Transcript Liturature Review of CVA (stroke) in Thailand

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
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. 2007, Geneva, World Health Organization.
Reduction of U5MR and MMR in Thailand, 1960-2008
MMR 1960-2006: six sources of references
450
400
MMR per 100,000 live births
350
BPS
300
BHP
250
RAMOS
200
TDRI
Lancet 2010
150
Achieving UHC
WHO
100
50
0
3
Year
Source: Why and how did Thailand achieve good health at low cost? (2011) http://ghlc.lshtm.ac.uk/
Long march towards universal health coverage in Thailand
Public policies to provide universal financial risk protection
GNI per capita, 1970-2009
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,
5
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
6
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)
7
Selected health interventions for cardiovascular
disease patients included in the UHC benefit package
Basic health care services for individual beneficiaries
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.
Expansion of open heart surgery and PTCA
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)
Heart
transplantation
Commencement of the benefits
2002
2004
2009
2010
2012
NHSO allocation
Item increase
Capitation increase
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
(O)
(P)
(Q)
( R)
(S)
(T)
(U)
(V)
(W)
NHSO allocation
OP averge cost
IP average cost
High cost
Accident and emergency
Special Denture
Prevention and promotion
Capital repleacement
Emergency medical services
Rehabilitation/Disability
No-fault liability
Quality based pay
Special medicine
ARV
RRT
Chronic
Psychitry
DMI
Special condition hospital
Compensate for abolish copayment
Compensate for health
personnel's work relate injury
Thai traditional medicine
Promote primary care
Support special tertiary care
Total
2003
574.0
303.0
32.0
25.0
175.0
83.4
10.0
-
2004
488.2
418.3
66.3
19.7
206.0
85.0
6.0
4.0
5.0
2005
533.0
435.0
99.5
24.7
210.0
76.8
6.0
4.0
0.2
10.0
1,202.4
1,308.5
7.1
1,396.3
From: Bureau of policy and planning, NHSO
2006
582.8
460.4
190.0
52.1
2.3
224.9
129.3
6.0
4.0
0.5
2007
645.5
514.0
193.8
51.0
248.0
142.6
10.0
4.0
0.5
20.0
2008
645.5
845.1
71.7
44.6
253.0
143.7
12.0
4.0
20.0
58.6
-
83.7
15.7
30.0
24.1
94.3
29.0
30.0
2009
667.0
837.1
68.2
70.9
262.1
148.7
5.0
1.0
20.0
5.0
63.4
32.5
43.0
72.3
0.4
0.4
1.0
0.9
1.0
1,983.4
2,194.3
2,298.0
7.0
1,717.8
2010
754.6
885.9
85.8
72.5
271.8
148.7
8.1
40.0
6.7
58.7
30.8
6.4
40.7
72.3
2011
795.4
954.7
94.2
76.5
2.3
312.5
148.7
12.0
2.7
25.0
4.7
62.5
67.2
13.1
4.2
34.0
64.1
0.8
2.0
10.6
0.8
2,497.2
1.0
6.0
11.2
1.5
2,693.5
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UHC scheme payment
Capitation in OP, DRG with global budget in IP
Basic health care
ARV drug
Fee schedule & development plan
UC fund
RRT
Chronic
(DM/HT)
Mental health
(Medicine)
Fee schedule &
development plan
Provider
Population/
patient
Point by no of pt
Medicine supply & development plan
10
Development of Thai DRGs
Version
1
2
Refined
Diagnosis
code
Procedure
code
Groups
Implement
No
ICD-10 (WHO)
1992
ICD-9-CM
2000
511
Nov 1998
No
ICD-10 (WHO)
1992
ICD-9-CM
2000
511
Feb 2001
5 levels
ICD-10 (WHO)
1992
ICD-9-CM
2000
1,283
Oct 2003
5 levels
ICD-10 (WHO)
2007
+ ICD-10-TM*
ICD-9-CM
2007
with extension
1,920
Oct 2007
5 levels
ICD-10 (WHO)
2010
ICD-9-CM
2010
with extension
HoNOS
Barthel index
3
4
5
DRG 2,450
TMHCC 54
SNAP 41
Expected
on Oct 2011
* Thai Modification for data entry only (not for new classification)
11
DRG evolution
• Reclassification
–Add group from previous other…
–Bilateral , Multiple procedures
–Special care
Oct.2007
• Unbundling
• Coding: ICD-10-TM (diagnosis)
ICD-9-CM 2005 with Extension
(Procedure)
Oct.2005
Apr.2005
Oct.2003
Thai
DRGs
Ver. 3.1
Feb.2001
Thai
DRGs ver.
4
Thai
DRGs
Ver. 3.5
Ver.3
Nov.1999


