CSMBS-สวัสดิการข้ าราชการ
Social security-ประกันสังคม
Household-ครัวเรื อน
Other-อืน่ ๆ
Expenditure by financing agent
NHA2005
ROW
0.2%
out of pocket
payment
27.6%
General
Government
exclude social
security
55.7%
all private
insurance
8.4%
Social security
8.0%
Expenditure by healthcare Function
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
NHA2005
Medical
Good, 10,573
Ancillary, 966
Capital, 9,721
IP, 89,024
Personal
Care, 204,383
Admin, 21,168
OP, 104,786
P&P, 11,842
P&P
Admin
Capital
Ancillary
Medical Good
IP
OP
19
CSMBS total expenditure and growth
1988-2006
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
40,000
0.3
28%
35,000
0.25
33,865
19%
19%
30,000
29,775
16%
25,000
0.2
26,857
13%
20,480
11%
20,000
8%
8%
14%
13%
23,743
19,351 18,932
8%
15,000
11%
18,589
17,907
17,498
21,623
0.1
10%
10%
6%
4%
14,671
0.15
0.05
13,563
11,390
10,000
0
8,229
8,921
7,268
5,000
5,816
-2%
6,270
million of employees/pensioners
-0.05
-5%
-
-0.1
Growth rate
real term
Norminal
Source: Comptroller General Department, Ministry of Finance (various years)
20
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IB. performance of UC scheme
21
-Thailand
Why general-tax-financed UC Scheme?
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
•
Contributory UC Scheme was not in the policy agenda during 2001 general
election,
–
–
–
•
Feasible to apply general tax, additional budget requirement was in fiscal capacity
Not feasible to collect premium
Urgency to nation-wide scale up immediately, political obligations to the constituency
Subsequent studies indicate the Concentration Index of various sources of
healthcare finance – Thailand 2002 (O’Donnell et al 2005)
CI
weight NHA
–
–
–
–
–
–
Direct tax
Indirect tax
Social insurance
Private insurance
Direct payments
Total Health Financing
0.9057
0.5776
0.5760
0.3995
0.4864
0.5929
–
General Tax
0.6996
0.1868
0.3155
0.0582
0.0668
0.3728
Note:
CI, an index of the distribution of payments, ranges (-1 to 1), a positive (negative) value indicates
the rich (poor) contributes a larger share than the poor (rich), a value of zero is everyone pays the
same irrespective of ability to pay
22
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Contribution of Social Health Insurance (SHI)
to UC Scheme system design
– SHI as a predecessor of UC
• Contract model contractual arrangement with competitive
public and private provider contractors
• Contract is feasible in the context of comprehensive
geographical coverage of MOPH healthcare infrastructure
• Closed-ended provider payment method
• Among a few developing countries, Thailand pioneers
capitation payment method
• Additional pay for A&E, high cost care, based on fee schedule
• Purchaser Provide split
• Social Security Office and National Health Security Office as
purchasers – design packages and payment methods
• MOPH, other public and private medical institutions as major
providers
• Comprehensive coverage
• Comprehensive service package, OP, IP, Prevention, Promotion
• Neither deductibles nor co payment at point of services, UC
scheme has nominal pay of US$ 0.75 per visit or admission
23
UC Scheme
SHI
-Thailand
Service
contractor
Primary Care Network.
