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Reviews of the Thai health care systems and knowledge gaps for health system

research

Phusit PrakongsaiSomsak Chunharas

International Health Policy Program (IHPP)Thai National Health Foundation (TNHF)

Presentation to the meeting on Health System Research Collaboration

Pan Pacific Hotel, Bangkok10 July 2009

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What are we trying to do?

• Build up (institutionalize) groups of researchers doing “health (services) system research” in Thailand

• Ensure continuous funding for research in areas of high priority

• Build network of researchers, users and funders

• Many groups already exist and work with certain degree of coordination and support => addressing high priority issues, linking to policy and decision making, involving the public, ensuring continuous funding and capacity building

2

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What are we talking about today?

• Health system research vs health services research?

• Health services “system” (design and organization/governance) vs health services/care (delivery).

• Health services system components (6 components as proposed by WHO)

• Implications (utilization of research results)– Policy development (financing, governance,

HRH, technology, HIS)– Health services delivery practices (model,

technology use,– Health services management ( HR management,

IT management)

3

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Outline of presentation

• The past decades of health system development and current context– The extension of social protection– Burden of disease (BOD) in 1999 and 2004– Economic crisis and pandemic of new emerging

diseases

• Health system building blocks framework– Health service delivery– Health workforce– Health information system– Medical products & technologies – Health care financing– Equity and efficiency

• Conclusions on knowledge gaps of health system research

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Health system development and the extension of

social protection • Almost three decades of the long march

through piecemeal social protection extensions: – 1975 Low income scheme 1990s social welfare +

elderly, children <12, disabled – tax financed supply side subsidies.

– 1980 CSMBS for public sector employee + dependants—tax financed non-contributory

– 1983 CBHI 1994 voluntary public subsidies insurance, 50/50

– 1991 SHI for private employee—pay roll tax financed tripartite, capitation contract model

– By 2001, 30% of 60m population still uninsured – By April 2002, fully achieved universal coverage

• All residual population--non-SHI and non-CSMBS were covered

5

1945

2000

2002

Informal user fee exemption

1980

1970

User fees

1-3rd NHP1962-76Provincial hospitals

Health Infrastructure extension--wide geographical coverage

Historical evolution: Infrastructure development + financial protection

extension

1975LIC

1990

Establishment of prepayment schemes

1983CBHI

1980CSMBS

1990SSS

Universal Coverage

CSMBS

2002 full achieve

Universal Coverage

SSS

LIC MWS 1994Pub VHI

CSMBS

SSS

Expansion consolidation of prepayment schemes

4th -5th NHP (1977-86) District hospitalsHealth centers

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Current context• Good news:

– Achieving universal coverage with improved financial risk protection and health equity,

– Achieving all MDG targets,– Establishment of a number of autonomous organizations

regarding health sector reform: HSRI, NHSO, THPF, NHCO, HISRO, HITAP, etc.

• Bad news:– Economic crisis and decrease in GDP of the country,– Political instability,– The pandemic of new emerging infectious diseases e.g.

SARS, H5N1, H1N1, – Unsuccessful containment of tuberculosis,– Poor governance of the health sector as well as other

sectors,• Lack of leadership since UC reform, MOPH leaders strongly

resist to reform, totally loss financial command to NHSO • Lack of strong units in PS Office/ Departments to generate

evidence • Lack of vision and no systematic training of new cadres of

qualified managers in long term

% of Total 52.6 42.8

Rank DiseaseDALY('000)

% %DALY('000)

Disease

1 HIV/AIDS 645 11.3 7.4 313 Stroke2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS3 Stroke 332 5.8 6.4 271 Diabetes4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease6 COPD 187 3.3 3.0 125 Traffic accidents7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer8 Diabetes 175 3.1 2.8 118 Osteoarthritis9 Cirrhosis 144 2.5 2.7 115 COPD

10 Depression 137 2.4 2.6 111 Cataracts

Male Female

DALY

Top ten DALY loss among Thais in 2004

Note – The number of total DALY loss increased from 9.5 million DALY loss in 1999 to 9.9 million DALY loss in 2004

Source: Thai BOD Study 2004

Year of DALY loss of Thais in 1999 and 2004 by risk factor

29

53

25

54

91

132

144

169

238

410

440

595

594

838

943

30

70

40

60

120

370

120

140

220

370

400

490

490

550

1310

0 200 400 600 800 1000 1200 1400

Malnutrition (Thai standard)

Malnutrition (International standard)

