International Health Policy Program -Thailand 1 Healthcare Financing in Thailand: an update in 2007...
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- Slide 1
- International Health Policy Program -Thailand 1 Healthcare
Financing in Thailand: an update in 2007 Updated by International
Health Policy Program (IHPP) Ministry of Public Health,
Thailand
- Slide 2
- International Health Policy Program -Thailand 2 Outline
presentation I. Background information on burden of disease and
health care finance IA. Burden of Disease in 2004 & national
health expenditure, 1994 2005 IB. Healthcare financing performance
Fairness in financial contribution EQUITAP results Incidence of
catastrophic and impoverishment from OOPs Equity in utilization
& benefit incidence analysis (BIA) II. Ongoing major works IIA.
Universal offer of VCT IIB. Major program review of cervical cancer
control IIC. Review of DCP2 and its application in chronic diseases
management IID. Annual hospital report III. Future challenges:
Renal replacement therapy, financial sustainability, and potential
moral hazards, etc.
- Slide 3
- International Health Policy Program -Thailand 3 IA. Background
information: BOD and financing healthcare
- Slide 4
- International Health Policy Program -Thailand 4 Profile: top 10
mortality, Thailand 2004 Total deaths 390,285 Top 10 deaths share
63% of total national deaths
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- International Health Policy Program -Thailand 5 Top 10 YLL
shares 63 % of total national YLL Profile: top 10 YLL, Thailand
2004 Total YLL 6.07 million years
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- International Health Policy Program -Thailand 6 Profile: top 10
YLD, Thailand 2004 Total YLD 3.1 million years Top 10 YLD shares
71% of total national YLD
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- International Health Policy Program -Thailand 7 Profile: top 10
DALY loss, Thailand 2004 Total DALY loss 9.17 million years Top 10
DALY shares 52% of total national DALY loss
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- International Health Policy Program -Thailand 8 DALY loss by
age group and gender, Thailand 2004
- Slide 9
- DALYs per 1,000 population, ranked 22 categories
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- International Health Policy Program -Thailand 10 Top 15 risk
factors, men Thailand 2004
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- International Health Policy Program -Thailand 11 Top 15 risk
factors, women, Thailand 2004
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- International Health Policy Program -Thailand 12 Total Health
Expenditure, NHA 1994 2005
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- International Health Policy Program -Thailand 13 Real term
growth GDP versus THE, 1994-2005 13
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- International Health Policy Program -Thailand 14 THE, Baht per
capita NHA 1994-2005 current and constant price (2003) 14
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- International Health Policy Program -Thailand 15 Trend of
financing sources NHA 1994-2005
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- Trends of financing agents, NHA1994-2005
- Slide 17
- Expenditure by financing agent NHA2005
- Slide 18
- Expenditure by public financing agents, NHA2005
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- International Health Policy Program -Thailand 19 Expenditure by
healthcare Function NHA2005 19
- Slide 20
- International Health Policy Program -Thailand 20 CSMBS total
expenditure and growth 1988-2006 Source: Comptroller General
Department, Ministry of Finance (various years) million of
employees/pensioners
- Slide 21
- International Health Policy Program -Thailand 21 IB.
performance of UC scheme
- Slide 22
- International Health Policy Program -Thailand 22 Why
general-tax-financed UC Scheme? Contributory UC Scheme was not in
the policy agenda during 2001 general election, Feasible to apply
general tax, additional budget requirement was in fiscal capacity
Not feasible to collect premium Urgency to nation-wide scale up
immediately, political obligations to the constituency Subsequent
studies indicate the Concentration Index of various sources of
healthcare finance Thailand 2002 (ODonnell et al 2005) CI weight
NHA Direct tax 0.90570.1868 Indirect tax 0.57760.3155 Social
insurance0.57600.0582 Private insurance0.39950.0668 Direct
payments0.48640.3728 Total Health Financing 0.5929 General Tax
0.6996 Note: CI, an index of the distribution of payments, ranges
(-1 to 1), a positive (negative) value indicates the rich (poor)
contributes a larger share than the poor (rich), a value of zero is
everyone pays the same irrespective of ability to pay
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- International Health Policy Program -Thailand 23 Contribution
of Social Health Insurance (SHI) to UC Scheme system design SHI as
a predecessor of UC Contract model contractual arrangement with
competitive public and private provider contractors Contract is
feasible in the context of comprehensive geographical coverage of
MOPH healthcare infrastructure Closed-ended provider payment method
Among a few developing countries, Thailand pioneers capitation
payment method Additional pay for A&E, high cost care, based on
fee schedule Purchaser Provide split Social Security Office and
National Health Security Office as purchasers design packages and
payment methods MOPH, other public and private medical institutions
as major providers Comprehensive coverage Comprehensive service
package, OP, IP, Prevention, Promotion Neither deductibles nor co
payment at point of services, UC scheme has nominal pay of US$ 0.75
per visit or admission
- Slide 24
- International Health Policy Program -Thailand 24 Advanced
characteristics of the UC Scheme
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- International Health Policy Program -Thailand 25 Capitation
rate Capitation rate and components Baht per capita, approved fig.