Typical model: health
centres and District hospital,
as mostly rural population
100 bed-hospital or over,
as mostly urban
population
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
Advanced characteristics of the UC Scheme
Referral
Ensure better referral
No referral, covered
within the contractor
provider
Payment
method
Capitation for OP, Global
budget and case base
payment (DRG) for IP. This
is to prevent underadmission of inclusive
capitation
Capitation inclusive of OP
and IP
Dental,
maternity
Integrated into curative
package
Separate package:
maternity: flat rate
payment, dental: FFS and
ceiling. Higher admin cost
Coverage
All family members,
individual member card
issued (not a family card)
Employee, exclude nonworking spouse and child
dependants
24
Capitation rate and components
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Baht per capita, approved fig. 2002-2007, plan fig. 2008
OP
IP
P&P
A&E
High cost care
Pre-hospital care
Capital replacement
Adjusted remote areas
No fault liability
Rehabilitation
Quality improvement
compensation for
30Baht termination
Diseases management
Capitation Baht
USD
Exchange
% nominal change
2002
2003
2004
2005
2006
574
303
175
25
32
93
-
574
303
175
25
32
10
83
-
488
418
206
20
66
10
85
10
5
533
435
210
25
99
10
77
7
0
583
460
225
52
190
6
129
7
1
1,202
30
40.1
1,202
30
40.1
0%
1,309
33
39.7
9%
1,396
35
39.9
7%
1,659
41
40.5
19%
2007
646
514
248
51
210
10
143
30
0
4
20
24
1,900
54
35.0
14%
2008
(plan)
673
810
267
10
167
140
2
4
45
2,117
60
35.0
11%
25
Discrepancy: proposed & approved capitation rate
2,000
1,788
1,670
Baht per capita
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
FY2002-2006
1,500
1,447
1,202
1,512
1,202
1,901
1,659
1,396
1,309
1,000
500
2002
2003
Proposed
2004
2005
2006
Approved
IHPP calculates capitation rate based on actual utilization rate and unit
cost. Due to fiscal constraint, it results in discrepancy
26
Household health expenditure
as % of household income by income deciles
8.17
8
1992
7
1994
6
1996
4.82
2
2.23
1
2.93
2.38 2.52
2.22
1.77 1.75 1.62
1.4
1.37
7
ec
il e
6
D
ec
il e
5
D
ec
il e
4
D
3
ec
il e
D
ec
il e
2
D
ec
il e
1
D
ec
il e
D
1.64
2.36
2.06 1.97
1.68 1.55
1.32 1.35 1.57
1.15
0
Source: NSO SES (various years)
1.99
1.27
2002
2004
1.27
1.1
1.07
2006
10
3.32 3.16
3.29
2.78
2000
2.45
9
3.67
2.57
ec
il e
3
2.87
D
4.58
ec
il e
4.58
8
4
1998
3.74 3.65
D
5.46
ec
il e
5
D
Health payment : Income (%)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
prior to UC (1992-2000) and after UC 2002-2006
27
Distribution of households with health
expenditures > 10% total consumption
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
by consumption expenditure quintiles
20.5%
30.3%
31.1%
33.1%
20.5%
Quintile 5
Quintile 4
24.6%
21.1%
21.9%
19.8%
Quintile 3
21.9%
19.6%
16.9%
17.1%
19.2%
24.5%
13.0%
14.8%
10.2%
11.2%
8.9%
2000
2002
2004
2006
Source: NSO’s SES (various years)
Quintile 2
Quintile 1
28
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Catastrophic health payments in Thailand,
1996-2002
1996
1998
2000
2002
0 to 0.5%
31.9
33.2
34.5
41.2
0.5 to 10%
51.3
51.5
50.8
48.1
10 to 25%
11.9
10.9
11.0
7.6
25 to 50%
3.5
3.6
3.1
2.5
More than 50%
1.4
0.8
0.7
0.5
100.0
100.0
100.0
100.0
% non food
expenditure on health
Total
Source: National Statistic Office, Household Socio-economic
Survey, various years.
29
Pre-post UC incidence of catastrophic expenditure
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Households with health payment > 10% of total consumption expenditures
All households
LIC/VHC
UC–E/-P
4.0%
5.6%
5.4%
2.7%
7.1%
4.7%
1.7%
5.0%
3.3%
1.7%
6.1%
3.2%
1.6%
4.3%
2.8%
1.6%
5.2%
2.6%
0.9%
3.3%
2.0%
0.9%
3.0%
1.9%
Year 2000
Quintile 1
Quintile 5
All Quintiles
Year 2002
Quintile 1
Quintile 5
All Quintiles
Year 2004
Quintile 1
Quintile 5
All Quintiles
Year 2006
Quintile 1
Quintile 5
All Quintiles
Source: NSO’s SES (various years)
30
Impact of UC: Catastrophic illnesses, impoverishment
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Limwattananon et al 2005
– Dataset: NSO SES 2000 (24,747 households), 2002 (34,785) and
2004 (34,843).
– Finding
• The incidence of catastrophic health expenditure (>10% of
total HH consumption) reduced
• From 5.4% in pre-UC 2000
• to 3.3-2.0% in post-UC 2002-2006
• An increase in the poverty headcounts due to OOP payments
dropped
• From 2.1% in pre-UC
• to 0.8-0.5% in post-UC.
– Conclusions
• Reduction in the catastrophe and impoverishment due to OOP
health payments is evident after the UC reform which provides
comprehensive coverage of health care with a very small
nominal fee.
31
Healthcare Catastrophe vs. OOP Payments & Income
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
data as of 2000
Source: van Doorslaer et al. (2005)
32
Utilization by UC members
source: NSO HWS2001, 2003, 2004, 2005 and 2006
Health center
District hosp.
Other govt. hosp
Total
Annual changes
Health center
District hosp.
