Monitoring progresses of health equity and the impact of achieving universal health coverage (UHC): Lessons from Thailand Phusit Prakongsai, MD. Ph.D. Bureau of International Health (BIH) Ministry of Public Health (MOPH), Thailand Presentation to the International Meeting on Public Health Development Index (PHDI) As a monitoring tool to monitor inequity of health development The Parklane Jakarta Hotel, Indonesia 6th October 2015 1

Why health equity? Consistent evidence indicating that disadvantaged groups have poorer survival chances; Large gaps in mortality can also be seen between urban and rural populations and between different regions in the same country; There are great differences in the experience of illness  disadvantaged groups not only suffer the heavier burden of illness, but also experience the onset of chronic illness and disability at younger ages; In Thailand, health equity has been raised in a number of policy statements and legal documents: Thai Constitution 2550(B.E.) Chapter 9 Section 51 & 80, The Statute on National Health System 2008, Chapter 3, Section 16, Patient’s and Human Rights, Government policy on health.

Possible consequences of scaling up health interventions Service coverage 52% (Population-weighted. average) Scaled up to 75% Option B Option A

Percentage of birth with professional attendant among different income quintiles in selected countries Source: Houweling et al. (2007)

Definition of Health Equity The International Society for Equity in Health (ISEqH) defined equity in health as “The absence of systematic and potentially remediable differences which are unnecessary and avoidable, but in addition, are also considered unfair and unjust, in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically” Inequity in health or ‘health inequity’ is differences in health that are avoidable, unjust, and unfair (Whitehead 1992). 5

Equality vs equity

Philosophies of health equity Characteristics Libertarianism Emphasize a respect for natural right – the rights to life and possessions A minimum standard of health care should be provided to all people, while additional health care can be obtained depending on individual’s purchasing power and preferences. Utilitarianism Maximize the sum of individual utilities and welfare, Concerns on efficiency and likelihood of medical success. Egalitarianism Aims to reduce health inequality, Health care should be financed according to ability to pay, Delivery of health care should be allocated according to health need.

How to measure health (in)equity?

Health workforce density by provinces, 2004 Per 100,000 population 1-10 11-20 21-30 31-40 41+ 1-100 101-150 151-200 201-250 251+ Doctors Nurses

Lorenz curve Progressivity of population income 100 80 Equality line 60 Income (cumulative %, L) L(p) 40 20 20 40 60 80 100 Population (cumulative %, p), ranked by income Accumulation of a variable of interest (here, income) with respect to cumulative ranking of this variable Lorenz MO. Methods for measuring the concentration of wealth. J Am Stat Assoc. 1905; 9.

The concentration curve The concentration curve graphs on the x-axis the cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable.

The concentration index Concentration index (CI) = 2 x shaded area CI lies in range (-1,1) CI < 0 because variable is “concentrated” among the poor 75% of disease burden Cumulative proportion of illness Poorest 50% of population

Health equity dimensions Equity in health care finance Equity in access to health care and health care use Equity in health status Equity in the distribution of government subsidy on health (benefit incidence analyses) Equity in health risk distribution Equity in quality of health services recieved

Dimensions and determinants of health equity Health financing Healthcare utilization Quality & responsive-ness Health status Government subsidy on health Health risk Geographic Region Urban vs. Rural Demographic Gender Age group Social Education Occupation Economic Income Wealth index 15

Data availability for H equity analysis and monitoring in Thailand (1) Input Output Outcome Impact HCF HRH Infra structure Gover nance Med/ Health tech HIS access quality safety efficiency Interven coverage Risk factors H outcome Responsive Equity Finan protect ion Civil registration and vital statistics  Biennial SES Biennial HWS Census / SPC NHES MICS Reproductive H survey NHA Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey, MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes

Data availability for H equity analysis and monitoring in Thailand (2) Input Output Outcome Impact HCF HRH Infra structure Gover nance Med/ Health tech HIS access quality safety efficiency Interven coverage Risk factors H outcome Responsive Equity Finan protect ion Facility-based report  H resource survey HIS electronic IP database Dis surveillance Behavioral H survey Sero-sentinel Survey Specific dis registration Quality assurance (HA)