2002-2007, plan fig. 2008
- Slide 26
- International Health Policy Program -Thailand 26 IHPP
calculates capitation rate based on actual utilization rate and
unit cost. Due to fiscal constraint, it results in discrepancy
Discrepancy: proposed & approved capitation rate
FY2002-2006
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- International Health Policy Program -Thailand 27 Household
health expenditure as % of household income by income deciles prior
to UC (1992-2000) and after UC 2002-2006 Source: NSO SES (various
years)
- Slide 28
- International Health Policy Program -Thailand 28 Distribution
of households with health expenditures > 10% total consumption
by consumption expenditure quintiles Source: NSOs SES (various
years)
- Slide 29
- International Health Policy Program -Thailand 29 Catastrophic
health payments in Thailand, 1996-2002 % non food expenditure on
health 1996199820002002 0 to 0.5%31.933.234.541.2 0.5 to
10%51.351.550.848.1 10 to 25%11.910.911.07.6 25 to 50%3.53.63.12.5
More than 50%1.40.80.70.5 Total100.0 Source: National Statistic
Office, Household Socio-economic Survey, various years.
- Slide 30
- International Health Policy Program -Thailand 30 Pre-post UC
incidence of catastrophic expenditure Households with health
payment > 10% of total consumption expenditures All households
LIC/VHC UCE/-P Year 2000 Quintile 14.0%2.7% Quintile 55.6%7.1% All
Quintiles5.4%4.7% Year 2002 Quintile 11.7% Quintile 55.0%6.1% All
Quintiles3.3%3.2% Year 2004 Quintile 11.6% Quintile 54.3%5.2% All
Quintiles2.8%2.6% Year 2006 Quintile 10.9% Quintile 53.3%3.0% All
Quintiles2.0%1.9% Source: NSOs SES (various years)
- Slide 31
- International Health Policy Program -Thailand 31 Impact of UC:
Catastrophic illnesses, impoverishment Limwattananon et al 2005
Dataset : NSO SES 2000 (24,747 households), 2002 (34,785) and 2004
(34,843). Finding The incidence of catastrophic health expenditure
(>10% of total HH consumption) reduced From 5.4% in pre-UC 2000
to 3.3-2.0% in post-UC 2002-2006 An increase in the poverty
headcounts due to OOP payments dropped From 2.1% in pre-UC to
0.8-0.5% in post-UC. Conclusions Reduction in the catastrophe and
impoverishment due to OOP health payments is evident after the UC
reform which provides comprehensive coverage of health care with a
very small nominal fee.