Other govt. hosp
Total
Ambulatory
2001 2003
36.8
32.1
24.2
27.1
26.2
10.9
87.2
70.1
-13%
12%
-58%
-20%
visits (million/yr)
2004 2005 2006
36.8
35.7
19.2
27.7
26.3
20.9
11.7
10.7
8.7
76.2
72.8
48.8
14%
2%
7%
9%
-3%
-5%
-8%
-4%
-46%
-21%
-19%
-33%
Hospital admissions (million/yr)
2001 2003 2004 2005 2006
1.0
1.7
2.8
2.0
1.4
3.4
2.0
1.7
3.7
1.9
1.6
3.6
1.8
1.7
3.5
96%
-20%
23%
0%
21%
8%
-5%
-4%
-4%
-7%
2%
-3%
Total Ambulatory Visits
(millions/yr)
(HWS 2001, 03, 04, 05, 06)
Million visits/yr
LIC/VHC & UC-E/-P
2.9
3.0
2.4
2.5
2.0
District hosp.
1.8
1.4
36.8
35.7
1.5
1.4
1.5
0.8
1.6
26.2
24.2
27.1
25
27.7
1.3
1.1
0.9
0.7
21.4
20
13.6
15
19.3
2003
2004
8.7
3.2
3.8
3.2
2.9
Private hosp.
0
2001
2003
2004
2005
2006
Million visits/yr
Private clinic
1.6
2005
Private hosp.
2006
CSMBS
10.7
10
5
0.6
0.3
Other gov. hosp.
11.7
0.7
0.3
2001
District hosp.
Other gov. hosp.
20.9
20.4
19.2
15.1
10.9
0.6
0.6
0.0
26.3
1.7
Private clinic
0.5
Health center
32.1
35
30
36.8
Health center
2.2
2.0
0.6
40
2.6
2.4
2.2
1.0
Million visits/yr
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
SSS
4.6
5.0
Health center
4.5
3.7
4.0
3.5
3.0
2.5
3.1
3.0
2.4
2.3
2.8
1.9
2.3
2.1
2.0
1.5
3.8
1.1
1.6
1.2
1.0
0.5
0.8
0.0
2001
District hosp.
Other gov. hosp.
1.4
0.9
3.4
3.1
0.6
0.7
0.7
2003
2004
2005
0.8
Private clinic
0.5
Private hosp.
2006
34
Average Ambulatory Visits
(per member/yr)
(HWS 2003, 04, 05, 06)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
1.13
0.38
1.09
1.12
0.91
0.36
Private hosp.
0.42
0.30
0.25
0.24
0.27
0.26
1.86
2.18
0.08
0.07
0.45
2.07
1.53
0.07
Private hosp.
0.41
0.31
0.24
0.23
0.58
0.56
0.23
0.56
0.06
0.18
0.77
0.11
0.09
0.09
0.08
0.13
0.04
2003
2004
2005
2006
Health center
1.80
2004
2005
UC-E/-P
1.98
1.93
0.11
0.11
0.51
0.47
0.11
0.37
2003
Other gov. hosp.
District hosp.
Health center
SSS
Other gov. hosp.
0.76
0.40
0.15
0.05
Private clinic
District hosp.
0.23
0.14
0.42
0.43
0.67
0.19
Private clinic
0.34
2006
1.67
0.09
Private hosp.
0.54
Private clinic
0.66
0.62
0.72
Other gov. hosp.
0.59
0.42
0.39
District hosp.
0.36
0.27
0.20
0.23
0.18
0.13
2003
2004
2005
2006
CSMBS
Health center
35
Insurance Use for OP Visit
(% compliance)
(HWS 2003, 04, 05, 06)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
SSS
100%
98.8%
94.2%
85.0%
94.1%
99.6%
94.0%
83.2%
90.0%
86.6%
81.9%
96.6%
80%
82.3%
UC-E/-P
60%
51.2%
98.1%
98.4%
80%
96.9%
99.8%
97.2%
97.6%
89.7%
82.5%
District hosp.
55.3%
Other gov. hosp.
58.5%
51.3%
40%
100%
50.5%
43.3%
Private clinic
20%
98.5%
Health center
97.3%
89.4%
83.1%
Health center
91.6%
Private hosp.
0%
District hosp.
2003
2004
2005
2006
60%
Other gov. hosp.
40%
31.5%
35.5%
CSMBS
31.1%
25.7%
Private clinic
20%
100%
1.9%
0.8%
0.9%
0.6%
0%
Private hosp.
80%
2003
2004
2005
100.0%
98.7%
99.1%
98.3%
99.4%
98.8%
97.5%
87.2%
89.6%
87.0%
90.1%
Health center
District hosp.