Three public health insurance schemes in Thailand after achieving UHC in 2002 Civil Servant Medical Benefit Scheme (CSMBS) Social Security Scheme (SSS) Universal health coverage (UHC) Introduced in 1963 1990 2002 Target beneficiaries Govt employees & dependents, retirees Private sector employee Informal sector who are neither covered by CSMBS nor SHI, Population Coverage 7% 13% 78% Funding Govt budget Payroll contribution, Tripartite Payment to health facilities Fee-for-service for OP, and DRG for IP Capitation (use DRG in risk adjusted part) Capitation for OP + DRG with global budget for IP

UHC cube: what has been achieved in Thai universal health coverage? X axis: 99% pop coverage by 3 schemes [UCS 78%, SHI 13%, CSMBS 7%] Y axis: Free at point of services, very minimum OOPs, Low incidence of catastrophic health expenditure and health impoverishment, Z axis: Extensive and comprehensive benefit package, very small exclusion list, Most high cost interventions were covered: dialysis, chemotherapy, major surgery, medicines including Essential Drug List (EDL).

Scheme beneficiaries by income quintile (2003 and 2007) UC scheme covers mostly the poor, approx 50% in Q1 & Q2 Source: Analysis of Health and Welfare Survey (various years)

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

Selected concentration curves of ambulatory service use among different types of health facilities in 2003

Distribution of government subsidies for health: Benefit incidence analysis (BIA), 2550-2007 B.E.

Financial risk protection (1) Household OOP as % household income, 1992-2008 Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

Incidence of catastrophic health spending OOP>10% total consumption expenditure Source: Analysis of Socio-economic Survey (SES)

The analysis of household impoverishment from health care costs in 1996 shows that approximately 20% of informal sector households and 16% of all households were impoverished from health care payments in 1996.

Sub-national health impoverishment 1996 to 2008

Analysis of Cigarette Smoking and Alcohol Drinking Behavior Survey (CSAD) in Thailand, 2007 Regular (weekly) alcohol drinking prevalence, % Binge alcohol drinking prevalence, %

Sources: Analyses from the 2002, 2004, and 2006 SES Household expenditure: tobacco, alcohol and health Median household expenditure (Baht per month), 2002-2006 Sources: Analyses from the 2002, 2004, and 2006 SES

Equity in MCH from analysis of MICS3 data

Access to reproductive health services in Thailand in 2009, by region Source: Access to reproductive health services in Thailand: is it equitable? Suratchada Kongsri et al (2011)

The impact of different provider payment methods on use of expensive procedures across 3 public insurance schemes Cesarean section Laparoscopic cholecystectomy Source: Limwattananon et al. (2009)

FFS payment of CSMBS and use of expensive OP medicines Variations across 3 public insurance schemes Source: Limwattananon et al. (2009)

DATA & INFORMATION CYCLE Essential indicators Definitions Tools Collect Feedback Program changes Policy changes Resource allocation Reporting: completeness Verification: data checks Adjustment Use Process Multiple indicators Context Overall performance Interpret Analyze Error and adjustment report Indicator computation Performance assessment Present Visualization of data Formats for communication

Lessons learnt and key challenges Despite political commitment and availability of several HH survey data, Capacity in regularly analyzing, monitoring, and reporting the progress of health equity in Thailand is limited, Multi-stakeholder’s participation, especially between data producers, researchers, and policy advocacy are needed, Effective mechanisms to disseminate and simplify the research findings to policy makers and the public are needed, There is a strong need for Translation of research findings into policy and practice, Adequate government budget and financial resources for developing the HH survey data and build up capacity, Appropriate indicators for HH socio-economic status.

Acknowledgements Ministry of Public Health (MOPH) of Thailand National Statistical Office of Thailand (NSO) Health Systems Research Institute (HSRI) Health Information System Development Office (HISO) Thai Health Promotion Foundation (THPF) National Health Security Office (NHSO) Long-term fellowship program of WHO