Ver.2


Ver.1
Reclassification
Recalibration
Clean up library
Unbundling  Additional lists
Recalibration
(Minor change)
12
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%
Source: NSO 2009 Panel SES, application of OECD unmet need definitions
13
Health
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Increased access to expensive health interventions for heart
disease patients among UHC beneficiaries, 2005-2012
14
Injection or infusion rate of thrombolytic agent
in ST-elevation MI (%)
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
Starting
special pay
Injection or infusion rate of thrombolytic
agent in ST-elevation MI (%)
36.88
32.15
17.41
48
5.38
1.71
0.49
49
9.88
50
51
52
53
54*
Case Fatality rate ST-elevation MI (%)
18.50
18.00
17.50
17.00
16.50
16.00
15.50
15.00
14.50
14.00
17.87
17.77
17.43
16.95
16.68
16.42
15.58
Case Fatality rate ST-elevation MI (%)
48
49
*54 = estimation from Aug. 2010 – Jul.2011
50
51
52
Source : IP individual record 2005- 2011 , NHSO
53
54*
Financial risk protection (1)
Reducing incidence of catastrophic health spending
OOP>10% total consumption expenditure
Source: Analysis of Socio-economic Survey (SES)
16
Financial risk protection (2)
Protection Thai HH against health impoverishment
UHC
achieved
17
UHC scheme improved equity in service use
0.50
0.40
2001
2003
0.30
2004
2005
0.20
Ambulatory care:
concentration index
0.10
0.00
-0.10
-0.20
-0.30
-0.40
-0.50
Health centre
Community hosp
Provincial hosp
Private hosp
Overall
2001
-0.294
-0.271
-0.037
0.431
-0.090
2003
-0.365
-0.315
-0.080
0.348
-0.139
2004
-0.345
-0.285
-0.119
0.389
-0.163
2005
-0.380
-0.300
-0.100
0.372
-0.177
18
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 1994-2010)
Thailand THE 1994-2010
UHC
achieved
2010
2009
2008
2007
2006
2005
2004
2003
0.0%
2002
0
2001
1.0%
2000
100,000
1999
2.0%
1998
200,000
1997
3.0%
1996
300,000
1995
4.0%
% GDP
5.0%
400,000
1994
Mil Baht
500,000
Year
Government spending
non-government spending
THE, %GDP
Total health expenditure during 2003-2009 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
19
Health
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-Thailand Program -Thailand
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.
20
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
21
Education strategies:
increase production and rural recruitment
Source: Noree & Pagaiya, 2011
Ratio doctor density
Between Bangkok to
Northeastern region
Rural
development
HFA/PHC
External
brain drain
1965
1970
1975
1980
1985
Economic
boom
1990
Economic
crisis Economic
recovery
1995
1995
1974
Collaborative Project to
Rural doctor program
increase production
(Rural recruitment and
of rural doctor 300-500 /year
hometown placement) 1979
Medical education reform
(PHC base, rural training)
2000
2005
2005
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)
22
Financial incentives
Ratio doctor density
Between Bangkok to
Northeastern region
Rural
development
HFA/PHC
External
brain drain
1965
1970
1975
1975
Hardship allowance
60-88 USD/mo
1980
1985
Economic
boom
1990
1995
1995
Non-private practice
allowance 250 USD/mo
1997
Increase Hardship allowance
Normal 55 USD/mo
Remote 250 USD/mo
Very remote 500 USD/mo
Economic
crisis Economic
recovery
2000
2005
2005
Special allowance
>3 yrs work - 125 USD/mo
Southern – 250 USD/mo
23
Four decades of infrastructure and workforce development
Hospitals
1,400
1,300
1,200
1,100
1,000
900
800
700
600
500