2006
60%
Other gov. hosp.
40%
35.0%
36.1%
32.5%
Private clinic
20%
7.5%
4.8%
5.6%
5.5%
0.4%
2004
2005
2006
Private hosp.
0%
2003
36
Total Hospital Admissions
(millions/yr)
(HWS 2001, 03, 04, 05, 06)
2.04
2.04
Million admissions/yr
LIC/VHC & UC-E/-P
1.94
1.81
2.0
0.3
0.20
0.2
0.20
District hosp.
0.17
Other gov. hosp.
0.17
0.19
0.15
0.2
0.17
0.12
0.1
0.12
0.1
0.03
0.08
0.12
0.09
0.08
0.07
0.02
0.00
District hosp.
0.01
0.01
2005
2006
Polyclinic
Private hosp.
0.0
1.5
1.74
1.04
1.68
1.62
1.65
2001
2003
2004
Other gov. hosp.
1.39
CSMBS
1.0
Polyclinic
0.5
0.35
0.37
0.33
0.34
0.03
0.02
0.03
0.03
0.15
0.0
2001
2003
2004
2005
2006
Private hosp.
Million admissions/yr
Million admissions/yr
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
SSS
0.5
0.43
0.40
0.44
0.4
District hosp.
0.4
0.29
0.29
0.3
Other gov. hosp.
0.3
0.20
0.17
0.2
0.14
0.2
0.1
0.08
0.07
0.1
0.10
0.07
0.12
Polyclinic
0.09
0.06
0.00
0.01
0.00
0.01
2003
2004
2005
2006
Private hosp.
0.0
2001
37
Average Hospital Admissions
(per member/yr)
(HWS 2001, 03, 04, 05, 06)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
0.06
0.06
0.07
0.06
0.07
Private hosp.
0.028
0.026
0.021
0.024
0.000
0.003
0.09
0.08
0.005
0.09
0.08
0.008
0.007
0.007
0.032
0.08
0.007
0.029
0.035
0.034
0.034
0.001
Polyclinic
0.027
Other gov. hosp.
0.002
0.030
0.024
District hosp.
0.014
0.012
0.010
0.012
2003
2004
2005
2006
0.006
Private hosp.
2001
0.052
0.021
0.024
SSS
Polyclinic
Other gov. hosp.
0.042
0.043
0.041
0.031
0.10
0.037
0.09
0.12
0.11
0.08
District hosp.
0.017
0.001
2001
2003
2004
2005
2006
LIC/VHS & UC-E/-P
0.001
0.014
0.013
0.000
0.013
Private hosp.
0.002
0.010
0.071
Polyclinic
0.068
0.075
0.016
2001
0.052
0.025
2003
0.050
District hosp.
0.033
0.026
0.021
2004
2005
2006
CSMBS
Other gov. hosp.
38
Insurance Use for IP admission (% compliance)
(HWS 2003, 04, 05, 06)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
SSS
140%
117.3%
120%
100%
UC-E/-P
78.6%
100.0%
67.9%
80%
District hosp.
112.3%
105.3%
100.7%
97.0%
91.5%
92.7%
92.8%
70.5%
71.5%
Other gov. hosp.
75.6%
60%
Polyclinic
58.7%
40%
100%
94.6%
92.4%
94.6%
41.8%
93.2%
District hosp.
80%
84.5%
84.9%
20%
0%
86.2%
79.3%
40%
20%
2004
13.3%
15.6%
16.0%
13.8%
9.0%
2003
13.2%
2004
2005
2006
2006
120%
102.2%
Private hosp.
96.0%
100%
8.9%
2005
CSMBS
Polyclinic
19.2%
0%
2003
Other gov. hosp.
60%
Private hosp.
80%
105.0%
101.1%
98.6%
District hosp.
109.8%
99.7%
97.8%
89.0%
63.7%
Other gov. hosp.
51.0%
70.5%
60%
Polyclinic
35.3%
40%
27.1%
20%
Private hosp.
