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Welcome to NHSO
Thailand’s UHC development
National Health Security Office
23 June 2014
Thailand: country profiles
•
Population - 64 million
•
GNI 2012 US$5,090 per capita
•
UHC achieved in 2001 under 3 scheme
•
•
civil servants, social security and UCS
Health status
 Life expectancy at birth 74 years
 IMR 20/1000 LB, MMR 30/100,000 LB
 Physicians per capita 5/10,000
•
Total Health Expenditure (NHA 2011)
 4.1% GDP
 12.4% out of pocket
3
3
Before
1974
1974
1975
1978
FFS with max
ceiling
WCF
Fee
Exemption
FFS
reimbursement
Capitation
contract model
LICS
Capitation for OP
DRG weighted
global budget for IP
CSMBS
Type B fee
exemption
1981
1990
1991
1998 Health care
reform project
SSS
HCS
Traffic Accident Protection Program (TAP)
1993
1994
MWS
1999
SIP in 6
provinces
Poor people
Near poor Uninsured
Oct. 2000
Fund-holding autonomous hospital (1 district)
Apr. 2001
UCS in pilot 6 provinces
Apr. 2002
UCS implemented nationwide
Year
Private employee
Government
employee
Population covered by Universal Coverage
4
Scheme (UCS)
Long march towards universal health coverage in Thailand
using National Health Accounts (NHA) data
GNI per capita, 1970-2009
Health service delivery system in Thailand
Specialized
hospitals 48
Province
Regional
hospitals 26
Provincial
hospitals 71
District
District hospitals
734
Subdistrict
Health centers
9,768
MOPH facilities
University
hospitals 11
25
Private
hospitals
322
Other
public
hospitals
60
Community
Medical
Centers 365
LGUs
Private clinics
17,671
Pharmacy
11,154
Adequate and appropriately manned rural health facilities
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 support
are essential.
7
Rural community hospital with 2-8
doctors cover 30-80,000 population
Seamless Health Service Networks
For more complex service,
secondary and tertiary hospitals
with specialized personnel , highly
diagnostic and treatment
technology are available .
Referral system was set up .
Medical school hospital
General hospital in every province
Regional hospital in every region
8
3 main schemes’ characteristics
CSMBS
Fringe benefit
Government employees,
pensioners and their
dependants5 Million (8%)
Nature
Population
Source of
finance
General tax
(~400 US$/Cap)
Management
organization
Benefit
package
Comptroller general under
ministry of finance
No preventive care
No explicit exclusion
Special bed
Providers
Public provider only, Private
in emergency, elective
surgery (2011)
Free choice public hospitals
Choice of
provider
Payment
OP: Fee-for-service
IP: DRGs (2007)
SSS
Mandatory
Formal-sector private
employees,
10 Million (16%)
UCS
Citizen entitlement
The rest of population who
are not covered by SSS and
CSMBS
47 Million (75%)
General tax
(84 US$/Cap)
Tripartite rate 1.5% of salary
(maximum salary: 500 US$)
(health care 106 US$ /Cap,
total 397 US$/Cap)
Social security office under
ministry of labor
Small number of limited
condition eg. Non medical
plastic surgery
National Health Security Office
(NHSO)
Small number of limited
condition
Prevention & promotion for all
Public and private hospital
more than 100 beds (50%
private)
Contracted hospital and its
network
Capitation OP and IP
(DRG for IP DRG RW> 2)
Public and private contracting
unit for primary care(CUP),
mainly District hospitals
Primary care contractor
services, plus referral
OP: Capitation
IP: DRGs with global budget
CSMBS = Civil Servant Medical Benefit scheme, SSS = Social Security Scheme, UCS= Universal
Coverage Scheme
9
Achieving efficiency and equity: role of
strategic purchaser
Provider payment: efficiency and cost
containment
• Budget
• Hard budget: annual expenditure exactly equal to
budget
• Provider payment: Closed-end
• Send strong signal
– Use generic medicines, appropriate dispensing of medical
technologies,
– Effective prevention of supplier-induced demand
– LOS stays at 4 in last 7-8 years
• Risk of under-service provision, counteracted by
– Complaint management through 1330 call centre,
– Quality assurance, accreditation, medical audit
– Setting separated payments for high cost previously
underprovided services.
