UHC in developing countries , Health system : Ethical dilemmas. Dr. Peerapol Sutiwisetsak Deputy Secretary General National Health Security Office Thailand Good afternoon , ladies and gentlemen , I am very pleased to present Thailand experience.

Thailand: country profiles Population - 64 million GNI 2012 US$5,090 per capita, Gini 42.5 UHC achieved in 2001 under 3 scheme civil servants, social security and UC Health status Life expectancy at birth 74 years IMR 20/1000 LB, MMR 30/100,000 LB Physicians per capita 5/10,000 ANC & hospital delivery 99-100 (2009) Total Health Expenditure US$300 per capita, 6% GDP Half from public , 14% of National budget Less than 40% out of pocket Thailand has just become an upper middle income country, with low level of poverty, moderate income inequity, and fair health status . We have achieved Universal Health Coverage since two thousand one (2001), with only six percent (6%) of our GDP spent on health and fourteen percent (14)% of national budget for health. The out of pocket health expenses reduced from more than seventy five percent(75)% in early nineteen eighties (1980s) to less than fourty percent (40)% after the UHC.

UHC can be started and achieved at low level of income GDP/capita UHC can be started and achieved at low level of income The children n elderly 71% 29% 20% Achieving UHC in Thailand is a long march starting since almost fourty years ago from the year nineteen seventy to two thousand ten. We spent twenty six years from nineteen seventy five to two thousand and one (1975 to 2001), to achieve full UHC. The X axis shows 40 years, the y axis shows GDP per capita in US dollars and the number twenty , twenty nine,seventy one , one hundred in rectangles show UHC coverage in percent of population. In nineteen seventy five (1975), Thailand started to cover the poor with free health services when the GDP per capita was only three ninety dollars (390 USD). In nineteen eighty (1980) we cover civil servants .Then in nineteen eighty three (1983), we moved to cover the near poor when the GDP per capita was seven sixty dollars(760 USD). With the rapid economic growth, we moved further to cover the regular employees with social security health insurance in nineteen ninety two (1992). The decision to cover the children, and the elderly in nineteen ninety five to six (1995-6) had moved the coverage up to seventy one percent (71)% . The UHC had become one of the main issue for political campaign in the two thousand (2000) general election, and the new government, the same ruling party as the current government, decided to move from seventy one percent (71%) to one hundred percent (100%) coverage in two thousand and two (2002). At that time our GDP per capita was only nineteen hundred dollars (1,900 USD ), five years after the Asain financial crisis. From the figure u can see that economic crisis maybe the best opportunity to move further on UHC as it is the time that everyone realize the important of UHC and also can accept all measures to reduce the cost of essential health services to support UHC. 100% 53% 42% year Suwit Wibulpolprasert, MoPH, Thailand

Health Insurance Schemes In principle, every Thai citizen must be the beneficiaries of one of the three health insurance scheme, but the survey in two thousand twelve (2012) found the population coverage was 99%.. The coverage of UCS is about seventy five percent (75%) of the population while CSMBS and SSS covered about eight percent (8% ) and sixteen percent (16% )respectively

Ethical point 1.Ensure Healthcare for all and poverty reduction 2.The Development of benefit package 3.The Transparency and participatory mechanism. 4.The Strategic purchasing under fiscal constraint 5. The Preliminary assistance for damage or injury caused by any services 6.The 24 hr services of the call center My presentation today will focus on 6 key issues as shown in this slide.

1. Ensure availability of quality health care for all Fast tracking rural health No investment in urban areas for 5 yrs. The first issue is that UHC is access to quality comprehensive essential health services and technology without financial barrier. It is useless to have free medical care, while the care is difficult to reach or low quality. It should be ethical to make essential health services universally available or to impoverish people with medical bills. First, we need to ensure quality comprehensive services nationwide. In early nineteen eighties (1980s), in spite of serious economic crisis, the Thai government made a bold decision, as part of the rural development policy, to freeze the new capital investment in urban hospitals for 5 years and shift the resources to build rural health centers and district hospitals to cover all rural communes and districts. Massive training of rural health personnel with compulsory public services were also carried out. This slide shows the evidence that before nineteen eighty two (1982), the budget to urban health facilities was higher than those to the rural ones. But since nineteen eighty three (1983) , the budget to the rural health facilities become prominent showing in the red line. Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

Adequate and appropriately manned rural health facilities Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential. The results are well equipped and manned modern rural health centers and rural district hospitals. The government also provides housing, subsidized utilities, and food, as well as good communication facilities and strong financial incentives for the rural health personnel Rural community hospital with 2-8 doctors cover 30-80,000 population