400
300
200
100
0
Doctors and nurses
120,000
The advent of
district hospitals (1977)
100,000
Now fully upgraded
to RNs
90,000
80,000
70,000
60,000
Public service mandate
of new MDs (1972)
50,000
40,000
30,000
20,000
10,000
0
1965
1970
All
1975
1980
District
1985
1990
1995
Other public
2000
2005
1965
Private
Source:
1,400
Health Resource Surveys (various years)
1970
1975
1980
Doctors
Population per bed
1,300
First batch of two-year
technical nurses (1982)
110,000
1985
1990
1995
2000
2005
Nurses
Population per doctor and nurse
10,000
9,000
Change in the use of primary health care
From reverse to upright triangle: PHC utilization
1977
1987
2000
2010
46%
(5.5)
24%
(2.9)
29%
(3.5)
27%
(11.0)
35%
(14.6)
38%
(15.7)
18.2%
(20.4)
35.7%
(40.2)
46.1%
(51.8)
12.6%
(18.1)
33.4%
(33.4)
54.0%
(78.0)
Regional H./General H.
Community H.
Rural Health Centres
Regional H./General H.
Community H.
Rural Health Centres
Regional H./General H.
Community H.
Rural Health Centres
Regional H./General H.
Community H.
Rural Health Centres
Starting Primary Care
The Decade of
Services
Health Center
Development
Universal
(1992-2001)
Coverage
Community
National
Policy
Economic
Health Act
Health
Crisis
Volunteers
Adopted
Health For All
Policy
Wat Boat
Project
Health
Centers
Traditional
Medicine
1964
1932
1950
1968
1966
1975 1978
1981 1985 1992 1996 1997 1999 2001
Tropical
Diseases
Control
Programs
- Sarapee
Project
- BanPai
Project
2007
1974
Rural Doctors
Movement
Stating
Rural
Health
Services
2002
Expanded
Community
Hospitals
Health Card
Project
Health Care
Reform
Project
Thai Health Fund
Decentralization
Lampang Project
Samoeng Project
Nonetai Project
Primary Care
Development
Civil Society Movement
Source: Komartra Chungsathiensarp, 2551
before
after Pay by quality based pay
Sources : Healthcare Accreditation Institute (Public Organization), 2011.
adapted by Bureau of Service Quality Development, NHSO. หมายเหตุ ปี 2554 เป็นข้อมูล ณ ไตรมาส 2
Monitoring & Evaluation of health systems reform /strengthening
A general framework
Inputs & processes
Financing
Indicator
domains
Governance
Infrastructure
/ ICT
Health
workforce
Supply chain
Information
Data
sources
Administrative sources
Financial tracking system; NHA
Databases and records: HR,
infrastructure, medicines etc.
Policy data
Outputs
Outcomes
Impact
Intervention
access &
services
readiness
Coverage of
interventions
Improved
health outcomes
& equity
Prevalence risk
behaviours &
factors
Social and financial
risk protection
Intervention
quality, safety
and efficiency
Responsiveness
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
Data availability for M&E system in Thailand
Input
HCF
HR
H
Infra
struct
ure
Gov
er
nan
ce
Output
Med/
Healt
h tech
HIS
acc
ess
safe
ty
effic
ienc
y
Interve
n
coverag
e
Impact
H
outco
me



Census / SPC
Equit
y
Finan
prote
ct
ion






NHES
MICS


Reproductive H
survey



Re
sp
on
siv
e


Biennial HWS
NHA
Risk
factor
s

Civil registration
and vital
statistics
Biennial SES
qual
ity
Outcome




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

Health
International
ProgramPolicy
International Health Policy
-Thailand Program -Thailand
The principle of
“Triangle that moves the mountain”
Knowledge
power &
management
Social
and civic
movement
Political
commitment/
Policy
linkages
30
Health
International
ProgramPolicy
International Health Policy
-Thailand Program -Thailand
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)
31