24 June 2009At Faculty of Economics, TU Chalermpol CHAMCHAN Doctor of Area Studies, Graduate School...

24 June 2009At Faculty of Economics, TU

Chalermpol CHAMCHAN

Doctor of Area Studies, Graduate School of Asian and African Area Studies (ASAFAS), Kyoto University 1

“Impacts and Constraints of Universal Coverage (UC) in Thailand’s Public Health System”


I. Background The UC policy incorporated

◦1) Financial reforms with closed-end provider payment method – the capitation method – and

◦2) Strengthened primary care network with more attention on health promotion and disease prevention works (PP) – a concept of “Primary Care Unit (PCU)” under “Contracted Unit of Primary Care” (CUP) structure.

Major strategic policies: สร้�างนำ�าซ่อม (SNS: health promotion and prevention (PP) ahead curative health care) and ใกล้�บ้�านำใกล้�ใจ (KBKJ: health facility near dwelling)

24 June 2009At Faculty of Economics, TU 6

Upper-Secondary and Tertiary Care/ General Hosp.

Provincial level (in Provincial city)

Primary Care Unit (PCU)/ Sub-district level

Secondary Care/ Community Hosp.

District level

Provincial public care network and referral system


Regional IP care-referral system

Khonkaen Hosp.(General and Regional Hosp.)

Kalasin Hosp.

Other provincial Hosp.

in neighborhood

Other provincial Hosp.

in neighborhood


CUP structure and main constituent parts

These changes, both of the financing and structural reforms of health service delivery, have affected providers from managing staffs to health practitioners in the country.

I. Background


Study questions: Q.1 How are performances of UC and its impacts on

public health system?

Q.2 What are crucial constraints and critical obstacles to the sustainability of UC and the health system?

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I. Background


Field surveys: Khonkaen and Kalasin provinces of the northeast region

Areas in the northeast region were selected as, hosting the largest number of population - comparatively

poorer than those in other regions - but equipped and provided public health resources the least advantage.

tentatively the most affected by the switching of salary subtraction of the capitation budget from at the provincial level to the national level

I. Background


Respondents: Providers at facilities in 9 districts, with care referral network from Primary and Secondary levels to Tertiary level

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Table 5.1 Summary of the Interviews, by Health Workplaces and Professions

Khonkaen (J uly-August 2005) Kalasin (J anuary-February 2006)

CUP (5) CUP(4) Professions PPHO

(1) DPHO

(5) Hospital

(5) PCU/ HC

(8)

Pri. H. (1)

PPHO (1)

DPHO (4)

Hospital

(4)

PCU/ HC (6)

Total

Director* - - 4 - - - - 3 - 7

Doctor - - 4 - - - - 4 - 8

Nurse - - 7 5 - - - 4 2 18

PHO, Health Academic,

Management Offi cer

1 5 3 4 1 1 4 2 5 26

Total 1 5 18 9 1 1 4 13 7 59

Note: * All directors of the hospitals are doctors. In parentheses are the numbers of visits at each place type.

I. Background


a) General Expressions agree with the concept of the 30 Baht Scheme and good wills of

the government in implementing UC. Budget management and allocation - more flexible, and clearly

defined with concrete strategy, policies and expected outcome to the providers.

However, Database of population and costs of health service - not properly

developed. System and health workers - not prepared to the changes. Structure of public health organization – PPHO, DPHO, hospitals

and PCUs/HCs – not yet properly reorganized---- Confusions!

Too much exploited for political benefits and popularity

II. Providers’ Views of the UC Implementation


B) Views respecting Impacts

i. Workloads (by policy changes and higher rate of care utilization)

ii. Care over-utilizations (Patient’s rights & Responsibilities) → Risks of malpractice → Work Depressions

iii. Structural changes of heath service system and financing

iv. Relationship Issues: (Patients & Providers, Providers & Providers)

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II. Providers’ Views of the UC Implementation


Workloads and Service Utilization


Structural changes: Structure of CUP and Cooperation of the Hospital, PCUs/HCs and the DPHO


Relationship Issues

Providers& Patients – Medical malpractice & Suings by patientsThe problem of malpractice sues by patients is suggested to be managed by, ◦Hospital qualification/Hospital Accreditation (HA) process◦Social recognition about “rights” with “responsibilities” of patients◦Risk management and patient monitoring system of the hospital◦Social embedment of the hospital in the community, regarding trusts of people toward health practitioners

Profession group & Profession group – Structure of returns and welfare


Based on the designed structure of medical care and referral network of the UC implementation, we found that impacts and failures of the policy intentions caused by constraints and difficulties, both physically and financially, at each level of health facility systematically affected and were affected as a cycle in the whole public health system.