Seamless Health Service Networks For more complex service, secondary and tertiary hospitals with specialized personnel , highly diagnostic and treatment technology are available . Referral system was set up . Medical school hospital For more complex service, patients can be refered to secondary and tertiary hospitals with specialized personnel , highly diagnostic and treatment technology . Referral system was set up in every region covering about three to five (3-5) million people per region General hospital in every province Regional hospital in every region

Source: Rural Health Division, MoPH 1. Healthcare for all : Changes in out-patient utilization: 46% (5.5) 29% (3.5) 24% (2.9) 1977 Regional H./General H. Rural Health Centres District Hospital 27% (11.0) 35% (14.6) 38% (15.7) 1987 2000 46.1% (51.8) 35.7% (40.2) 18.2% (20.4) 2010 54.0% (78.0) 33.4% (33.4) 12.6% (18.1) With good and well manned rural health facilities, more and more people used the rural health facilities . Then the structure of the out patient visits changed from a reverse triangle showing in the blue colour in nineteen seventy seven (1977) to an upright triangle with broader base .Then in two thousand ten (2010) , showing in the red colour, fifty four percent (54)% of OP services were provided by rural health centres, and thirty three percent (33)% by district hospitals. , while about twelve percent (12% ) by the urban provincial hospitals. We may say that the access to quality comprehensive essential health services are universal in Thailand. ( ) : Number of OPD visits (millions) Source: Rural Health Division, MoPH

UHC is effective for poverty reduction UHC achieved This figure is the evidence that between two thousand four and two thousand nine (2004 and 2009) , an additional two hundred ninety thousand households (290,000)were protected from medical bill induced poverty, as a result of UHC. This is a major achievement, of MDG1 on poverty reduction. Source: Viroj Tangcharoensathien Suwit Wibulpolprasert, MoPH, Thailand

2. The Ethic in the benefit packages development Evidence base transparent n participatory processes Life saving non cost-effective treatments but high impoverishment tendency w low budget impact Increase access at affordable budget by using mix payment methods to control cost and also stimulate demand and services The use of quality generic medicines, TRIPs flexibilities, and the promotion of rational drug use Second issue: The benefit package of the UCS covers all eight hundred (800) items of essential drugs and all cost effective affordable interventions. The current package is comprehensive, range from the low cost care such as outpatient services to high cost care such as chemotherapy, dialysis as Renal Replacement Therapy , open heart surgeries , ARV drugs . It also include Health promotion , Disease Prevention and community health development activities. The benefit package is continually developed by the Benefit Package Subcommittee, which involve all stakeholders and based on evidence on Cost Effectiveness Analysis and budget impact in a transparent manner. We established a Health Intervention and Technology Assessment Program to ensure good and strong sustainable capacity. Those life saving but non-cost effective measures with high tendency for impoverishment are also considered, for example Renal Replacement Therapy, Heart and Lung Transplant, and the one hundred fifty thousand dollars(150,000 USD) per year Imiglucerase for Gaucher disease. In order to ensure tight cost control and access to essential services with low supplies, we use mixed payment mechanism. In general we use capitation payment for out patient and DRGs with central reimbursement for Inpatient. For some services which we would like to stimulate supply, we also pay by ‘fix fee schedule’ . For example, the fix fee for pap smear has increased the coverage from thiryto to seventy five percent (30 to 75%. ) The tight cost control measures stimulate the providers to move towards using quality generic medicines in more rational manner. In some cases, we also implemented the TRIP flexibilities to ensure access to essential patented drugs.

Use of Lopinavir/Ritonavir (200/50mg) CL bottles CL UC Scheme This figure shows that the use of TRIPs flexibility or compulsory licensing to allow for low price good quality second line ARVs has increased the access to Lopinavir/Ritonavir by more than thirty (30) folds, from less than five hundred (500) per year to fifteen thousand (15,000) per year. Suwit Wibulpolprasert, MoPH, Thailand

3.The Transparency and participatory mechanism By law National Health Security board consists of Minister of Health chair the Board, 8 Government Ex-officio 4 Local Government Representatives, 5 representatives selected from 9 NGO constituencies 4 representatives from four Professional Councils, 1 representative from Private Hospital Association, 7 experts appointed by Cabinet [insurance, medical and public health, traditional medicines, alternative medicines, financing, lawyer and social science], Secretary General serves as secretary of the Board Public hearing from provider, people every year Annual accounting audit Satisfaction survey every year Third issue : The design of UHC System based on participatory mechanism, for example, by law the national health security board consist of various stakeholder such as five NGO, seven experts. Public hearing is one of the process by law which need to be done every year to adjust design of the scheme. The board have to create reports on implementation , obstacles to implementation , and all accounts and finances of the Board in order to annually submit to the Cabinet, the House of Representatives, and the Senate within 6 months from the last day of every fiscal year. Furthermore, NHSO ‘s annual accounting report is audited by the Office of the Auditor General of Thailand. Finally , to monitor further responsiveness from people, NHSO do a survey from both provider and people in satisfaction every year.