0%
8.3%
0.0%
2003
2004
2005
2006
39
The distribution of ambulatory service use among different income
quintiles in 2001 and 2003, by types of health facilities
6
Ambulatory visits per cap per year
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Distribution of ambulatory services at different health facilities between
the 2001 and 2003 HWS
5
0.7
4
3
0.4
2001
0.6
1.8
0.3
0.4
0.4
0.7
2
0.6
0.7
0.6
1
1.2
Q1
0.6
0.4
1.3
0.7
0.5
0.4
0.7
0.6
1.0
0.7
0.2
0.5
0.6
0.2
0.1
Q2
Q3
Q4
Q5
0
2003
0.7
0.3
0.4
0.9
1.9
0.7
0.6
0.7
0.6
0.3
0.3
0.2
Q3
Q4
Q5
1.3
Q1
Q2
Income quintiles
Health centre
Community hospital
Provincial and regional hospital
Private clinic
Private hospital
Concentration indices of ambulatory service use among different types of health facilities in 2001 & 2003
Type of health facilities
2001
2003
Health centers
- 0.2944
- 0.3650
Community hospitals
- 0.2698
- 0.3200
Provincial and regional hospitals
- 0.0366
- 0.0802
Private hospitals
0.4313
0.3484
40
Selected concentration curves of ambulatory service use among
different types of health facilities in 2003
Distribution of hospitalization among different types of health facilities
between the 2001 and 2003 HWS
0.25
Admission per cap per year
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
The distribution of hospitalization among different socio-economic groups
in 2001 and 2003, by types of health facilities
0.03
0.2
0.01
0.02
0.05
0.15
2001
0.05
0.01
0.01
0.02
0
prov / reg
hospitals
Q4
Q3
Q2
0.01
0.02
Q1
0.02
0.03
0.05
0.04
district hospitals
0.05
0.05
0.03
2003
0.03
0.05
0.1
Q5
0.06
0.01
0.01
0.01
0.01
0.03
0.02
0.01
0.01
0.00
0.01
0.02
private hospitals district hospitals
prov / reg
hospitals
private hospitals
Types of health facilities
Concentration indices of hospitalization among different types of health facilities in 2001 & 2003
Types of health facilities
2001
2003
Community hospitals
- 0.3157
- 0.2934
Provincial and regional hospitals
- 0.0691
- 0.1375
Private hospitals
0.3199
0.3094
Overall hospitalization
- 0.0794
- 0.1208
42
Selected concentration curves of hospitalization among different
types of health facilities in 2003
Who benefits from public subsidies
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Limwattananon et al 2005
• Benefit Incidence Analysis: compare pre-UC 2001 and post-UC
2004 using NSO HWS2001, 2004
– OP care
• Post UC 2004, the pro-poor subsidy was very pronounced at District
Health System (DHS)
• Concentration Index = - 0.3326 and - 0.2921 for Health Centre
and District Hospital respectively.
• Less progressive at provincial hospitals (PH)
• CI = - 0.1496.
– IP care
• More progressive in favour of the poor at DH
• CI = - 0.3130 in 2001 and - 0.2666 in 2004.
• Weaker progressive in favour of the poor at PH
• CI = - 0.1104 in 2001 and - 0.1221 in 2004
– Conclusions
• The pro-poor subsidy were strongest for DHS.
• Lessons indicates DHS plays key role in fostering the pro-poor nature of
public subsidy.
• Close to client services, better accessed
44
A comparison of percent distribution of net government health subsidies among different
income quintiles in 2001 and 2003
35
30
31
28
25
22
20
percent
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Percent distribution of net government health subsidies among
different income quintiles in 2001 and 2003
20
17
17
15
15
16
18
15
2001
2003
10
5
0
Q1
Q2
Q3
Q4
Q5
Income quintile
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
45
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Concluding remarks 1
•
Enabling factors for achieving UC
– Strong political supports
– Health systems capacity and its resilience to rapid nation-wide
program scale-up in 6 months
– Lessons from predecessors
• SHI capitation contract model
• CSMBS “no go” fee for service, due to cost escalation and inefficiencies
• Voluntary Health Card Scheme – adverse selection and non-viable
