Universal Health Coverage: Thailand experience Ekachai Piensriwatchara, MD. Walaiporn Patcharanarumol, PhD. 17 July 2017 Yokohama, Japan
ASEAN-Japan 15 July 2017 Statement of the Minister of Public Health, Thailand 1. With strong political commitment, UHC can be started and achieved at low level of income 2. Peace and sustained economic growth mobilized more money for health 3. Universal access to good quality essential health services is the real goal 4. Strong capacity on health system and policy research 5. Participatory governance systems ensures real ownership 2
1. UHC can be started and achieved at low to middle income level 29% 42% 53% 70% 100% Population coverage 3
2. Peace and sustained economic growth mobilized more money for health 4
From security and debt service budget to health 30 25 *Security 24.7 25.8 24.4 Percentage 20 15 10 5 0 22.6 16.9 8.2 3.4 2.9 *Debt serv. 5.1 4.4 4.2 3.2 *Education 4.1 4.3 17.9 *Health 4.4 16.1 23.5 21.8 13.5 13.1 13.7 13.2 12.5 9.1 8.1 7.6 7.8 7.1 5.0 5.3 Year 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 Source: Bureau of Budget; Dr.Suwit s presentation 30 Sept 2011 5
More budget to health 986.6 mil. (3.4%) 16,225.1 mil. (4.8%) 77,720.7 mil. (78x) (8.1%) 29,000 mil. 1972 335,000 mil 1990 1,028,000 mil (35x) 2011 Budget for health rose to 13% of government budget 2004 Government budget Budget for health 6
Continued political commitment to UC Scheme: Budget, Baht per capita, by Regime 2002-2017 8 governments, 13 Health Ministers, 11 Permanent Secretaries 3,500 3,000 2,500 2,000 1,500 1,202 1,202 1,308 1,396 1,659 1,899 2,100 2,202 2,401 2,546 2,755 2,895 3,028 3,109 1,000 500-2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 G 1 G 2 G 3 G 4, 5 G 6 G 6, 7 G 7 G 7, 8 G 8 M 1 M 2 M 3 M 4 M 5-7 M 8 M 9 M 9 M 10 M 11 M 12 M 12 M 13 M 13 7
3. Universal access to good quality essential health services is the real goal Free but inaccessible health services and/or poor quality is not UHC. Thai s UHC focuses on Primary Health Care. Evolution of rural health systems since before UHC 780 district hospitals: one district hospital per district 9,777 health centers: one health center per rural commune Rapid increase in HRH training, i.e., doctors, nurses, voluntary health volunteers, etc, through rural recruitment, local training and hometown placement and compulsory public work for graduates with adequate motivation and incentives; 8
District health system: hub for pro-poor outcomes The Lancet 2013;381:2118-33. Primary health care 1. Health promotion 2. Disease control 3. Health care 4. Rehabilitation 5. Consumer protection temple Rural health centers with 3-6 nurses and paramedics cover 2,000-5,000 population community Rural Health facilities school private sector Local authority Rural community hospitals with 2-8 doctors cover 30-80,000 population 9
Huge increase in access to primary care 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 / General Hospital District Hospital Rural Health Centres Regional / General Hospital District Hospital Rural Health Centres Regional / General Hospital District Hospital Rural Health Centres Regional / General Hospital District Hospital Rural Health Centres Note: (number of OP visits in million) Source: Suwit s presentation on 30 Sep 2011 and updated 2010 data 10
4. Strong capacity on health system and policy research Home grown technical capacities Designing and implementing UC scheme Provider payment methods: capitation, DRGs, fee schedule IT to support UHC Medical audit Priority setting using many tools, including health technology assessment, budget impacts, supply side readiness, Monitoring progress of UHC Population coverage using citizen ID of CRVS; everyone is count Service coverage -> effective coverage of 6 conditions: HIV, TB, cervical cancer, DM, Hypertension, cerebrovascular disease Financial risk protection: catastrophic and medical impoverishment 11
UC Scheme achievements Some key achievements Improved equity in financing healthcare; Health Research Policy and Systems2013;11:25 Increased access to care by beneficiaries; Journal of Public Economics2015;121:79-94 Pro-poor utilization and benefit incidence; BMC Public Health2012; 12(suppl 1): S6 Preventing non-poor households become poor from medical bills; Bulletin of the World Health Organization2007; 85: 600 6 Gaining efficiency and cost containment; Economic & Political Weekly2012; 47: 53-7 UCS flourishes despite eight rival governments, six elections, two coup d etat, thirteen health ministers, between 2001-2015 UCS gradually owned by the people, not political party who initiated it. 12
New interventions assessed for service coverage Contribution by IHPP and HITAP Interventions (Indication) Cost-effectiveness Budget impact UC Scheme coverage Lamivudine (Chronic hepatitis B) Cyclophosphamide + azathioprine (Severe lupus nephritis) Peg-interferon alpha 2a + ribavirin (Chronic hepatitis C) Adult diapers (Urinary and fecal incontinence) Cost-saving Low Yes Cost-saving Low Yes Cost-effective (ICER=86,600*) Cost-effective (ICER=54,000* ) High High No No Anti IgE (Severe asthma) Cost-ineffective High No Implant dentures Note: * Threshold: ICER = 160,000 ThaiBaht per QALY Source: UC Benefit package project Cost-effective (ICER= 5,147*) Low No 13
Incidence of catastrophic health spending >10% of household expenditure, before and after UC Scheme in 2002 Health Research Policy and Systems 2013;11:25 14
Sub-national health impoverishment 1996 to 2008 15
5. Participatory governance systems ensures real ownership Voices of people Board of UC scheme: 5 seats from civil society (out of 30), chaired by the Minister of Health satisfaction survey of providers and patients Call Center 1330 of UC Scheme Annual public hearing at the national level, regional level and now extend to provincial level Call Center 1330 of UC Scheme Public hearing of UC Scheme 16
Satisfaction of UC beneficiaries & health care providers (%) 100 90 80 70 60 50 40 30 20 10 0 83 83.483.284.083.1 88.3 89.389.8 92.8 90.8 95.596.62 45.6 39.3 47.7 50.956.5 50.7 60.3 78.8 66.9 68.5 67.6 64.4 UC people provider 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: NHSO 17
Summary UHC is context specific learn from others and adapt but not copied Political and financial commitment is the key factors on both health systems development and financial protection Ensuring equitable access to and good quality of health care services is as important as the financial protection The success of UHC depends much on the spirit of committed health workers not only money National capacity for evidence based policy is really needed 18
Situations that lead to reform 1997 Constitution Politics (Window of opportunity) 2001 general election 1993, 1996,1997 HCF workshops Experien ces SSS & HCS HCRP (EU) 1998-2000 Evidences & capacity IHPP HSRI 1992 SIP (WB) 1999-2001 HITAP UC working group 2000 HISRO Triangle that moves the mountain Social mobilization A civil proposal on UC 19
Thank you for your attention 20