Benefit package designs
• Benefit package
– Initial package: historical precedence, no application of
cost effectiveness
– Later inclusion guided by evidence
• Benefit Package Sub-committee, NHSO
– Key platform for decision on what new medical
intervention is included into the package
– National capacity (HITAP and IHPP) to generate
evidence on
• Cost effectiveness, incremental cost effectiveness ratio
– ICER: not more than one GNI per capita for a QALY gain
•
•
•
•
12
Catastrophic prevention
Medium to long term budget impact assessment
Ethical concerns
Supply side capacity to scale up new interventions
Increase fiscal space & deepen financial risk
protection
• NHSO
[single purchaser from multiple sellers]
– Bargaining power over price, quantity and quality of
products and services, e.g.
• Central purchasing of assured quality products or constraint fee
» Hemo-dialysis, down from US$ 67 to US$ 50 per session,
approx 1 million sessions per annum, saving US$ 170 million
per annum
» Cataract soft lens, down from US$130 to US$90 with assured
quality, saving US$ 40 million per annum
» Erythropoietin, down from US$ 21 to US$ 8, saving US$ 12
million per annum
» Drug coated Stent for coronary artery, down from US$2,700 to
US$ 600, saving US$ 21 million per annum
Service management: PHC orientation
• District health system is a typical contractor
provider network
• Gate keeping role for OP and IP
• Patient bypassing contractor provider network without
referral are liable for full payment
• Rationale use of service by level: lower unit cost
• Better access: lower transport cost shouldered by patients
• Better outcome: continuity of NCD control, DM, HT
• Referral backups
• Provincial hospitals with specialists
• Regional excellent centres strengthened for sub-specialty
care
– e.g. heart, cancer, trauma, premature newborns
14
Expanding benefit
package
2013 (B.E.2556)
- Expand target group for seasoning influenza vaccines
- stem cell transplantation in Leukemia and lymphoma with indication
- Strategic plan for long-term care in
frail elderly in Home care and community care
2012 (B.E.2555)
- Liver transplantation in patient age <18
years
- Heart transplantation
2009 (B.E.2552)
- High cost drug in J2-National drug lists
- Seasoning Influenza drug list
2007 (B.E.2550)
- Thai traditional medicine services
2010 (B.E.2553)
- Orphan drug, Thai traditional medicines
- Psychosis admission without limitation
2008 (B.E.2551)
- Renal replacement therapy (CAPD, HD, KT)
- Methadone drug as a replacement drug in drug addicts
2005 (B.E. 2548)
Benefit package for HIV/AIDS include ARV, Laboratory, counseling, Voluntary Counseling
and Testing (VCT), condoms.