Not using safety belt

Water and sanitation

Air pollution

Illicit drugs

Inadequate exercise and activity

Inadequate vegetable and fruit intake

Hyperlipidemia

Obesity and overw eight

Not w earing helmet

Hypertension

Smoking

Alcohol consumption

Unsafe sex

Ris

k fa

ctor

Year of DALY Loss (x 1000)

1999

2004

Profile of DALY loss, Thailand 2004

DALYs Lost by age and sex and disase categories, Thailand 2004

0

200

400

600

800

1,000

1,200

1,400

1,600

0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+

Males Females

Dis

ab

ility

Ad

just

ed

life

Ye

ar

Lo

st (

'00

0s)

Group III Injuries

Group II Non-communicable diseases

Group I Infections, maternal, perinatal and nutritional cond

Prevalence of smoking by educational level, 2001-2006

65.674.1

80.7

66.975.9

81.771.6 75.9

86.4

6.2

4.2

6.6

7.1

5.45.9

6.25.2

4.628.2

21.712.7

26.018.7

12.422.2 18.9

9.0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%pr

imar

ysc

hool

or

low

er

seco

ndar

ysc

hool

colle

ge o

run

iver

sity

prim

ary

scho

ol o

rlo

wer

seco

ndar

ysc

hool

colle

ge o

run

iver

sity

prim

ary

scho

ol o

rlo

wer

seco

ndar

ysc

hool

colle

ge o

run

iver

sity

2001 2003 2006

Educational level and year

perc

ent currently smoke

ever smoke

never smoking

Prevalence of smoking by income quintile, 2001-2006

67.0 66.4 66.7 69.4 74.368.2 67.3 68.9 71.9 76.6

71.1 71.6 74.3 74.8 78.7

7.0 5.5 5.4 5.05.9

6.6 6.8 6.66.4

6.35.6 5.8

5.2 5.86.3

26.0 28.1 27.9 25.619.8 25.2 25.9 24.5 21.7 17.1

23.3 22.6 20.5 19.4 15.0

0%

20%

40%

60%

80%

100%

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

2001 2003 2006

Income quintile and year

Perc

en

t currently smoke

ever smoke

Never smoke

Prevalence of drinking alcohol by educational level 2-0012006

58.7 62.270.6

62.9 63.8 65.3 60.3 62.074.0

27.1 22.915.3 24.8 22.9 20.0 28.9 26.5

16.5

14.2 14.9 14.1 12.3 13.3 14.7 10.8 11.5 9.5

0%

20%

40%

60%

80%

100%

2001 2003 2006 2001 2003 2006 2001 2003 2006

Primary school or low er Secondary school College or university

Educational level and year

Perc

en

t Drink alcoholregularly

Drink alcoholoccasionally

Never drinkalcohol

Prevalence of drinking alcohol by income quintile, 2-0012006

58.4 59.5 59.9 60.9 60.2 64.1 61.9 61.3 63.2 62.470.9 71.6 70.4 68.7 68.5

30.2 27.9 25.4 23.8 26.224.2 23.4 24.1 21.4 23.2

16.8 15.8 15.4 17.3 17.1

11.4 12.6 14.7 15.3 13.6 11.7 14.7 14.6 15.4 14.4 12.3 12.6 14.2 14.0 14.4

0%

20%

40%

60%

80%

100%

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

2001 2003 2006

Income quintile and year

Perc

en

t

Drink alcohol regularly

Drink alcohol occasionally

Never drink alcohol

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System building blocks of a health system:

its aims and desirable attributes

Source: WHO. Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007, Geneva, World Health Organization.

Health service delivery:Better coverage of essential vaccines, ARV and

condom use

0

20

40

60

80

100

120

Year (B.E.)

Per

cen

t co

vera

ge BCG

DPT

OPV

Measles

Hep B3

TT pregnant women

Compulsory licensing

Include ART in UC package

Generic production of triple ART

0

10

20

30

40

50

60

70

80

90

100

2004 2005 2006 2007

(%)

General client

Regular client

Spouse or regular partner

Non-regular partner

Percentage of female sex worker consistently use condom when having sex with general client in the past 1 month, 1995 – 2007

Current situation and challenges of human resources

for health in ThailandFigure 1 Physicians per 1,000 population and GDP per

capita

0

1

2

3

4

5

0 5000 10000 15000 20000 25000 30000 35000 40000

GDP per capita (USD)

Ph

ys

icia

ns

pe

r 1,

00

0 p

op

ula

tio

n

Thailand

Source: World Development Indicator 2002 and World Health Report 2006

Figure 2 Health w orkforce production capacity in 2004, 2005 and 2006

7,770

6,936

1,3491,482478

1,417

4,319

1,577

502 793

2,179

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Phy sicians Dentists Pharmacists Nurses

