healthcare landscape in thailand, an overview - aug 2014

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Prepared by Catapult! August 2014!

Healthcare Landscape in Thailand!An Overview!

2

Contents!!

1. Growth Hypothesis for Healthcare in Thailand 03

3. Key Drivers and Challenges 12

2. Current Healthcare Market Context 05

4. Back Up 14

3

null hypothesis – to be disproved!

4

Null Hypothesis!market potential in Thailand’s hinterland is rather small!

Factors to Examine

* UCS is Universal (Health) Coverage Scheme

Country’s health system is not yet mature to pursue growth in

the country’s hinterland 1.

Capacity (health infrastructure) in the hinterland is not ready to

support market development 2.

!  Current UCS* mechanism system has not matured, to warrant pursuing growth (and invest in market development) in the country’s hinterland

!  Government places less emphasis on (disease) diagnosis and is not likely to change emphasis in the near future

!  Current health infrastructure and facilities are not capable, or adequately developed

!  Health services personnel issues exist, both in terms of personnel shortage and lack of adequate trained personnel

Market and business key drivers are yet weak to pursue growth in

the country’s hinterland 3.

!  Public hospitals have neither the funds, nor the mechanism, to expand infrastructure; they are also not geared to take-in more patients

!  Private hospitals are concentrated in/around Bangkok and therefore, demand in up-country is rather small

This document argues that companies need to push for growth from the hinterland, albeit in different ways than what has been tried thus far

5

current market context and evolving scenario!

6

Health System Overview!!

* refer back up slide for summary on existing health coverage schemes in Thailand ** NHSO is National Health Security Office Sources: World Bank Report, 2011; Health Insurance System Research Office 2013

Universal Coverage Scheme (UCS)

Since 2001

Its Impact !  There has been a steady expansion in

access to health services, in utilization of facilities & in financial protection among patients -  However, significant disparities exist across

geographical regions within the country

!  Expenditure on health is significant -  Overall health expenditure is at ~4% of GDP

-  Govt. health expenditure, as % of total govt. expenditure, is at ~14%

Key Challenges for the System

!  Comprehensive coverage is provided to Thai people under health schemes* !  Preventive & diagnostic care getting increased emphasis – approx. 11% of

total NHSO** expenditure was in a clinical setting !  Est. only 5.7% of UCS members (of the total ~75% of population) were

registered with private-sector provider network " majority services are dispensed at public facilities

!  NHSO regional offices are responsible for purchase decisions " a critical step in segregating the purchaser-provider role

Key Features

1.  Ensuring greater autonomy within NHSO** 2.  Increasing (public) hospital deficits,

leading to financial strain 3.  Increasing private sector involvement 4.  Addressing the ever-expanding burden of

chronic diseases 5.  Collecting, reporting, monitoring data on

quality of care & clinical outcome assessment

7

Key Supply-Side Indicators!relative to population!

* refers to Bangkok Metropolitan Region that comprises 50 districts governed under the Bangkok Metropolitan Administration (BMA) Notes: (column-wise) % totals may not add up to 100%, due to rounding-off error; Some hospitals in the Central region are included in BMR geographical area Sources: Thailand National Statistics Office (NSO), Secondary research, Catapult analysis

Thailand Map % of Population

% of Hospitals

% No. of Beds

% of all Doctors

North 18% 20% 20% 16%

North-East 34% 28% 20% 20%

Bangkok 09% 10% 20% 25%

Central 25% 26% 25% 28%

South 14% 16% 15% 12%

Though Bangkok* gets disproportionately high share of healthcare (infrastructure and) resources, other regions are grossly under-served,

suggesting un-tapped demand potential

8

Spread of Hospital Infrastructure!by type (private, public)!

Thailand Map

Notes: No. of hospitals as of 2011 (best estimates); Central region includes provinces around Bangkok & includes area under BMA Sources: Thailand NSO, Ministry of Public Health (MOPH), various Secondary research, Catapult analysis

50

215

Private Hospitals Public Hospitals

Northern Region

100

235


Bangkok

35

180


Southern Region

40

320


North-Eastern Region

Public hospitals are ~3/4th of all facilities, but grossly under-served

due to multiple factors

95

40


Central Region

Total, est. 1300

hospitals in

Thailand

9

Health Status Indicators!most recent assessment!

Notes: All data pertains to 2011; health system performance assessment period between 2001-10 Sources: Report on Govt. Spending & Central-Local Relations in Thailand’s Health Sector (Aug 2012) - World Heath Organization (WHO), MoPH, various Secondary research, Catapult analysis

There is evidence of recognition by the government that better diagnosis would lead to reduced healthcare expenditure; Further, the NHSO regions – 13 in all – have been given

greater autonomy in financing decisions and management

!  Steady expansion of service availability, combined with broadening health protection coverage has been associated with an increase in utilization of health services

!  Though there is little evidence of the extent to which the health system has contributed to improved health outcomes, data indicates recent improvement in outcomes

!  Measures of primary health care performance in preventing and managing chronic illness show a mixed picture -  Diagnosis rates remain much lower when

compared to other upper middle-income countries (one that Thailand itself is)

-  Though chronic disease management has improved, gaps remain

Top 10 Causes of Death in Thailand

Thailand is among leading countries for death due to Lung, Liver, Kidney diseases; It ranks #6 in the world

for road accidents as a leading cause of death

14%

10%

7% 6%

6%

6%

5%

5%

4% 4%

Stroke

Coronoary Heart Disease

Diabetes Mellitus

Lung Disease

Road Traffic Accidents

HIV / AIDS

Liver Disease

Influenze & Pneumonia

Kidney Disease

Liver Cancer Cause of 2/3rd of all deaths

Health System Performance (select)

10

Situation Assessment!summary!