- Slide 32
- International Health Policy Program -Thailand 32 Healthcare
Catastrophe vs. OOP Payments & Income data as of 2000 Source:
van Doorslaer et al. (2005)
- Slide 33
- Utilization by UC members s ource: NSO HWS2001, 2003, 2004,
2005 and 2006
- Slide 34
- International Health Policy Program -Thailand 34 Total
Ambulatory Visits (millions/yr) (HWS 2001, 03, 04, 05, 06) LIC/VHC
& UC-E/-P SSS CSMBS
- Slide 35
- International Health Policy Program -Thailand 35 Average
Ambulatory Visits (per member/yr) (HWS 2003, 04, 05, 06) UC-E/-P
SSS CSMBS 1.86 2.18 2.07 1.53 1.13 1.09 1.12 0.91 1.80 1.98 1.93
1.67
- Slide 36
- International Health Policy Program -Thailand 36 Insurance Use
for OP Visit (% compliance) (HWS 2003, 04, 05, 06) UC-E/-P SSS
CSMBS
- Slide 37
- International Health Policy Program -Thailand 37 Total Hospital
Admissions (millions/yr) (HWS 2001, 03, 04, 05, 06) LIC/VHC &
UC-E/-P SSS CSMBS
- Slide 38
- International Health Policy Program -Thailand 38 Average
Hospital Admissions (per member/yr) (HWS 2001, 03, 04, 05, 06)
LIC/VHS & UC-E/-P SSS CSMBS 0.09 0.08 0.09 0.08 0.08 0.06 0.06
0.07 0.06 0.07 0.10 0.09 0.12 0.11 0.08
- Slide 39
- International Health Policy Program -Thailand 39 UC-E/-P SSS
CSMBS Insurance Use for IP admission (% compliance) (HWS 2003, 04,
05, 06)
- Slide 40
- International Health Policy Program -Thailand 40 The
distribution of ambulatory service use among different income
quintiles in 2001 and 2003, by types of health facilities 2001 2003
Concentration indices of ambulatory service use among different
types of health facilities in 2001 & 2003 Type of health
facilities20012003 Health centers - 0.2944- 0.3650 Community
hospitals- 0.2698- 0.3200 Provincial and regional hospitals-
0.0366- 0.0802 Private hospitals0.43130.3484
- Slide 41
- Selected concentration curves of ambulatory service use among
different types of health facilities in 2003
- Slide 42
- International Health Policy Program -Thailand 42 The
distribution of hospitalization among different socio-economic
groups in 2001 and 2003, by types of health facilities
Concentration indices of hospitalization among different types of
health facilities in 2001 & 2003 Types of health
facilities20012003 Community hospitals - 0.3157- 0.2934 Provincial
and regional hospitals- 0.0691- 0.1375 Private
hospitals0.31990.3094 Overall hospitalization- 0.0794- 0.1208
20032001
- Slide 43
- Selected concentration curves of hospitalization among
different types of health facilities in 2003
- Slide 44
- International Health Policy Program -Thailand 44 Who benefits
from public subsidies Limwattananon et al 2005 Benefit Incidence
Analysis: compare pre-UC 2001 and post-UC 2004 using NSO HWS2001,
2004 OP care Post UC 2004, the pro-poor subsidy was very pronounced
at District Health System (DHS) Concentration Index = - 0.3326 and
- 0.2921 for Health Centre and District Hospital respectively. Less
progressive at provincial hospitals (PH) CI = - 0.1496. IP care
More progressive in favour of the poor at DH CI = - 0.3130 in 2001
and - 0.2666 in 2004. Weaker progressive in favour of the poor at
PH CI = - 0.1104 in 2001 and - 0.1221 in 2004 Conclusions The
pro-poor subsidy were strongest for DHS. Lessons indicates DHS
plays key role in fostering the pro-poor nature of public subsidy.
Close to client services, better accessed
- Slide 45
- International Health Policy Program -Thailand 45 Percent
distribution of net government health subsidies among different
income quintiles in 2001 and 2003 Note: -Overall net government
health subsidies in 2001 were approximately 58,733 million Baht,
and in 2003 were 80,678 million Baht (in 2001-value) - The
concentration index of government health subsidies in 2001 was
-0.044 and in 2003 was -0.123
- Slide 46
- International Health Policy Program -Thailand 46 Concluding
remarks 1 Enabling factors for achieving UC Strong political
supports Health systems capacity and its resilience to rapid
nation-wide program scale-up in 6 months Lessons from predecessors
SHI capitation contract model CSMBS no go fee for service, due to
cost escalation and inefficiencies Voluntary Health Card Scheme
adverse selection and non-viable financially Linking evidence to
policy decision Integral relationship among researchers reformists
politicians Pragmatism Limited chance to achieve UC by contributory
scheme, especially among informal sector, not feasible for
contribution collection and enforcement Learning from SHI, UC takes
further advanced steps, Well thought systems design towards
efficiency, cost containment, ensure referral, advocates of primary
care contractor
- Slide 47
- International Health Policy Program -Thailand 47 Concluding
remarks 2 UC Schemes covers the poor, half belongs to Q1 and Q2
However, the Scheme faced chronic under-funding, capitation was
below than the proposed figures based on cost and utilization
Significant increase in utilization more on OP than IP In view of
under-funding and increased utilization danger of poor quality of
services and serious hospital financial constraints Empirical
evidence indicates Pro-poor budget subsidy, DHS is a major hub of
fostering the pro- poor nature of financing healthcare Policy msg.