Satisfaction: UC members and providers Percent Expand financial incentives The patient satisfaction the blue line is high from the beginning of the UHC, but the provider satisfaction the red line was initially low due to increasing workload and inadequate budget. However, it was improved after higher budget allocation and higher financial incentives. Source: Satisfaction survey NHSO & ABAC University in various years

4.Strategic purchasing : Better Value for Money Close end capitation based budget with mixed payment mechanisms mainly on capitation (OP) and Case Mix (IP) and some FFS and PC as gate keeper Involvement of the private providers, e.g, providing primary care in the urban areas, emergency medical services, and some specific tertiary care, e.g., cardiac surgery Central bargaining and purchasing with VMI (Vendor Managed Inventory) Various strategic purchasing measures allow us to get the best possible services and also control quality and cost at the same time. Apart from the mixed payment methods , we also involve the private providers based on win-win situation. As the public health facilities in the urban areas, especially the capital city, are mainly tertiary care, we involve private hospitals and networks of private clinics to provide primary care services. A few five star private hospitals provide limited number of cardiac surgery for our patients at our price. For example, five thousand dollars (5,000 USD) for Coronary Bypass Graft. This allow more access and at the same time the private hospitals have more cases to maintain the skill of their cardiac surgeons. For some high cost medical devices, and drugs, we used participatory processes in central procurement with Vendor Managed Inventory system. It allows much reduced prices and ensure central quality control.

5.The Preliminary assistance for damage or injury caused by any service According to the Section Forty one of National Health Security Act ,The Board shall earmark an amount of money, not exceeding 1 percent of money to be paid to Health care units, as preliminary assistance to reimburse beneficiaries who are subject to damage or injury caused by any service provided by the Health care unit The No fault assistance or compensation helps reduce the court cases and allow better satisfaction to both the patients and providers. The number of patient receive compensation increase every year. Some cases were submitted by the attending doctors for the benefit of their patients. From: NHSO data 2011

Complaint – quality care 6.The 24 hrs services of the call center 1330 Total call 743,744 (3) Information 729,320 (98.35%) (1) Complaint – quality care 4,386 (0.51%) (2) Complaint - general 5,758 (0.75%) (4) Inpatient bed finding 4,280 (0.39%) 96.18% Complete cases in 30 days 96,45% Complete cases in 30 day The last issue , We provide 24 hr services of the call center thirteen thirty (1330). Every year we have about eight hundred thousand phonecalls. Mostly, people asked for more information and more understanding about their right and benefit . This can make benefit and right in text come true and make more access to quality care About half of complaints are not serious and can be compromised and but other serious complaints have to react under the law. According to Section fifty seven (57) and fifty nine (59) of the National Health Security Act , patients who had been violated their right to health care , they can submit a request to NHSO , such cases will be investigated and solved by the Health Service Standard and Quality Control Board. Eventually, we can solve more than ninety percent (90%) of cases within thirty days (30). From : NHSO data 2011

Three key take home messages UHC is the accesses to health services without financial barrier, not merely financial protection. It is can be achieved at low level of income and it is effective for poverty reduction Fiscal spaces and innovative financing are possible with political leadership - resources must be used cost-effectively thru Health Technology Assessment and strategic purchasing Mechanisms to assure sustainable financing and meeting the emerging challenges are needed and should be developed thru evidence based health systems researches Three keys from our experiences maybe useful for developing countries. …… Thank you very much for your attention. Sawasdee krub. Suwit Wibulpolprasert, MoPH, Thailand

Thank you Thank you very much for your attention.

TRIPS flexibilities TRIPS stands for Trade-Related Aspects of Intellectual Property Rights agreed in DOHA , 2001 Flexibilities : special mechanism is allowed for developing countries to gain access to essential drugs and or to protect health system Such as to import some generic drugs aiming to lower ARV cost for HIV patients The example of flexibilities is CL in ARV drug Thailand,

MDG 1 The Millennium Development Goals (MDGs) are eight international development goals that were officially established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 193 United Nations member states and at least 23 international organizations have agreed to achieve these goals by the year 2015. The first goal is : Eradicating extreme poverty and hunger