Transcript Thailand’s Universal Coverage: Performances, Constraints

“Impacts and Constraints of Universal
Coverage (UC) in Thailand’s Public
Health System”
Chalermpol CHAMCHAN
Doctor of Area Studies, Graduate School of
Asian and African Area Studies (ASAFAS),
Kyoto University
At Faculty of Economics, TU
24 June 2009
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
The UC policy incorporated
◦ 1) Financial reforms with closed-end provider payment
method – the capitation method – and
◦ 2) Strengthened primary care network with more attention
on health promotion and disease prevention works (PP) – a
concept of “Primary Care Unit (PCU)” under “Contracted
Unit of Primary Care” (CUP) structure.

Major strategic policies: สร้ างนาซ่ อม (SNS: health promotion
and prevention (PP) ahead curative health care) and ใกล้ บ้านใกล้
ใจ (KBKJ: health facility near dwelling)
At Faculty of Economics, TU
24 June 2009
At Faculty of Economics, TU
24 June 2009
At Faculty of Economics, TU
24 June 2009
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24 June 2009
Primary Care Unit (PCU)/
Sub-district level
Provincial public care network
and referral system
Upper-Secondary and Tertiary Care/
General Hosp.
Provincial level (in Provincial city)
Secondary Care/ Community Hosp.
District level
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24 June 2009
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Regional IP care-referral system
Other provincial Hosp.
in neighborhood
Kalasin Hosp.
Khonkaen Hosp.
(General and Regional Hosp.)
Other provincial Hosp.
in neighborhood
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I. Background
These changes, both of the financing and structural
reforms of health service delivery, have affected
providers from managing staffs to health practitioners
in the country.
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24 June 2009
I. Background
Study questions:
 Q.1 How are performances of UC and its impacts on
public health system?

Q.2 What are crucial constraints and critical obstacles to
the sustainability of UC and the health system?
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I. Background
Field surveys: Khonkaen and Kalasin provinces of the
northeast region
Areas in the northeast region were selected as,
 hosting the largest number of population - comparatively
poorer than those in other regions - but equipped and
provided public health resources the least advantage.

tentatively the most affected by the switching of salary
subtraction of the capitation budget from at the provincial
level to the national level
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I. Background
Respondents: Providers at facilities in 9 districts, with care
referral network from Primary and Secondary levels to
Tertiary level
Table 5.1 Summary of the Interviews, by Health Workplaces and Professions
Khonkaen (July-August 2005)
CUP (5)
DPHO
Hospital
PCU/HC
(5)
(5)
(8)
Kalasin (January-February 2006)
CUP(4)
PPHO
DPHO
Hospita
PCU/HC
(1)
(4)
l
(6)
(4)
3
4
4
2
Professions
PPHO
(1)
Director*
Doctor
Nurse
PHO, Health
Academic,
Management
Officer
-
-
4
4
7
5
-
1
5
3
4
1
1
4
2
5
26
1
5
18
9
1
1
4
13
7
59
Total
Note:
Pri. H.
(1)
* All directors of the hospitals are doctors.
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In parentheses are the numbers of visits at each place type.
24 June 2009
Total
7
8
18
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II. Providers’ Views of the UC Implementation
a) General Expressions


agree with the concept of the 30 Baht Scheme and good wills of the
government in implementing UC.
Budget management and allocation - more flexible, and clearly
defined with concrete strategy, policies and expected outcome to
the providers.
However,
 Database of population and costs of health service - not properly
developed.
 System and health workers - not prepared to the changes.
 Structure of public health organization – PPHO, DPHO, hospitals
and PCUs/HCs – not yet properly reorganized---- Confusions!

Too much exploited for political benefits and popularity
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II. Providers’ Views of the UC Implementation
B) Views respecting Impacts
i. Workloads
(by policy changes and higher rate of care utilization)
ii. Care over-utilizations (Patient’s rights & Responsibilities) → Risks
of malpractice → Work Depressions
iii. Structural changes of heath service system and financing
iv. Relationship Issues: (Patients & Providers, Providers & Providers)
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Providers& Patients – Medical malpractice & Suings by patients
The problem of malpractice sues by patients is suggested to be
managed by,
◦Hospital qualification/Hospital Accreditation (HA) process
◦Social recognition about “rights” with “responsibilities” of
patients
◦Risk management and patient monitoring system of the hospital
◦Social embedment of the hospital in the community, regarding
trusts of people toward health practitioners
Profession group & Profession group – Structure of returns and
welfare
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III. Constraints and Consequences in Public
Health Service System

Based on the designed structure of medical care and referral
network of the UC implementation, we found that impacts
and failures of the policy intentions caused by constraints and
difficulties, both physically and financially, at each level of
health facility systematically affected and were affected as a
cycle in the whole public health system.