invest more in DHS (further) reduction in the incidence of
catastrophic illnesses (further) reduction of impoverishment from
medical bills
- Slide 48
- International Health Policy Program -Thailand 48 IIA. Ongoing
major work: Universal offer of VCT
- Slide 49
- 32.6% 10.4% 39.7% 11.7% The potential VCT uptake with zero
price Current price
- Slide 50
- Predicted Demand for VCT by Regions IDU MSM SW Gen. Pop.
- Slide 51
- International Health Policy Program -Thailand 51 IIB. Ongoing
major work: Major program review of cervical cancer control
- Slide 52
- International Health Policy Program -Thailand 52 National
Coverage of Cervical Cancer Screening (Household Survey -2006)
Source: NSOs Sexual and Reproductive Health Survey (2006)
- Slide 53
- International Health Policy Program -Thailand 53 Reported
Achievement by Set Targets (2005) Source: NHSO (2006)
- Slide 54
- International Health Policy Program -Thailand 54 Work
Components
- Slide 55
- International Health Policy Program -Thailand 55 IIC. Review of
disease control priorities (DCP-2) and its application to the 10 th
National Health Development Plan
- Slide 56
- International Health Policy Program -Thailand 56 Objectives of
the study on DCP-2 and the 10 th National Health Development Plan
To review patterns of burden of disease and risk behavior of Thais
in 1999 and 2004 To review cost-effective medical treatments and
public health interventions suggested by DCP-2 in accordance to BOD
of Thailand To explore similarity and dissimilarity of current
practice for disease control and prevention on top-ten priority of
disease burden in Thailand, compared to suggestions from the DCP-2
To estimate the magnitude of government investment in disease
prevention and reduction in health risk behavior, health promotion,
screening and early detection of disease in high priorities,
compared to investment in curative interventions To provide policy
recommendations on improving efficiency and efficacy of public
investment in health promotion, disease prevention, curative
interventions, and economic gains from more investing in health To
develop plan and framework for investing in health and estimate the
medium term expenditure framework (MTEF), compared to government
health budgets
- Slide 57
- Scope of the study Review burden of disease (BOD) and risk
behavior of Thais in 1999 and 2004 Select top-ten burden of disease
contributing to highest DALY loss in 2004 as the scope of the study
Review recommendations for effective medical treatments and public
health interventions in DCP-2, compared to current practice and
clinical guideline practices in Thailand Provide policy
recommendations for improving efficiency in health investment in
health promotion, disease prevention, screening, curative and
reducing risk behavior Estimate public resources required for
investment in health promotion, disease prevention, and public
health program in reducing risk factors and behavior of each
disease, compared to curative program and other sectors Estimate
budget requirements for health investment in the 10 th National
Health Development Plan and present research findings for public
hearing of all stakeholders
- Slide 58
- International Health Policy Program -Thailand 58 IID.
