strengthening health systems: lessons learned from 2nd decade of thailand’s uhc 2016.8.25

Celebrating The Legacy of HRH Prince Mahidol of Songkla:

A Century of Progress in Public Health and Medicine in Thailand

Strengthening Health Systems:Lessons Learned from 2nd Decade of Thailand’s UHC

Borwornsom Leerapan, MD PhDPresent at Countway Library of Medicine, Harvard University

25 August 2016Pix source: student.mahidol.ac.th

Outline

Pix source: online.wsj.com

1. Thailand’s health systems development before and after Universal Health Coverage (UHC)

2. Lessons learned from Thai UHC

3. Implications for the future of UHC

Q1: What had been the progress of Thailand’s health systems development?

Pix source: online.wsj.com

Source: WHO (2000). The World Health Report 2000; Pix source: Modified from: buelahman.files.wordpress.com

The World Health Report 2000:• The WHO’s first major analysis of the world’s healthcare systems.• Health systems of all member states were analyzed and ranked by eight measures that

explain how health systems perform. • Thailand was ranked the 47th on the overall health systems performance.

Japan(10th)

Thailand(47th)

China(144th)

Germany(25th)

Japan(10th)

Canada(30th)

USA(37th)

UK(18th)

Swiss(20th)

Mexico(61th)

France(1st)

India(144th)

Israel(28th)

Italy(2nd) Australia

(32nd)

Timeline

PM received Certificate in Public Health from Harvard

(1921)

The "people's constitution” promulgated and widely hailed as a landmark in democratic

political reform (1997)

Socioeconomic and Political ContextsEra of the Beginning of Modern Medicine and Public Health

Asian Financial Crisis or "Tom Yum Goong Crisis”

(1997)

UHC officially started with the National

Health Security Act (2002)

Small pox vaccination

ended(1980)

Era of the Cold War

Primary Health Care

Declaration of Alma-Ata

(1978)

PM was the Director-General of

the University Department, Ministry of Education

(1923)

Kingdom of Siam changed from

absolute monarchy to constitutional

monarchy(June 24, 1932)

PM received M.D.(cum laude)and was elected a member of the

Alpha Omega Alpha(1928)

PM was liaising with the Rockefeller Foundation for

financial and technical aid to improve

Thailand's medical and public health

education(1916-1923)

PM died at the age of 37 years (24 Sep 1929)

Having built one provincial hospital in

every province in Thailand (1957)

HRH Prince Mahidol(PM) resigned from the Royal Thai Navy

to pursue his conviction by

studying at Harvard(1916)

Thailand joined WHO

(1947)

Starting the policy to build a community hospital in every

district nationwide(1974)

Timeline of Health Systems Development in Siam/Thailand

Ministry of Public Health established

(1942)

The first HIV/AIDS

patient found in Thailand(1984)

Medical Welfare Scheme started

(1975)

Era of Primary Health Care towards UHC

National Essential Drug List started

(1981)

Healthcare Accreditation

Institute established

(1999)

The National Health Act

(2007)

The Health Promotion Act

(2001)

Data source: Thailand Health Profile 2008-2010; Pix source: www.en.psu.ac.th/about-psu/introduction/27-history/224-biography-of-his-royal-highness-prince-mahidol-adulyadej.html

Restructuring University of Medical Sciences (currently Mahidol University)

out of Ministry of Public Health (1959)

The whole class of medical graduates from CMU moved

to the USA(1965)

Siam was renamed Thailand

(24 June 1939)

The 1st National Economic and Social

Development Plan (1961-1966)

Source: Patcharanarumol et al. (2011). Why and how did Thailand achieve good health at low cost; Pix source: HISRO (2012).

Thailand’s Path to UHCHealth Systems Development, 1970s-2000s

“Infrastructure has been built over time”

Source: Thailand’s National Statistical Office, the Health and Welfare Surveys in 1991, 1996, 2001, 2003.Pix Source: TDRI; Health Insurance System Research Office (2012).