financially
– Linking evidence to policy decision
• Integral relationship among researchers – reformists – politicians
– Pragmatism
• Limited chance to achieve UC by contributory scheme, especially among
informal sector, not feasible for contribution collection and enforcement
•
Learning from SHI, UC takes further advanced steps,
– Well thought systems design towards efficiency, cost containment,
ensure referral, advocates of primary care contractor
46
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Concluding remarks 2
•
UC Schemes covers the poor, half belongs to Q1 and Q2
– However, the Scheme faced chronic under-funding, capitation was
below than the proposed figures based on cost and utilization
– Significant increase in utilization more on OP than IP
– In view of under-funding and increased utilization  danger of poor
quality of services and serious hospital financial constraints
•
Empirical evidence indicates
– Pro-poor budget subsidy, DHS is a major hub of fostering the pro-poor
nature of financing healthcare
• Policy msg.  invest more in DHS
– (further) reduction in the incidence of catastrophic illnesses
– (further) reduction of impoverishment from medical bills
47
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IIA. Ongoing major work:
Universal offer of VCT
48
-Thailand
The potential VCT uptake with zero price
General Population
Sex Workers
% Accepted
100%
100.0%
77.0%
80%
60.7%
60%
69.7%
65.9%
32.6%
30.2%
19.0%
20%
Current price
5.9%
61.2%
35.7%
31.5%
28.9%
20%
100.0%
89.7%
80%
67.9%
39.7%
50.0%
Current price
B
pt
No
t
ro
ac
ce
ah
t
t
Ba
h
90.2%
11.7%
66.0%
37.1%
34.8%
30.9%
20%
0%
WTP for VCT
WTP for VCT
pt
ac
ce
ah
t
B
ro
Ze
No
t
t
Ba
h
1
ah
t
20
0
B
ah
t
40
0
B
ah
t
60
0
B
ah
t
B
0
80
1,
00
0
B
ah
t
pt
ac
ce
ah
t
B
ro
Ze
No
t
t
Ba
h
1
ah
t
20
0
B
ah
t
40
0
B
ah
t
60
0
B
0
80
B
ah
t
ah
t
0%
B
00
0
100.0%
98.4%
86.7%
80%
40%
16.0%
13.5%
% Accepted
100%
60%
28.5%
12.5%
Ze
Men Having Sex with Men
% Accepted
100%
20%
1
WTP for VCT
IV Drug Users
40%
ah
t
0
20
WTP for VCT
60%
B
ah
t
B
40
0
B
0
60
80
0
B
B
00
0
1,
No
ah
t
ah
t
pt
ta
ro
Ze
cc
e
Ba
Ba
ht
ht
ht
1
50
Ba
Ba
ht
10
0
Ba
ht
20
0
Ba
ht
30
0
Ba
ht
40
0
Ba
ht
Ba
ht
50
0
00
0
1,
ah
t
0%
0%
1,
10.4%
60%
40%
23.1%
100.0%
97.4%
93.7%
87.0%
80%
44.4%
40%
% Accepted
100%
Predicted Demand for VCT by Regions
90%
All regions
North
Northeast
South
All regions
73.8%
72.6%
68.3%
64.8%
70%
60%
Gen. Pop.
72.0%
66.3%
62.8%
56.7%
50%
64.0%
60.2%
57.7%
57.2%
54.7%
50.4%
46.5%
49.5%
48.5%
44.2%
43.5%
40%
39.0%
34.2%
33.0%
30%
26.1%
20%
14.1%
10%
North
Northeast
South
96.2%
93.8%
91.2%
89.6%
88.3%
90%
SW
86.8%
85.5%
83.9%
81.6%
79.3%
80%
72.1%
69.3%
70%
64.4%
61.8%
61.0%
60%
56.1%
55.4%
50%
46.3%
42.6%
39.3%
40%
30%
0%
0
50
100
150
200
250
300
350
200
400
300
400
VCT price (Baht)
All regions
Bangkok
North
South
100%
100%
90%
90%
IDU
80%
71.4%
67.4%
62.1%
62.2%
70%
60%
54.7%
54.6%
49.1%
50%
40%
38.3%
36.6%
31.0%
27.5%
30%
24.3%
20%
17.7%
15.5%
11.8%
7.1%
10%
0%
500
600
VCT price (Baht)
All regions
Proportion accepting VCT (%)
Proportion accepting VCT (%)
Central
100%
Proportion accepting VCT (%)
Proportion accepting VCT
Central
82.6%
80%
97.4%
Central
700
North
95.6%
77.4%
70%
84.4%
81.4%
78.7%
66.2%
South
MSM
91.6%
91.4%
80%
800
68.5%
65.4%
60%
59.5%
54.0%
50%
44.7%
42.9%
40%
30%
25.0%
20%
10%
0%
0
100
200
300
400
500
VCT price (Baht)
600
700
800
0
100
200
300
400
500
VCT price (Baht)
600
700
800
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IIB. Ongoing major work:
Major program review
of cervical cancer control
51
-Thailand
National Coverage of Cervical Cancer Screening
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
(Household Survey -2006)
28.2%
36.7%
13.5%
10.1%
5.0%
1.9%
4.7%
Never
None in 5 yr.
Once in 5 yr.
Once in 3 yr.
Once in 2 yr.
Once in 1 yr.
Once in 4 yr.