Sustainable Development of Healthcare System Performance in
Thailand
- Slide 59
- International Health Policy Program -Thailand 59 Objectives To
review previous studies of Thai healthcare performance and current
approaches from international perspectives Based on process of
consultation and consensus agreement among major stakeholders in
Thailand, to develop and conceptualize the Thai healthcare system
performance framework To build up institutional capacity and foster
networking with all stakeholders and technical partners for a long
term national capacity in healthcare performance assessment To
assess and produce a public report on Thai healthcare performance
in for FY2007 (pilot phase in 4 Provinces) To develop strategy and
policy approach to catalyze improvement in the performance in the
positive ways
- Slide 60
- International Health Policy Program -Thailand 60 Conceptual
Framework of Healthcare System Performance Review: Concept; Domain;
Indicators; Information system Review Existing: Indicators; Data
source; Information system Thai conceptual Framework: Goals;
domain; Indicators; data Gap?: Data (available; quality)
Information system; DevelopMeasure Level: Hospital and CUP Report:
Level (province, region) Indicators Benchmarking Analyze, Synthesis
Revised Improvement: Personnel; IT; Management Survey? Users:
Public Central government Local government Healthcare planner
Hospital manger Health insurer Academia
- Slide 61
- International Health Policy Program -Thailand 61 III. Future
challenges
- Slide 62
- International Health Policy Program -Thailand 62 Prevalence
Hypertension: 23% male, 21% female All samples are hypertensive,
>140/90 mmHg,
- Slide 63
- International Health Policy Program -Thailand 63 Prevalence DM:
6% male, 7% female All samples have FBS, >126 mg/dl
- Slide 64
- International Health Policy Program -Thailand 64 Death from
Diabetes PoorestRichest Death rate Diabetes death
- Slide 65
- International Health Policy Program -Thailand 65 Death from
Ischemic Heart Disease PoorestRichest Death rate IHD death
- Slide 66
- Slide 67
- CEA and CUA societal perspectives PD and HD at NPV 2005
- Slide 68
- Budget impact analysis 2 scenarios: universal versus limited
access to RRT at the lowest cost estimate (250,000 Baht / case/
year) 2005 (year 1) 2009 (year 5) 2014 (year 10) 2019 (year 15)
Universal access to RRT (million Baht) 3,99418,05832,25543,804 As %
of UC budget5.518.423.723.6 As % of THE1.75.97.7 RRT for KT
eligible (mil Baht)1,9818,94415,96621,625 As % of UC
budget2.79.111.7 As % of THE0.92.93.8 UC budget (million
Baht)73,13698,074135,987185,248 Total health expenditure (million
Baht) 230,836303,931417,522572,659
- Slide 69
- International Health Policy Program -Thailand 69 Future
Challenges (1) Most of the crude ground works had achieved PHC
focus and reorientation, pro-poor achievement, extensive financial
protection of the poor, very minimum catastrophic incidence, BUT
Need to increase value for money Maintain decent quality of care
and continued advancement in medical progress Evidence based and
learning organization for MOF (CSMBS) SSO and NHSO BOB, MOF Fiscal
Policy Office, NESDB Harmonization across 3 public insurance scheme
Adequate and sustainable financing of the pro poor UC scheme
- Slide 70
- International Health Policy Program -Thailand 70 Future
Challenges (2) Focus more on effective coverage of increasing trend
of chronic conditions and effective prevention of injuries Renal
Replacement Therapy for chronic kidney disease patients is not
covered by UC Scheme (while SHI and CSMBS cover fully) Results in
catastrophic health expenditure by households Need serious informed
policy decision and long term financial implications Cost per life
year saved (Teerawatananon et al 2005) Peritoneal dialysis 10,170
US$ Hemodialysis 10,490 US$ Cost per life year saved
(Lertiendumrong et al 2005) Antiretroviral Therapy 590 US$ GNI US$
2,540 per capita (2004 WDR) Cost per life year saved for RRT 4
times of GNI per capita, 18 times as expensive as the current
national ART program. Ethical dimension of not extend RRT to UC
members
- Slide 71
- International Health Policy Program -Thailand 71
Acknowledgments National partners National Health Security Office
(NHSO) and other partners who initiate, design and steer the UC
scheme HSRI for supports on NHA development since day one until
institutionalized HISRO, HISO for their technical and financial
supports Ministry of Public Health (MOPH) major healthcare
providers and steer the implementation of UC scheme. National
Statistical Office (NSO) for national household surveys Thailand
Research Fund (TRF) for institutional grants to IHPP International
partners World Bank and MOPH partnership on Country Development
Partnership in Health Sector ILO for peer reviews of capitation
rate 2002, and long term financing forecast 2005-2020 WHO and
Harvard for studies on ethical dimension of RRT extension to UC
members EU funded Equity in financing, health utilization and
public subsidies in Asia Pacific (EQUITAP)