Nu

mb

er)

2004 2005 2006

Figure 3 Population per Health w orkforce in 1987, 1997 and 2006

14,800

3,6491,073

5,595

36,516

1,743

17,711

10,178

2,965

7,3407,862

617

0

5000

10000

15000

20000

25000

30000

35000

40000

Phy sicians Dentists Pharmacists Nurses

Nu

mb

er

1987 1997 2006

Figure 7 Annual resignation rate of health w orkforce betw een 1999-2005

6.86

17.41

21.58

8.769.17 10.16

19.58

25.59 26.00

43.66

45.03

16.68

9.37 9.90

5.57 5.100

5

10

15

20

25

30

35

40

45

50

1999 2000 2001 2002 2003 2004 2005

ปี�

per

cen

tag

e

Pharmacists Dentists Phy sicians Nurses

Inequity in geographical distribution of Health

workforce in 2007

Physicians800-3,3053,306-6,2746,245-9,2729,243-12,300

Pharmacists4,600-8,4328,433-12,27412,275-16,11516,116-19,956

Nurses280 - 652653 - 904905 - 1,1561,157 – 1,408

Dentists5,500-15,14315,144-25,76725,768-36,39036,391-47,011

Child mortality in Thailand from various sources of surveys

Source: Hill et al. Int J Epidemiol 2007 (with updates)

0

10

20

30

40

50

60

70

80

90

100

1970 1975 1980 1985 1990 1995 2000 2005

Un

der

5 m

ort

alit

y ra

te (

per

1,0

00)

Vital registration DHS 1987 - direct Census 1990 - indirect Census 2000 - indirect

SPC 1985 - direct SPC 1985 - indirect SPC 1995 - direct SPC 1995 - indirect

SPC 2005 - indirect SPC 2005 - direct Predicted

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Comparison between broad causes of death from vital registration (VR) and verbal

autopsy (VA)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

All Infectious All CVD All Cancers All other non-communicable

All injuries Ill-defined

Broad causes of death from VR and VA estimated:female,Thailand,2005

estimate VR

Health care finance and service provision of Thailand

after achieving universal coverage (UC)

General tax

General tax Standard Benefit

package

Tripartite contributions Payroll taxes

Risk related contributions

Capitation

Capitation & global Co-payment budget with

DRG for IP

Services

Fee for services Fee for services - OP

Population Patients

Ministry of Finance - CSMBS(6 million beneficiaries)

National Health Insurance Office The UC scheme (47 millions of pop.)

Social Security Office - SSS(9 millions of formal employees)

Voluntary private insurance

Public & Private Contractor networks

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Scheme beneficiaries by income quintiles, 2004

4% 1%

25%7%

5%

25%

11% 14%

23%

26% 31%

17%52% 49%

10%

0%

20%

40%

60%

80%

100%

CSMBS SSS UC

Q1 (poorest) Q2 Q3 Q4 Q5 (the richest)

The incidence of catastrophic health payments from 2000 to 2007

2000 2002 2004 2006 2007

Q1(poorest)

4.0% 1.7% 1.6% 0.9% 1.9%

Q5(richest)

5.6% 5.0% 4.3% 3.3% 2.8%

All quintiles 5.4% 3.3% 2.8% 2.0% 2.2%

Note: Catastrophic health expenditure refers to household out-of-pocket payments for health exceed 10% of household consumption expenditure

Total health expenditure 1994-2005

0

50,000

100,000

150,000

200,000

250,000

300,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Mil

. B

aht

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

%G

DP

public private %GDP

Total health expenditure during 2003-2005 ranged from 3.49 to 3.55% of GDP, THE per capita approx 100 USD

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Real term growth GDP versus THE, 19-942005

25

9.5%

15.6%

4.6%

-11.4%-13.4%

15.6%

3.6%

6.3%8.3%

-0.1%-0.6%

-15.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

THE GDP

Trend of financing sourcesNHA 1994-2005

0

50,000

100,000

150,000

200,000

250,000

199419951996199719981999200020012002200320042005

million baht

Government NON Government

55

45

53

47

53

47

46

5554

45

36

64

3737

6356

646356

4444

55

45

36

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Health care expenditure in Thailand by function in 2001 and 2005