Source: NSO’s Sexual and Reproductive Health Survey (2006)
52
Reported Achievement by Set Targets
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
(2005)
65%
62%
58%
52%
49%
51%
62%
50%
42%
All regions
Central
North
Pap smear
South
Northeast
VIA
Source: NHSO (2006)
53
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Work Components
Work package 1: determination of the programme performance
(survey and review of literature)
Jan-Apr 07
Findings: effectiveness of the current practice
Input
Work package 2: economic evaluation for an optimal policy strategy
Findings: a mixed menu of cost-effective interventions for
prevention and control of cervical cancer in Thailand
Mar-Jul 07
Input
Work package 3: policy analysis for introduction of the new policy
strategy for prevention and control of cervical cancer in Thailand
Findings: better understanding the social, political and institutional
factors and constraints for introduction of the new policy strategy
Apr-Sept 07
Input
Work package 4: estimation of human resource and infrastructures
required for introduction of the new policy strategy
Findings: short- and long-term plans for human resources and
infrastructures
Aug-Dec 07
54
-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IIC. Review of disease control priorities
(DCP-2)
and its application to the 10th
National Health Development Plan
55
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Objectives of the study on DCP-2 and
the 10th National Health Development Plan
•
To review patterns of burden of disease and risk behavior of Thais in
1999 and 2004
•
To review cost-effective medical treatments and public health
interventions suggested by DCP-2 in accordance to BOD of Thailand
•
To explore similarity and dissimilarity of current practice for disease
control and prevention on top-ten priority of disease burden in Thailand,
compared to suggestions from the DCP-2
•
To estimate the magnitude of government investment in disease
prevention and reduction in health risk behavior, health promotion,
screening and early detection of disease in high priorities, compared to
investment in curative interventions
•
To provide policy recommendations on improving efficiency and efficacy
of public investment in health promotion, disease prevention, curative
interventions, and economic gains from more investing in health
•
To develop plan and framework for investing in health and estimate the
medium term expenditure framework (MTEF), compared to government
health budgets
56
Scope of the study
Review burden of disease (BOD)
and risk behavior of Thais in 1999 and 2004
Select top-ten burden of disease contributing to
highest DALY loss in 2004 as the scope of the study
Review recommendations for effective medical treatments and public health interventions
in DCP-2, compared to current practice and clinical guideline practices in Thailand
Estimate public resources required for investment in health promotion,
disease prevention, and public health program in reducing risk factors and
behavior of each disease, compared to curative program and other sectors
Provide policy recommendations for improving efficiency in health investment in
health promotion, disease prevention, screening, curative and reducing risk behavior
Estimate budget requirements for health investment in
the 10th National Health Development Plan
and present research findings for public hearing of all stakeholders
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
IID.
Sustainable Development of Healthcare
System Performance in Thailand
58
-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Objectives
•
To review previous studies of Thai healthcare performance and
current approaches from international perspectives
•
Based on process of consultation and consensus agreement
among major stakeholders in Thailand, to develop and
conceptualize the Thai healthcare system performance
framework
•
To build up institutional capacity and foster networking with all
stakeholders and technical partners for a long term national
capacity in healthcare performance assessment
•
To assess and produce a public report on Thai healthcare
performance in for FY2007 (pilot phase in 4 Provinces)
•
To develop strategy and policy approach to catalyze
improvement in the performance in the positive ways
59
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Conceptual Framework of Healthcare System Performance
Review:
Concept;
Domain;
Indicators;
Information system
Review Existing:
Indicators;
Data source;
Information system
Thai conceptual Framework:
Goals; domain; Indicators; data
Survey?