2002 (B.E. 2545)
Universal health coverage for Thai citizen including health promotion, disease prevention, diagnosis,
treatment, dental care, drug listed in national drug list, rehabilitation
15
UCS institutional arrangements
Fund and system
manager
provider
Head Quarter & Branch Address of NHSO
NHSO
Bureau of Audit
Office of the secretariat
Cluster of Strategy
and evaluation
Bureua of
Strategic
management
Cluster of Fund
administration
Bureau of
Registration
administration
Bureau of Planning
and evaluation
Bureau of Quality
and health outcome
monitoring
Bureau of
Executive
information
administration
Bureau of
International
universal health
coverage
Bureau of Fund
allocation and
reimbursement
Bureau of
Finance and
accounting for
universal health
care fund
Bureau of Medical
audit
Cluster of Universal
health care services
delivery management
Cluster of Office
administration
Bureau of primary
health care promotion
Bureau of General
administration
Bureau of Medicines,
medical supplies and
vaccines
management
Bureau of Legal
affairs
Bureau of secondary,
tertiary and specifics
cares
HIV/AIDS and
tuberculosis
Program
Chronic diseases and
special diseases Program
Renal diseases
Program
Bureau of Finance
and accounting for
administrative fund
Bureau of Health
insurance information
technology
management
Bureau of Human
resources and change
management
Bureau of Quality and
good governanace
development
Cluster of Branch office
mission and participation
Bureau of Public and
private participation
promotion
Bureau of Customer
services and right
protection
Bureau of Regional
support and coordination
NHSO Region 1-13
Administration for UC budgeting
Submit a request for
annual budget
3 Main
scheme
Financial
sub-board
recommendation
13 Branch
offices
Recommendation
Central
headquarter
Preliminary approved
annual budget
NHSO
Timetable
for
budget
subsidies
plan
Bureau of
the budget
Submit annual
government
budget plan
Approved annual
budget
MOPH
Submit the approved
annual budget
request
National health
security board
Preliminary approved
annual budget
suggestion
MOF
Apply annual budget
request
1
The Cabinet
2
The Parliament
19
Timetable for UC budgeting , FY2013
Submit
Nov. a request for
annual budget
2011
Financial
sub-board
recommendation
13 Branch
offices
NHSO
Sep.
2012
Recommendation
Central
headquarter
Timetable
for
budget
subsidies
plan
Feb.
2012
Bureau of
the budget
Preliminary approved
annual budget
National health
security board
Preliminary approved
Apr.
annual budget
Apr.
2012
suggestion
Submit
Apr.annual
government
2012
budget plan
Approved annual
budget
Submit the approved
Feb.
annual budget
2012
request
2012
Apply annual budget
Mar.
2012
request
1
The Cabinet
2
May
2012
The Parliament
20
Outcomes of UC Scheme
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)
23
Outcome: increased government health spending
Thailand THE 1994-2010
2010
2009
2008
2007
2006
2005
2004
0.0%
2003
0
2002
1.0%
2001
100,000
2000
2.0%
1999
200,000
1998
3.0%
1997
300,000
1996
4.0%
1995
400,000
Year
Government spending
Source: NHA1994-2010
non-government spending
THE, %GDP
% GDP
5.0%
UHC
achieved
1994
Mil Baht
500,000
Outcome: Protection against health impoverishment
UHC
achieved
Outcome: health impoverishment sub national
1996 to 2008
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
Per 100 households
Per 100 households
Per 100 households
0 – 0.5
0 – 0.5
0 – 0.5
0.6 – 1.0
0.6 – 1.0
0.6 – 1.0
1.1 – 2.0
1.1 – 2.0
1.1 – 2.0
2.1 – 3.0
2.1 – 3.0
2.1 – 3.0
3.1+
3.1+
3.1+
3.1+
1996
2004
1998
2000
2002
Per 100 households
Per 100 households
Per 100 households
Per 100 households
0 – 0.5
0 – 0.5
0 – 0.5
0 – 0.5
0.6 – 1.0
0.6 – 1.0
0.6 – 1.0
0.6 – 1.0
1.1 – 2.0
1.1 – 2.0
1.1 – 2.0
1.1 – 2.0
2.1 – 3.0
2.1 – 3.0
2.1 – 3.0
2.1 – 3.0
3.1+
3.1+
3.1+
3.1+
2006
2007
2008
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
27
Changes in utilization:
primary secondary and tertiary 1977-2010
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
Challenges for further reforms
• Harmonization of the three main schemes is challenging
as individual fund has its’ own legal framework and
governing board
• Burden Of Disease challenges
– Increased diseases burden from chronic NCD
– Little success in controlling traffic injuries
• Health systems capacity to cope with
– Increased workload and very strained health workforces
– Decentralization context –threats and opportunities
– Public private dialogues, better trust and collaboration
• Medical tourism and internal brain drains
• Long term financial sustainability
• Aging society
29
Thank you for your attention