Health administration and health insurance

8.5%

Medical goods4.3%

Ancillary services 0.4%

Prevention and public health services

4.8%

Services of curative & rehabilitative care

78.1%

Gross capital formation

3.9%

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8.2

4.8

3.7 3.7

2.92.6 2.5

2.01.6

1.32.2

1.8 1.8 1.6 1.4 1.4 1.3 1.4 1.2 1.10

1

2

3

4

5

6

7

81992

1994

1996

1998

2000

2002

2004

Household OOP for health, % income 1992-2004

Household consumption: tobacco, alcohol and health

Median household expenditure per month Sources: Analyses from 2006 SES

52 65

152

303

433

303

390433

650

867

47 6093

120

205

0

500

1000

Q1 Q2 Q3 Q4 Q5

Income quintiles

Bah

t p

er c

apit

a

Tobacco

Alcohol

Health expenditure

Distribution of ambulatory services at different health facilities between the 2001 and 2003 HWS

1.2 1.0 0.7 0.5 0.1

1.91.3

0.7 0.60.2

0.70.6

0.4

0.20.2

1.8

1.3

0.90.7

0.3

0.70.6

0.7

0.7

0.6

0.4

0.4

0.30.4

0.3

0.3

0.40.4

0.5

0.6

0.7

0.6

0.60.7

0.6

0

1

2

3

4

5

6

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

Income quintiles

Am

bu

lato

ry v

isit

s p

er

ca

p p

er

ye

ar

Health centre Community hospital Provincial and regional hospital Private clinic Private hospital

The distribution of ambulatory service use among different income quintiles in 2001 and 2003, by types of health facilities

2001 2003

Concentration index

Type of health facilities 2001 2003

Health centers - 0.2944 - 0.3650

Community hospitals - 0.2698 - 0.3200

Provincial and regional hospitals - 0.0366 - 0.0802

Private hospitals 0.4313 0.3484

Source: Prakongsai P et al. Assessing the impact of a policy on universal coverage on financial risk protection, health care finance, and benefit incidence of the Thai health care system. Presentation to the 6th IHEA World Congress, July 2007, Copenhagen

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Equity in utilization: Concentration Index OP service by levels: 2001 to 2007

Facility levels 2001 2003 2004 2005 2006 2007

Health centers -0.294 -0.365 -0.345 -0.380 -0.267

-0.292

District hospitals -0.270 -0.320 -0.285 -0.300 -0.256

-0.246

Provincial and regional hospitals -0.037 -

0.080 -0.119 -0.100 0.028 0.013

Private hospitals 0.431 0.348 0.389 0.372 0.516 0.528

Overall -0.090 -0.139 -0.163 -0.177 -0.054

-0.041

31

Note: CI range from -1 to + 1. Minus 1 (plus 1 ) means in favour of the poor (rich), or the poor (rich) disproportionately use more services than the rich (poor).

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Equity in utilization: Concentration Index IP service by levels: 2001 to 2007

Types of health facilities

2001 2003 2004 2005 2006 2007

Community hospitals -0.316 -0.293 -0.294

-02.66 -0.242

-02.93

Provincial and regional hospitals -0.069 -0.138

-0.114

-0.156 -0.049

-0.114

Private hospitals 0.320 0.309 0.254 0.366 0.398 0.464

Overall -0.079 -0.121

-0.127

-0.114

-0.051

-0.080

32

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Equity in budget subsidies: BIA, 2001 and 2003

A comparison of percent distribution of net government health subsidies among different income quintiles in 2001 and 2003

28

20

17 17 18

31

22

1516

15

0

5

10

15

20

25

30

35

Q1 Q2 Q3 Q4 Q5

Income quintile

perc

ent

2001

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

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Kakwani index of health care finance from 2000 to 2006

  2000 2002 2004 2006

Out of Pocket -0.1502 -0.0755 -0.0764

-0.0450

Direct tax 0.3913 0.4159 0.4424 0.3617

Indirect tax -0.0964 -0.0691 -0.0435

-0.0831

Premium Insurance -0.3623 -0.3906 -0.3233 na

Social health Insurance Contribution 0.1650 0.1121 0.1046 na

Premium Insurance+SHI Contribution na na na

-0.0491

34

0

10

20

30

40

50

1 (poorest) 2 3 4 5 (richest)

Economic status quintile

Un

de

r 5

de

ath

s p

er

1,0

00

liv

e

bir

ths

1990 census 2000 census

RR = 2.8 (95% CI 2.5-3.0)

RR = 1.8 (95% CI 1.6-2.0)

55% (39%-68%) reduction

Error bars are 95% CIs

Equity in health:Child mortality by economic status

Source: Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez AD, Lim SS. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369:850-855

Inefficiency of the Thai health care system:CSBMS expenditure from 1989 to 2008, current year

price

Note: Expenditure for 2008 is extrapolated from 6 months actual spendingSource: Ministry of Finance, Comptroller Generals Department, various years