Users:
•Public
Central government
Local government
Healthcare planner
Hospital manger
Health insurer
Academia
Measure
Gap?: Data (available;
quality)
Information system;
Develop
Level:
Hospital and CUP
Analyze,
Synthesis
Report:
Revised
•Level (province, region)
Indicators
Benchmarking
Improvement:
Personnel; IT;
Management
60
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
III. Future challenges
61
-Thailand
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Effective coverage of hypertension,
adult >15 yr. 2003
Source: National Health Exam Survey
Female (N=7,580)
Male (N=7,544)
12
6
0%
19
11
5
64
5
20%
treated + well control
Diagnosed, no treatment
77
40%
60%
80%
100%
Treated, not well controlled
Not diagnosed
Prevalence Hypertension: 23% male, 21% female
All samples are hypertensive, >140/90 mmHg,
62
Effective coverage of DM, adult >15yr. 2003
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Source: National Health Exam Survey
Female (N=2,601)
15
Male (N=2,045)
9
0%
34
24
2
49
2
20%
66
40%
treated + well control
Diagnosed, no treatment
60%
80%
100%
Treated, not well controlled
Not diagnosed
Prevalence DM: 6% male, 7% female
All samples have FBS, >126 mg/dl
63
Death rate
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Death from Diabetes
Poorest
Diabetes
death
Richest
64
Death rate
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Death from Ischemic Heart Disease
Poorest
IHD
death
Richest
65
The estimated number of ESRD patients accessing to RRT at the incidence rate of
300 PPM during 2005 - 2004
200,000
160,000
140,000
Only patients aged less than 70 years
Only patients aged less than 60 years
132,409
120,000
92,634
100,000
80,000
60,000
40,000
20,000
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
No. of ESRD patients
180,000
188,435
universal access to RRT
Year
CEA and CUA societal perspectives
PD and HD at NPV 2005
Age
(years)
Cost effectiveness analysis (CEA)
Baht per 1 DALY gained
Cost utility analysis (CUA)
Baht per 1 DALY gained
Shifting from
palliative care to
PD
Shifting from
palliative care to
HD
Shifting from
palliative care to PD
Shifting from
palliative care to HD
15
460,814
475,285
660,682
706,662
20
461,847
476,761
661,704
708,879
25
463,096
478,519
662,982
711,511
30
464,607
480,612
664,578
714,636
35
466,434
483,103
666,570
718,341
40
468,643
486,067
669,052
722,735
45
471,314
489,593
672,138
727,944
50
474,542
493,793
675,966
734,126
55
478,446
498,802
680,699
741,473
60
483,170
504,789
686,540
750,226
65
488,895
511,966
693,733
760,685
70
495,846
520,601
702,584
773,231
Budget impact analysis
2 scenarios: universal versus limited access to RRT
at the lowest cost estimate (250,000 Baht / case/ year)
2005
(year 1)
2009
(year 5)
2014
(year 10)
2019
(year 15)
3,994
18,058
32,255
43,804
As % of UC budget
5.5
18.4
23.7
23.6
As % of THE
1.7
5.9
7.7
7.7
1,981
8,944
15,966
21,625
As % of UC budget
2.7
9.1
11.7
11.7
As % of THE
0.9
2.9
3.8
3.8
UC budget (million Baht)
73,136
98,074
135,987
185,248
Total health expenditure
(million Baht)
230,836
303,931
417,522
572,659
Universal access to RRT
(million Baht)
RRT for KT eligible (mil Baht)
Future Challenges (1)
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
•
Most of the crude ground works had achieved
– PHC focus and reorientation, pro-poor achievement, extensive
financial protection of the poor, very minimum catastrophic incidence,
BUT
• Need to increase value for money
• Maintain decent quality of care and continued advancement in medical
progress
• Evidence based and learning organization for
• MOF (CSMBS) SSO and NHSO
• BOB, MOF Fiscal Policy Office, NESDB
• Harmonization across 3 public insurance scheme
• Adequate and sustainable financing of the pro poor UC scheme
69
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Future Challenges (2)
•
Focus more on effective coverage of increasing trend of chronic
conditions and effective prevention of injuries
•
Renal Replacement Therapy for chronic kidney disease patients is
not covered by UC Scheme (while SHI and CSMBS cover fully)
– Results in catastrophic health expenditure by households
– Need serious informed policy decision and long term financial
implications
– Cost per life year saved (Teerawatananon et al 2005)
• Peritoneal dialysis
10,170 US$
• Hemodialysis
10,490 US$
– Cost per life year saved (Lertiendumrong et al 2005)
• Antiretroviral Therapy
590 US$
– GNI
• US$ 2,540 per capita (2004 WDR)
– Cost per life year saved for RRT
• 4 times of GNI per capita,
• 18 times as expensive as the current national ART program.
– Ethical dimension of not extend RRT to UC members
70
Program
Health Policy
International
-Thailand
Program
Policy
Health
International
-Thailand
Acknowledgments
•
National partners
– National Health Security Office (NHSO) and other partners who initiate,
design and steer the UC scheme
– HSRI for supports on NHA development since day one until institutionalized
– HISRO, HISO for their technical and financial supports
– Ministry of Public Health (MOPH) major healthcare providers and steer the
implementation of UC scheme.
– National Statistical Office (NSO) for national household surveys
– Thailand Research Fund (TRF) for institutional grants to IHPP
•
International partners
– World Bank and MOPH partnership on Country Development
Partnership in Health Sector
– ILO for peer reviews of capitation rate 2002, and long term financing
forecast 2005-2020
– WHO and Harvard for studies on ethical dimension of RRT extension to
UC members
– EU funded Equity in financing, health utilization and public subsidies in Asia
Pacific (EQUITAP)
71