As of this argument, three components are described to highlight the causes, the consequences and the linkages of the systematic problems, which determinate effectiveness and performances of UC, and as well were impacted by the UC implementation, in the public health service system.

III. Constraints and Consequences in Public Health Service System


Systematic constraints and negative cyclic consequences in care provision system are

drawn out

Concerning,1. Primary Constraints2. Linking Consequences3. Secondary constraints

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Shortages and Misdistributions of health personnel (across the country, and levels of health facilities in the area) + Resignations and Drains of Health Workers from the Public Sector

Under-estimated and under-approved UC budget Inconsistency between health strategies and public

recognitions towards UC

Primary Consequences

Workloads and Poor performances

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1. Primary Constraints


Shortage of health workforces


Drains of health workforces


Disadvantageous returns in comparison with the returns offered by private hospitals or clinics[1].

Workplace and location of the public hospital.

Workloads at the public hospital.

Personal and family factors.

[1] Na-ranong (1992) pointed out an evidence from a case study in community hospitals of the MOPH that the determinant of the resignation of a doctor from the public sector were mostly the financial factors, respecting disadvantageous salary level and returns.

Drains of doctors


Two points of the issue were expressed i) “public post” and “workloads” and ii) “location of the hospital”

Draining to Sub-district Local Government Organization (SLGO)

Resignations of nurses

Drains of the PHO group at the PCU/HC level


Under-estimated and under-approved UC budget


“Adequacy” ---- survival of the health facility and its financing----enough and the hospital could survive, even with some financial deficits and debts.

However, “Adequacy” ---- in relation to assigned work tasks and expected outcomes by the NHSO, the MOPH and the patients----hardly enough and inadequate to have the facility achieving at the quality levels

Adequacy of the capitation rates and UC budget


“Investments” for long-term development and quality improvement of services provided ---- said to be forgotten, due to the limitations and inadequacy of the budget----affects not only the sustainability of the facilities themselves but also of the whole health service provision system.

“Salary subtraction” of the UC budget at the national level & at the provincial level

“The co-payment”: The fixed 30 baht/visit

Adequacy of the capitation rates and UC budget


From PCUs to Secondary and Tertiary level hospitals

Failures of strategies to strengthen service provisions at primary care level, and health promotion and prevention (PP)---Failures of the SNS and KBKJ strategies

From Secondary level hospitals to Tertiary level hospital

Over-referring of In-Patient cases

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2. Linking consequences:


สร้�างนำ�าซ่อม and ใกล้�บ้�านำใกล้�ใจ Strategy

Even if PP work is perceived to have been given more attention from the health policy agenda with more purposeful work plans,

the implementation is facing many difficulties and constraints from both the nature of PP work itself, and the unsupportive

workforce and budget, specifically at the PCU/HC level.

A. The Nature of PP WorkB. Inadequate Workforce with Heavy Workloads

C. Unsupportive UC Budget for PP Work


Backward from

Tertiary level hospitals to Secondary level hospitals Infeasible reallocations of health personnel from provincial

cities to rural districts

Secondary care level hospital to PCUs Infeasible strengthening primary care network

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3. Secondary Constraints


Figure 6 Systematic Constraints and Cyclic Consequences in Public Health Service System at the Provincial Level


“…where shortages (and inequitable distributions) of health workforces are still prevalence in many areas and sufficient budget funding are not yet acquired, the public health care system (and UC) as a whole is vulnerable and might not be sustainable in the long-run

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Thailand’s health system has achieved intermediate goal but not yet the final one of the UC policy.

‘Universal inclusion’ is to be achieved, but “Universal access” is still not ensured that it is equitable

to all insured population UC system is insufficiently provided with health resources,

and as a result ineffectively functioning and vulnerable

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(1) Assuring universal

and comprehe

nsive health

insurance coverage.

(1) Assuring universal

and comprehe

nsive health

insurance coverage.

(2) Ensuring adequate

and equitable access to needed health

service.

(2) Ensuring adequate

and equitable access to needed health

service.

(3) Increasing

the effectiveness and

sustainability of health system

(3) Increasing

the effectiveness and

sustainability of health system

Source: Docteur et al. 2003Source: Docteur et al. 2003

ConclusionsConclusions

24 June 2009 At Faculty of Economics, TU

To empower Primary Care Unit (PCU) and enhance its staffs

To put forward a concrete agenda to relieve shortages of health workforce and its misdistribution nationwide

To adjust financing mechanism of UC in term of fund sourcing and budget managements

To promote better community participation and patients’ responsibilities

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Policy SuggestionsPolicy Suggestions

24 June 2009At Faculty of Economics, TU Chalermpol CHAMCHAN Doctor of Area Studies, Graduate School...

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