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Strategic purchasing: a comparative assessment of Civil Servant Medical Benefit Scheme and Universal Coverage Scheme in Thailand

Walaiporn Patcharanarumol International Health Policy Program (IHPP)iHEA, Milan; Wednesday 15 July, 2015

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Thai Universal Health Coverage

Act 2002 Royal Decree 1980 Act 1990

Comptroller General Dept, MOF

Social Security Office, MOL

National Health Security Office

Public (75%) & private (25%) health facilities

47 mln pop (reside in rural areas; Q1-2;

children, elderly, informal wk)

10 mln pop (urban; Q4-5;

children, elderly, public sector wk)

10 mln pop (city; Q4-5; only adult

workers in private sector)

Tax funded Tax funded Tripartite cont

UC Scheme Civil Servant Scheme

Social Health Insurance

67 million Thai populations

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Thai Universal Health Coverage

Act 2002 Royal Decree 1980 Act 1990

Comptroller General Dept, MOF

Social Security Office, MOL

National Health Security Office

Public (75%) & private (25%) health facilities

47 mln pop (reside in rural areas; Q1-2;

children, elderly, informal wk)

10 mln pop (urban; Q4-5;

children, elderly, public sector wk)

10 mln pop (city; Q4-5; only adult

workers in private sector)

Tax funded Tax funded Tripartite cont

UC Scheme Civil Servant Scheme

Social Health Insurance

67 million Thai populations

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Key actors – UC Scheme“Clear mission of a purchaser”

Purchaser:National Health Security Office

Government: Cabinet, Executive Board &

Quality Board

75% of total pop:Rural areas, Q1-2, informal workers

Providers:Network of health center &

district hospital

•Contract agreement•Payment

•Medical Audit

•Data submission

•Direction e.g.BP sub-committee

•Financial audit

•Regular meetings

•UCS close ended-budget

•Annual report•Members Registration

•Provide services

Member of the Board

Member of the Board

•Hotline 1330

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Key actors – Civil Servant Scheme"Mission: money transaction for providers”

Purchaser:Comptroller General Dept,

MOF

Government: Ministry of Finance &

Director of CGD

10 mln pop:Urban areas, Q4-5,

Govt staff, pensioners

Providers:Mainly public hospitals

•Payment•Medical Audit

•Data submission - DRG•Claim reimbursement - FFS

•Financial audit

•Regular meetings•Open-ended budget •Annual report •Members declaration

•Provide services

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Key findings 1 Purchaser-GovernmentUC Scheme Civil Servant Scheme

1. PG: policy framework

The 2002 Act - clear expectation and mandate of an effective and efficient purchaser by NHSO

No role of purchaser (by law and perception) – only money transaction for providers by CGD

2. PG: accountability

Independent government body with the Boards of multi-stakeholders

Dept of MOF, bureaucratic system

3. PG: resources of government budget

Close ended-budget with “negotiation”, however, approved < proposed budget, pressure btw PP

Open ended-budget with a sense of “entitlement”

4. PG: promoting equity

• Budget for under-served areas• Special mech e.g. mobile cataract surgery team to rural areas, contracting private hospitals for open heart surgery

No

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Key findings 2 Purchaser-ProvidersUC Scheme Civil Servant Scheme

5. PP: which providers (quality, equity)

Geographic limitation of health centers and district hospitalsHospital Accreditation which happened before UC era

Any public hospitals according to the convenience of the members

6. PP: improve health systems efficiency

• Close ended payment• Primary health care• Health technology assessment• National Essential Drug List

• National Essential Drug List but still under Fee-For-Service reimbursement for out-patient service

7. PP: provider performance (quality imp)

• Special payment e.g. asthma patient - corticosteroid inhalation / no readmission

• No

8. PP: mutual accountability and transparency

• In-house and networking for medical, coding & billing audit (DRG) -> hospitals return money back if fraud or get more payment if incomplete

• Audit by outsourcing

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Key findings 3 Purchaser-CitizensUC Scheme Civil Servant Scheme

9. PC: engage with citizens to determine their health needs and protecting financial catastrophe

• Citizen Representatives are member of the Boards (5/31)• Expansion of benefit package based on evidence of HTA and sub-committee of Benefit Package process

• No process, subject to providers’ and members’ requests

10. PC: citizens’ awareness of their entitlements, obligations and access to services

• Capitation - incentive of providers to register members • Political campaign, advertisement• Attractive slogan “30 baht cures all diseases”

• Government process, official letter circulation

11. PC: views of citizens

• Annual public hearing, satisfaction survey (providers and citizens)• Hotline 1330, 24 hrs / 7 days

• Telephone of the MOF – not effective, official working hours, together with other tasks of CGD

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FactorsContributing factors Undermining factors

A. Legal framework

• Clear policy, expectation and mandate of “a purchaser” for benefit of people and health system

• Clear policy of not to be “a purchaser”, just only for money transaction• Too many other important tasks e.g. advice on fin mgt, public procurement in the organization

B. Governing body, organization and accountability framework

• An independent organization• Governing body of multi-stakeholders – citizens’ engagement• Adequate number and competency of staff (useful of health background)

• Government structure with rigid mandate using command and control• Inadequate and no health background staff

C. Resources • Too tight budget – pressure and conflict btw purchaser and providers

• Too easy budget – soft budget -> inefficiency of the system

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FactorsContributing factors Undermining factors

D. Information • Information management• Using appropriate ICT• Pool of information

• Fragmented data requirement of different schemes creates trouble to providers – information rather than service orientation

E. Communi-cation

• Two way communication• Proactive communication – NHSO staff visited providers

• Official process of bureaucratic channels - ineffective

F. Audit • Neutral auditing mechanism• Team work of audit• An opportunity for improvement

- Knowledge and skill of the audit team and providers- Data quality of providers

• Penalty and incentives

• Bad attitude, perception and practice of investigators and being investigated persons

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Conclusion – some improvements

• Strategic for more impacts UCS – adequate budget and more equity in resource

allocation among health facilities Civil servant scheme – more efficiency of the scheme and

more equity across the schemes

• In case of multi-purchasing mechanisms in a country (e.g. Thailand), Strategic purchasing function of one purchasing mechanism

alone is not adequate Limited outcomes and impacts within one purchasing

mechanism – smaller population coverage, smaller impact Urgent needs of strategic purchasing across purchasing

mechanisms -> harmonization is needed

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www.wpro.who.int/asia_pacific_observatoryhttp://resyst.lshtm.ac.uk@RESYSTresearch

The research is a collaboration between RESYST and the Asia Pacific Observatory on Health Systems and Policies (APO)

RESYST is funded by UK aid from the UK Department for International Development (DFID). However, the views expressed do not necessarily reflect the Department’s official policies.

More information: http://resyst.lshtm.ac.uk/research-projects/multi-country-purchasing-study