Thailand’s Path to UHCCoverage of Health Insurance, 1970s-2000s

21

3

UCS

SSS

(SSS)

(UCS)

(CSMBS)

CSMBS

Long-term drive vs. “Big Bang” reform

Data source: http://data.worldbank.org; Pix Source: Health Insurance System Research Office (2012).

Thailand’s Path to UHCAgainst GNI per Capita, 1970s-2000s

Long-term drive vs. “Big Bang” reform

Thailand’s Path to UHCKey Features of the UCS Policy

2

1

3

Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

Thailand’s Path to UHCHealth Expenditures as % GDP, 1990s-2000s

Total Health Expenditures

General Government Health Expenditures (excl. Social Security)

Out-of-Pocket Payment

Private Insurance

Social Security Scheme

Source: International Health Policy Program, the national health account of Thailand 1994-2008.

“Significant increase of health expenditures by the government ”

Others

Thailand’s Path to UHCService Utilization Rates among UCS members

“Better access and greater utilization of healthcare services”

Source: National Health Security Office (2011)

(Visits/capita/year) (Admissions/capita/year)

Thailand’s Path to UHCThai Households with Medical Impoverishment

“Prevention of medical impoverishment”

Source: Health Insurance System Research Office (2012)

Before UCS After UCSStarting UCS

Thailand’s Path to UHCThai Households with Medical Impoverishment

Source: Health Insurance System Research Office (2012).

Before UCS After UCSStarting UCS

“Less medical impoverishment nationwide”

Q2: What are the lessons learned from UHC implementations in Thailand?

Pix source: online.wsj.com

Thailand’s Path to UHCWhy the UCS was launched in 2001?

Source: Wasi (2002). “Triangle That Moves The Mountain” and Health Systems Reform Movement in Thailand; HISRO (2012); Pix source: www.pinterest.com/pin/88594317647694761/

“The Public Health Triumvirate”

• Major political party putting UHC as one of its priorities in the 2001 general election (with “30-baht treats all diseases”campaign slogan)

• Civil society securing Parliament’s commitment to the UHC

1) Creation of Relevant Knowledge

2) Social Movement 3) Political Involvement

• Scholarly assessments showing the UHC was “financial and programmatically feasible”

What’s Next?Policy Recommendations at the End of 1st Decade

Ø Two sets of policy recommendations are offered with a view to sustaining and improving of UHC over the next 10 years (2011-2020):

1) “The Unfinished Agenda”1. Governance and strategic purchasing2. Managing the purchaser-provider split3. Harmonizing the three public health insurance schemes

2) “The Future Agenda”1. The private sector2. Decentralization3. Epidemiological transition and the ageing of the population4. Quality monitoring, quality assurance and health technology

assessment

Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

• Social accountability, transparency, protection against political manipulations • Relationship between the purchaser (NHSO) and the provider (MOPH)• Equitable distribution of human resources

Source: HISRO (2012); Pix Source: www.hfocus.com; web.facebook.com/aanuchitn

#1 Governance and Strategic Purchasing #2 Managing the Purchaser-Provider Split

#3 Harmonizing Three Public Health Insurance Schemes

• Reducing inequities in benefits, level of expenditures• Addressing inefficiencies across the schemes • Standardizing common features

Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

#4 The Private Sector

• Establishing a single regulatory system for both public and private providers • Engaging more with the private sector in the delivery of publicly-funded care,

especially in the urban settings

Source: HISRO (2012); Pix Source: www.bumrungrad.com/en/clinics-and-centers

#5 Decentralization

• Exploring local commission of health services• Balancing centralization and decentralization

Source: HISRO (2012).

Source: HISRO (2012); Pix Source: www.bumrungrad.com/en/clinics-and-centers

Thailand’s 13 Regional Healthcare Governance Structure (since 2012)

#6 Epidemiological Transition and Ageing Population

• Developing appropriate long-term care models—hospital care still dominates other care models in Thailand

• Greater investment in disease prevention and health promotion• Addressing social determinants of health

Data source: NSO. Population and Housing Census 1970, 1980, 1990, 2000, 2010; NESDB. National Projections for Thailand 2010-2040.Pix source: Foundation of Thai Gerontology Research and Development Institute. This report on the situation of Thai elderly 2014.