Figure 1 CSMBS expenditure 1989-2008 current year price, annual nominal growth rate %

58,390

23%

19%16%

33%

26%

12%

22%

14%

6%

-7%

12% 12%

7%

11%

15%13%

26% 26% 26%

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

*

million B

aht

-10%

0%

10%

20%

30%

40%

% g

row

th

OP IP

Total Growth rate

Inequity in quality and patterns of health service provision:

Percentage of caesarian section to total deliveriesby health insurance schemes

15.4% 15.9% 16.4% 17.0% 17.2% 17.8% 18.3% 18.9% 19.8% 20.0% 20.0% 20.1%

17.0% 17.3% 16.2% 16.8% 18.4%20.2% 20.3% 21.6% 20.6% 20.1% 19.3% 19.7%

28.8%

36.3%

30.5%

24.3%

35.9%

42.3%

37.7%41.4%

45.6%

40.1%

48.4% 48.1%

9.8%

14.3%

6.0%

9.3%

14.0%12.2% 12.7%

18.5%16.4% 16.4%

20.4%

15.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2004Qtr1

2004Qtr2

2004Qtr3

2004Qtr4

2005Qtr1

2005Qtr2

2005Qtr3

2005Qtr4

2006Qtr1

2006Qtr2

2006Qtr3

2006Qtr4

UC SSS CSMBS ROP

Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

Inequity in quality and patterns of health service provision:Propensity of receiving single source antiplatelets

0%

2%

4%

6%

8%

10%

12%

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

2003 2004 2005 2006 2007

CS

SS

UCE

UCP

clopidogrel, cilostazol: 6 regional hospitals

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Discussion – Key concerns in HSD (1)• An increasing disease burden from chronic NCD and the

situation of aging society, => what needs to be changed wrt financing model and service delivery model/practices? (F, D)

• Inequitable health risk distribution among different SE groups, => alternative model for financing, resource allocation and service purchasing (F)

• Inefficiency and inequitable access to good quality of health services among beneficiaries of different health insurance schemes, => should we have a single system with multiple fund manager? How else could be improve inefficiency, inequitable access and quality/safety? (G, D)

• Poor governance of health systems in Thailand, => what roles and functions and relationship should be like between 4 major organizations in health system (MOPH, NHSO, NHCO, HPF) (G)

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Discussion – Key concerns in HSD (2)

• The unknown impact of current economic crisis on health of the population (F, G, D)

• The internationalization of health care seeking => should Thailand develop itself as medical hub for international patients? (G, F, HRH)

• The pandemic of new emerging infectious disease and unsuccessful control of tuberculosis and HIV/AIDS, => does it have to do with financing model, HRH quantity and quality, or management capacity? (D, G, HRH)

• Maldistribution and internal brain drain of HRH. => what policy options should be adopted, separating HRH payment from service purchasing package? (HRH)

• Complex and inefficient HIS (multiple purchasers and MOPH line of command) => standardization will help? What else should be done? Humanware? (HIS)

• Access to & more efficient use of (new) technology => CL and R&D investment for local production of health tech, and R&D for national health priority? (Technology)

=> the future role of HiTap? (G) how to influence cost-effective use of technology (D)

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Potential areas for research collaboration between

Thai partners and AHSPR (1)• Effective health and non-health interventions towards

NCD which is an increasing BOD in Thailand and many developing countries,– Policy recommendations for the Thai government through

the 10th national Development Plan,

• Reorientation of public resources towards health promotion and disease prevention of disease burden priorities e.g. – HIV/AIDS, – road traffic injuries, – Obesity / overweight and inadequate activity and exercise, – tobacco and alcohol consumption,

• Social determinants of health (SDH)

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Potential areas for research collaboration between

Thai partners and AHSPR (2)• Improving equitable quality and patterns of health

service provision among beneficiaries of different health insurance schemes provider payment reform,

• Harmonization of benefit package and provider payment methods among three public health insurance schemes,

• Effective health interventions to tackle mal-distribution and internal brain drain of HRH,

• Economic impact on health of the population,• Sustainability of health care finance in Thailand,• Improving efficiency and rational drug use of the Thai

health care system,• Improving health information system in Thailand, • Enhancing regulatory capacity and governance of the

Thai health care system.

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Your ideas/suggestion

• Which area/issues are of high priority?• How should we go about doing it?

– Potential researchers– Needs for new capacity in research– Funding for research– Institutional backup => what should be the

role of IHPP, HFRO,HISO, HRO, CHEM, other faculties in universities?

• International collaboration– Research conduct (technical collaboration)– Capacity building – Research funding – how should we go about?

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Thank you for your attention