Transcript Treatment of HIV/AIDS: self reliance efforts from Thailand

Achieving Universal Health
Coverage: The Roles of Evidence,
Social Movements and Policy
Commitment
Dr. Suwit Wibulpolprasert
Senior Adviser on Disease Control, MoPH, Thailand,
PHA3, July 9th, 2012
University of Western Cape, South Africa
1
Thailand at a glance (2011)
• Lower middle income with good health status
- Gross National Income: US$ 3,760 per capita
– Poverty – 2% of population
– Gini index 42.5
- MMR 30/100,000 LB and IMR 20 per 1,000 LB
• UHC achieved in 2001 under three schemes –
the CSMBS, the Social Security and the UC
• Health expenditure (THE):
• US$ 300 per capita – 6% GDP
• Half from public – 13% of National Budget
• Less than 50% out of pocket health expense
2
Five important points
• UHC is for poverty reduction not only
health benefits
• UHC can be started at low level of
income
• The need to ensure availability of
satisfactory services.
• Mobilizing more resources for UHC
• Getting more health for the existing
resources
3
Households with catastrophic illnesses
1. UHC for Poverty reduction (MDG 1)
Prediction without UC
Actual situation
ถ้ าไม่ มีหลักประกันสุ ขภาพถ้ วนหน้ า
200,000 208,338
ค่ าพยากรณ์ ตามสถานการณ์ จริง
195,845
176,981
150,000
156,301
136,622
121,358
125,551
100,000
109,247
100,604
97,517
79,237
50,000
1996
2539
1998
2541
2000
2543
2002
2545
2004
2547
2006
2007
62,975
2008
2549 2550 2551
2. We can start UHC when we are still low income
US $
4,000
2,700
2001: 29% of
population are
uninsured
1,900
3,000
1490
2,000
2002 Universal
Coverage for entire
population achieved
1980 CSMBS
introduced
1990 SHI
introduced
760
1,000
390
710
1975 Low Income
scheme introduced
1983 CBHI
introduced
year
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
0
1970
GDP/capita
1997: Asian
financial crisis
Long march towards Thai UHC: You don’t have to wait
until you are rich to start and achieve UHC
National Health Security Act was proposed by 50,000 Thai citizens and
it has 5 influential board members from civil society organizations
The Three Schemes of UHC - 2010
Gold card
2001
NHS
O
48 mil.
NHS
O
Capitation
80 $US/y
7
Civil servants
Employees
1963
1991
CSMB
S
6.0 mil.
Comptroller
SSO
TAX
Contribution
9.0 mil.
SSO
“Fee for service” Capitation
350 $US/y
75/y
“Public /
Private
Providers
Service
s
Private room
non- ED
Insurees
,
Right
Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand
3. Ensuring universal availability of
satisfactory health services
• Extensive expansion of rural health services
in early 80s, as part of PHC/HFA and rural
development policies – inspite of economic
crisis
• How? - Freeze new capital investment in
urban health facilities for 5 years and
reallocate the budget to build rural health
centers and district hospitals, with extensive
production of Community Health Workers
• Extensively increased use of rural facilities
8
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand
Health Systems Strengthening as essential
components of the UHC
• Useless to have financial protection when the
quality essential health services are not
universally available
• Adequate facilities, manned by dedicated welltrained HRH
• Retention of Health Professionals in the rural
areas – multiple ‘supply’ and ‘demand’ side
measures.
• Diabetic Conditions in some countries
9
Dr. Suwit
Reallocation of budget during Economic Crisis in early
1980s, to build rural facilities and HRH
Budget (billion Bahts)
4
3.68
3.5
3.01
Fast tracking rural health
3
2.9
3
2.4
2
1.5
1.88
2.04
0.5
2.27
2.23
2.43
No investment in urban areas for 5 yrs.
1.68
1
2.15
3.1
2.73
2.64
2.5
3.15
Provincial
District
0
1982
1983
1984
1985
1986
1987
1988
1989
Year
10
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand
Adequate and appropriately manned rural health facilitieis
Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population
Extensive production
of appropriate cadres
and motivated health
personnel with
mandatory public
works and adequate
Rural community hospital with 2-8
doctors cover 30-80,000 population
support are essential.
Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand
11
From reverse to upright triangle: PHC
utilization (OP visits)
1977
Budget shift
1989
Peace, econ gwt,
democracy
2000
12
46.2%
(5.5)
Provincial hospitals
24.4%
(2.9)
Community hospitals
29.4%
(3.5)
Rural health centers
27.7%
(10.9)
Provincial hospitals
32.8%
(12.9)
Community hospitals
39.4%
(15.5)
Rural health centers
18.2%
(20.4)
Provincial hospitals
35.7%
(40.2)
Community hospitals
46.1%
(51.8)
Rural health centers
( ) : Number of OPD visits (millions)
Source: Rural Health Division, MoPH
12
Dr. Suwit Wibulpolprasert,
Ministry of Public Health,
Satisfaction of UC people & provider
Percent
100.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
83.0
45.6
83.4
39.3
83.2
47.7
83.1
84.0
56.5
50.9
88.3
50.7
89.3
89.8
60.3
78.8
Expand
financial
incentives
2003
2004
2005
2006
2007
UC People
2008
2009
provider
2010
Millions
Visits
160
149.58
150
140.7
140
128.73
130
120
111.95 112.49 111.64
114.77
119.29
110
100
200325462004254720052548
2006
Source : Report 5, 0110 , Yr 2003 – 2011
2007 2550
2008 2551
2009 2552
2010 2553
2011
2549
14
Millions
Visits
6.0
5.59
5.5
5.21
5.0
4.5
4.73
4.30
4.88
4.95
4.34
4.16
4.0
3.5
2003
2546
2004
2547
2005
2548
2006
2549
Source : NHSO IP data in Yr. 2003-2011
15
2007
2550
2008
2551
2009
2552
2010
2553
15
Source of finance 1994-2010
Increased public financing sources with less OOPs
UHC
achieved
100%
75%
37% 35% 35% 34% 33%
17% 14% 15% 15% 14%
69%
67%
67%
2008
2009
2010
2001
69%
2007
2000
64%
2006
1999
56%
2005
50%
58%
2004
51%
57%
2003
50%
58%
2002
50%
1998
44%
50%
1997
42%
44%
1996
25%
1995
50%
1994
%
44% 43% 42%
27% 27% 26% 27%
0%
Year
Public
SHI
16
Households
Other private
4. Mobilize more resources
• Peace and Economic growth – less proportion of
budget to security and serving public debt
• National public health expense increased from 5% of
national budget in 1980s to 13% in 2010
• ‘Community Health Development Fund’ – co-pay
by local governments - $US 150 m in 2010
• Dedicated Health Promotion Fund – 2%
additional levy on tobacco and alcohol excise tax –
$US 100 m in 2010 – ‘support HiTAP’
17
From security and debt service budget to health
30
*Security
25
20
16.1
17.9
*Debt serv.
13.713.5
13.1
13.2
12.5
9.1
8.1
10
8.2
3.4
3.2
5.1
4.2 4.1 4.3
*Health
7.6
5.0 5.3
4.4
2.9
Year
Source: Bureau of Budget
1,999
1,997
1,995
1,993
1,991
1,989
1,987
1,985
1,983
1,981
1,979
1,977
1,975
1,973
1,971
0
18
7.8
7.1
2,003
5
4.4
2,001
15
16.9
24.4
23.5
21.8
*Education
22.6
1,969
Percentage
25.8
24.7
18
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand
More Budget to Health
986.6 mil. ฿ 16,225.1 mil. ฿
(3.4%)
(4.8%)
77,720.7 mil. ฿
(78x)
(8.1%)
29,000 mil. ฿
1972
335,000 mil ฿
1,028,000 mil ฿ (35x))
1990
National budget
2010 PH
budget
rose to
14% of
National
buget
2004
PH budget
19
19
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand
5. Better Value for Money
• Close end capitation based budget with
mixed payment mechanisms mainly on
capitation (OP) and Case Mix (IP) and some
FFS and PC as gate keeper
• Base on National Essential Drug List and use of
TRIPs flexibilities - article 31(b) and Doha
declar, and strict control of high price EDs
• Base on intensive study on cost-effectiveness
of health technologies – IHPP, HITAP, etc.
• Central bargaining and purchasing with VMI
• Drug price of all hospitals on web site
20
Health Insurance coverage of three population groups
in selected Asian countries in 2009
21
Source: Tangcharoensathien V et al, Health Financing Reform in South-East Asia (2009)
Comparing % of Out of Pocket Health Expense and
% of Public Expenditure on Health
%
90
81.1
80
70
57.6
60
54.0
51.2
54.0
50
40.4
40
38.3
36.6
34.2
31.4
30
20
10
15.0
8.5
10.5
12.713.9
7.8
9.2
7.6
5.9
8.0
12.1
18.4
14.3
12.4
7.8
1.0
0
Brunei
Cambodia Indonesia
Laos
Malaysia Myanmar Philippines Singapore Thailand
GGHE as % of General government expenditure
in 2010
VietNam
China
Out of pocket expenditure as % of THE
Japan
South
Korea
ASEAN plus three HMM Joint Statement
July 6th, 2012
…….We commit to collectively accelerate the
progress towards UHC in all countries by
……….the formation of an ASEAN Plus Three
network on UHC. We concur and will
collectively move the issue of UHC to be
discussed and committed at the highest
regional and global development forum,
including the ASEAN Plus Three Summit,
and the United Nations General
Assembly.
23
Dr. Suwit
10 ASEAN Plus China Health Minister Meeting
– July 6th 2012
• Most of them agreed with removal of Tobacco
from the Free Trade Agreements
• All agreed to support ‘specifically dedicated fund
from tobacco and alcohol tax to be used for
tobacco and alcohol control and other health
promotion activities’
• Thai Health Promotion Foundation – 2%
additional levy on top of the excise tax to
tobacco and alcohol – 100 million per year
24
Dr. Suwit
What we must reiterate to politicians and
society
“Because we are poor,
we can not afford
not to have primary health care
based Universal Health
Coverage”
25
Dr. Suwit
“Triangle that move
the mountain”
Knowledge
generation &
management
Social
movement
“Tipping point”
Three groups
of people
Political/
Policy
linkages
Conductive
Environment
Stickiness of
the issue
26
Dr. Suwit Wibulpolprasert,
Ministry of Public Health,