#7 Quality Monitoring, Quality Assuranceand Health Technology Assessment

• Developing methods to routinely collect and assess clinical outcomes • Building institutional capacity for health technology assessment (HTA)

Source: HISRO (2012); Pix source: www.hitap.net/en/

Source: www.ha.or.th; forumhai.com/2016/gallery; www.tqa.or.th/en/

AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US

OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11

Quality Care 2 9 8 7 5 4 11 10 3 1 5

Effective Care 4 7 9 6 5 2 11 10 8 1 3

Safe Care 3 10 2 6 7 9 11 5 4 1 7

Coordinated Care 4 8 9 10 5 2 7 11 3 1 6

Patient-Centered Care

5 8 10 7 3 6 11 9 2 1 4

Access 8 9 11 2 4 7 6 4 2 1 9

Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11

Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5

Efficiency 4 10 8 9 7 3 4 2 6 1 11

Equity 5 9 7 4 8 10 6 1 2 2 11

Healthy Lives

4 8 1 7 5 9 6 2 3 10 11

Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508

COUNTRY RANKINGS

Top 2*

Middle

Bottom 2*

EXHIBIT ES-1. OVERALL RANKING

Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).

Pix source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

The Commonwealth Fund’s Ranking of Healthcare Systems (2014)

Q3: What would be the policy implicationsfor the future of UHC worldwide?

Pix source: online.wsj.com

Politics MattersFour Major Types of Healthcare Systems

Source: Adapted from Roemer (1993). National Health Systems Throughout the World.

US Singapore Germany Japan Canada Taiwan UK Cuba

The leastmarket interventions

-Private financing -Private providers

Socialist Health Systems

Entrepreneurial Health Systems

Comprehensive Health Systems

Welfare-oriented Health Systems

The most market interventions

-Public financing -Public providers

Coalitions, Elections, Military Coups Political Turmoil in Thailand, 2000s-2010s

Thaksin Shinawatra(1st Term)2001/2-2005/3

Thaksin Shinawatra(2nd Term)2005/2-2006/9

SurayudChulanont2006/10-2008/1

Sam

akSu

ndra

vej

Som

chai

Won

gsaw

at Abhisit Vejjajiva2008/12-2011/8

Abh

isitV

ejjaj

iva

2008

/12-

2011

/8

Yingluck Shinawatra2011/9-2014/5

Prayut Chan-o-cha2014/5-present

??Assuming General Election in late 2017

2001 2002 2003 2004 2005 2006 2006 2008 2009 2010

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

*The dark green shaded boxes represent the coup-appointed governments

The National Committee on Resource Mobilization for Sustainable UHC (2015)

• Sustainability • Adequacy• Fairness• Efficiency

The National Committee on the Development of National Health Security Systems (2016)

• Sustainability & Adequacy• Fairness• Systems Efficiency &

Resource Distribution• Effectiveness & Efficiency

of Health Services Source: http://ihppthaigov.net/document/safe/SAFE(ENG)Feb2016.pdf

Beyond Healthcare FinancingControl Knobs Framework for Health Reform

Source: Adapted from Roberts et al. (2003).

Source: Hoffman et al. (2012). A Review of Conceptual Barriers and Opportunities Facing Health Systems Research to Inform a Strategy from WHO.

Summary

Pix source: online.wsj.com

1. Prince Mahidol put forth the foundations of medical education and public health infrastructure in Thailand.

2. Lesson learned from Thailand is that a long-term health systems development is required for UHC, including: v Creation of relevant knowledgev Social movement v Political involvement

3. Sustainability of UHC depends on:v Systems thinking v Institutional capacities to create and apply relevant knowledge

Pix source: Courtesy Akarin Nimmanit, MD