As of this argument, three components are described to
highlight the causes, the consequences and the linkages of
the systematic problems, which determinate effectiveness
and performances of UC, and as well were impacted by the
UC implementation, in the public health service system.
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Systematic constraints and negative cyclic
consequences in care provision system are
drawn out
Concerning,
1. Primary Constraints
2. Linking Consequences
3. Secondary constraints
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1. Primary Constraints



Shortages and Misdistributions of health personnel (across the
country, and levels of health facilities in the area) +
Resignations and Drains of Health Workers from the Public
Sector
Under-estimated and under-approved UC budget
Inconsistency between health strategies and public
recognitions towards UC
Primary Consequences

Workloads and Poor performances
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Shortage of health workforces
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Drains of health
workforces
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Drains of doctors

Disadvantageous returns in comparison with the returns
offered by private hospitals or clinics[1].

Workplace and location of the public hospital.

Workloads at the public hospital.

Personal and family factors.
[1] Na-ranong (1992) pointed out an evidence from a case study
in community hospitals of the MOPH that the determinant
of the resignation of a doctor from the public sector were
mostly the financial factors, respecting disadvantageous
salary level and returns.
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Resignations of nurses

Two points of the issue were expressed i) “public
post” and “workloads” and ii) “location of the
hospital”
Drains of the PHO group at the PCU/HC level

Draining to Sub-district Local Government
Organization (SLGO)
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“Adequacy” ---- survival of the health facility and its financing---enough and the hospital could survive, even with some
financial deficits and debts.
However, “Adequacy” ---- in relation to assigned work tasks and
expected outcomes by the NHSO, the MOPH and the patients---hardly enough and inadequate to have the facility achieving
at the quality levels
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“Investments” for long-term development and quality
improvement of services provided ---- said to be forgotten,
due to the limitations and inadequacy of the budget---affects not only the sustainability of the facilities
themselves but also of the whole health service provision
system.

“Salary subtraction” of the UC budget at the national level
& at the provincial level

“The co-payment”: The fixed 30 baht/visit
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24 June 2009
2. Linking consequences:
From PCUs to Secondary and Tertiary level hospitals

Failures of strategies to strengthen service provisions at
primary care level, and health promotion and
prevention (PP)---Failures of the SNS and KBKJ
strategies
From Secondary level hospitals to Tertiary level hospital

Over-referring of In-Patient cases
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24 June 2009
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
Even if PP work is perceived to have been given more attention
from the health policy agenda with more purposeful work plans,
the implementation is facing many difficulties and constraints
from both the nature of PP work itself, and the unsupportive
workforce and budget, specifically at the PCU/HC level.
A. The Nature of PP Work
B. Inadequate Workforce with Heavy Workloads
C. Unsupportive UC Budget for PP Work
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3. Secondary Constraints
Backward from
Tertiary level hospitals to Secondary level hospitals
 Infeasible reallocations of health personnel from provincial
cities to rural districts
Secondary care level hospital to PCUs
 Infeasible strengthening primary care network
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Figure 6 Systematic Constraints and Cyclic Consequences in Public Health Service
System at the Provincial Level
Primary Constraints at
Facilities in Primary Care
Level +
Impacts of the UC
implementation
Workloads and Poor
performances of
service provisions at
the primary care level
Consequences of
Failures at primary
care level
Infeasible to
strengthen Primary
care network
Primary Constraints at
Facilities in Secondary
Care Level +
Impacts of the UC
implementation
Workloads and Poor
performances of service
provisions at the secondary
care level
Consequences of
Over-referring of
In-Patient cases
Primary Constraints at
Facilities in Tertiary Care
Level +
Impacts of the UC
implementation
1) Primary Constraints
Infeasible Reallocation
of health personnel in
the province
Workloads and Poor
performances of service
provisions at the primary
care level
2) Linking Consequences
Secondary
Constraints
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of Economics,
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2009
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
“…where shortages (and inequitable
distributions) of health workforces are still
prevalence in many areas and sufficient budget
funding are not yet acquired, the public health
care system (and UC) as a whole is vulnerable
and might not be sustainable in the long-run
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Conclusions
Thailand’s health system has achieved intermediate goal
but not yet the final one of the UC policy.
(1) Assuring universal
and comprehensive
health insurance
coverage.
(2) Ensuring
adequate and
equitable access to
needed health service.
(3) Increasing the
effectiveness and
sustainability of
health system
Source: Docteur et al. 2003



‘Universal inclusion’ is to be achieved, but
“Universal access” is still not ensured that it is equitable
to all insured population
UC system is insufficiently provided with health resources,
and as a result ineffectively functioning and vulnerable
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Policy Suggestions

To empower Primary Care Unit (PCU) and enhance its staffs

To put forward a concrete agenda to relieve shortages of
health workforce and its misdistribution nationwide

To adjust financing mechanism of UC in term of fund
sourcing and budget managements

To promote better community participation and patients’
responsibilities
24 June 2009
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