Overall Goals on Health Issues 1.

Challenges in Health Outcomes 2.

Nature of Health Spending by Govt. 3.

Evolving Role of Local Administration 4.

Private Sector Role in Care Delivery 5.

Key Factors Key Observations !  Non-equitable delivery of healthcare, disparities in spending for those

covered under different schemes, variance in quality & capacity of facilities are only some of the key gaps that remain, as per Thailand’s 11th National Health Development Plan

!  While overall health outcomes have improved (studied between 2004-09), management of various chronic conditions have not. Recent surveys show poor management of various chronic conditions among existing patients (e.g. diabetes, hypertension – to name only two)

!  Though spending under UCS remains equitable*, challenges are in nature of spending – pre-dominantly on personnel costs – & spending (or lack of) in the hinterland for specialized services. Bangkok gets a disproportionately high share due to its high share of patient referrals

!  Examples of local administration (e.g. BMA) successfully managing its funds (staff & facilities) requirement already exist. This was piloted in 2 other regions. This is being further expanded under the Decentralization Act & when fully expanded will aid decision-making

!  Overall participation by the private sector is limited as it serves mainly the more lucrative segments of the market (e.g. medical tourists, civil servants). Private sector care givers (& also device, pharma companies) must look at the systemic changes already taking place

* spending under Universal Coverage Scheme is basis population spread across the country Note: BMA is Bangkok Metropolitan Administration Sources: Thailand NSO, MoPH, WHO, various Secondary research, Catapult analysis

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Impact of Medical Tourism!is there a greater role for it to play?!

Evaluation in the Overall National

Context

Negatives

Positives

Key Factors to Consider* 1.  Health infrastructure

capacity addition & utilization of hospital services

2.  Training & development of medical professionals

3.  (Best) Practices to improve treatment outcomes & treat complex diseases

4.  Price of treatment, spc. for treatment of locals**

5.  Overall impact on the health system (finances, personnel, care delivery)

Current literature suggests medical tourism business mainly serves foreign patients ! it may well have a limited role to play, unless specific measures are introduced to

benefit the public health delivery system

1.  Overall image perception of Thailand as a high-quality medical tourism destination

2.  Adoption of latest technologies & treatment practices, albeit in select areas

3.  Other benefits (e.g. indirect employment generation) that may have accrued are not studied

1.  Private hospital capacity, as a segment, has in fact declined

2.  Majority of in-patient capacity in the private serves foreign patients

3.  Barring arrangements (e.g. for civil servants) private hospitals remain out of reach for Thai people

4.  Causes health personnel shortage

* in no particular order of importance ** as opposed to medical tourists coming in to country for medical treatment Reference: 2013 Paper ‘Medical Tourism in Malaysia, Singapore & Thailand’, Centre for Health Economics, Chulalongkorn University

12

drivers and challenges for future growth!

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Drivers and Challenges!!

Macro-Economic factors

Health Financing & Sector reforms

Disease Burden & Treatment Challenges

Health Infrastructure

!  Despite (political) challenges, a V-shaped recovery expected for the Thai economy in 2015*. GDP is expected to grow 5.5% (vs. 2014) & then moderate, going forward

!  Historically, services sector & private investments have a large share to GDP growth & unless these revive, growth will be anemic at best

!  Government finances are troubled & expenditure on health already makes for a large share (~14%) of total govt. spending

!  3 main challenges exist, overall: i.  Inequalities in utilization &

spending under different health coverage schemes

ii.  Mounting cost pressures

iii. (Still) Unclear roles in administration / financing between central & local authorities

!  Thailand is a rapidly ageing society & also faces increasing burden of chronic diseases

!  Though private facilities generally tend to offer best-in-class services, the same has not necessarily percolated to public facilities in the hinterland

!  Improvement in skills among health professionals remains a challenge

!  Thailand’s health infrastructure is predominantly in the public sector

!  Evidence suggests a large majority of Thai people (barring civil servants) do not tend to use private hospital facilities. This suggests not only disparate standards of care, but lack of interplay (between public-private) to benefit the larger population

* uncertainty remains unusually high given prevailing political situation Sources: Various news reports, Bank of Thailand, ADB, World Bank reports, WHO reports, Catapult analysis

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back up!

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Health Coverage Schemes!summary !

Scheme / Details

Universal Coverage Scheme

(UCS)

Social Security Scheme (SSS)

Civil Servant Medical Benefit Scheme

(CSMBS)

Private Insurance*

Scheme nature;

Coverage

Citizen entitlement (those not covered

by SSS or CSMBS); comprehensive

1.5% of salary equally by 3-parties;

comprehensive

Non-contributory scheme;

comprehensive, higher than UCS & SSS

Private contract

Beneficiaries Thai citizens Private sector

employees, excl. dependents

Government employees, dependents** (and

retirees) Those insured

% Population covered (est.) 75% 16% 9% Est. 6-9 Mn.***

Source of finance; Cap†

General tax; (US$ 79/ cap)

Pay-roll tax, Tri-party – Employer, Employee, Govt.; (US$ 71/cap)

General tax, non-contributory scheme;

(US$ 367/cap)

Insurance buyers; as per contract

Management organization NHSO, MOPH

Social Security Office, Ministry of Labor and

Welfare

Controller General, Ministry of Finance

Private insurance companies

* Additional coverage by private contract ** Dependents include parents, spouse and up to 2 children under 20 years of age *** These beneficiaries are also covered under either UCS, or SSS † Cap show avg. spending/capita/annum, paid by the govt. to a hospital (2010). Amount varies according to type of treatment

Sources: World Bank Report – 2011, Health System Research Institute, various Secondary research

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