Health system components to support UHC: Thai experience on pre-requisites for UHC Phusit Prakongsai, M.D. Ph.D. International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the Exchange and Study Program on UHC Monitoring and Evaluation VIC3 Bangkok Hotel 9 September 2013 Good morning everyone. First of all, I would like to thank the CAP UHC program for inviting me to share Thai experiences in the pre-requisite of health system components prior to achieving UHC.

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

Reduction of U5MR and MMR in Thailand, 1960-2008 If we look at the progress of reduction in under five and maternal mortality in Thailand, there are considerable achievements from 1960 until present. Under five mortality reduced from almost 100 per 1000 live births in 1970 to around 10 per 1000 live births in 2008, and maternal mortality reduced from 421 per 100,000 live births in 1960 to less than 40 per 100,000 live births in 2009. Achieving UHC 3 Source: Why and how did Thailand achieve good health at low cost? (2011) http://ghlc.lshtm.ac.uk/

Long march towards universal health coverage in Thailand Public policies to provide universal financial risk protection GNI per capita, 1970-2009 The historical milestone is described against the economic capacity of the country measured in term of Gross National Income per capita between 1970 and 2009 Our experiences showed that even we were low income country, in 1975 we introduced low income scheme when the GNI per capita was 390 US Dollar. Community based health insurance scheme was introduced in 1983 when GNI was 760 US dollar, Thailand had proved that universal coverage can be achieved despite the GNI per capita of less than 2000 US Dollar. While the USA whose income was 13 times richer than Thailand, they still cannot reach UC. I would say, reaching UC is the real political and financial commitment

UHC policy objectives Improving health of all Thais by providing equitable access to quality health services in accordance with health need of the population, Preventing Thai households from being financially catastrophic when facing with high cost care,

Health care financing strategies of the UHC policy Removal of financial barriers to health services; Risk sharing  expand the UHC scheme to cover uninsured and merge LIC and voluntary health card scheme, Shift of the main source of HCF from OOPs to general tax; Sustainable systems: Policy sustainability  Law Financial sustainability Institutional sustainability Participatory process Protect people right

UHC cube: what has been achieved in Thai UHC? X axis: 99% pop overage by 3 schemes [UCS 75%, SHI 20%, CSMBS 5%] Y axis: Free at point of services, very minimum OOP, 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 (Essential drug list) A brief description on how far Thailand had achieved to date on the UC Cube. By 2012 population coverage was 99% by 3 schemes, UC Scheme covers the largest population, 75% of total Services by all 3 schemes were literally free, Benefit package is comprehensive, range from the low cost such as outpatient services to high cost care such as chemotherapy, hemodialysis and open heart surgeries, All services cover medicines, This results in a very minimum level of catastrophic health expenditure and prevent non-poor people become poor from medical bills. These achievements are outstanding.

Selected health interventions for cardiovascular disease patients included in the UHC benefit package Basic health care services for individual beneficiaries Expansion of open heart surgery and PTCA Basic health care services OP IP High cost care including open heart surgery and PTCA Accident and emergency, disease management Health promotion and disease prevention, Emergency medical services, etc. Renal replacement therapy For ESRD patients (Pilot project in FY2007 and extend to the whole country in FY2009) Chronic NCDs (2nd prevention for DM/HT) (Pilot project in FY2009 and extend to the whole country in FY2010) Since achieving UHC in 2002, a number of health interventions related to cardiovascular and heart disease have been provided by the UHC scheme. We included open heart surgery and PTCA for coronary heart disease patients into the UHC benefit package since 2002, RRT for ESRD patients in 2009, secondary prevention for diabetic and hypertensive patients in 2010, and recently heart transplantation in 2012. Heart transplantation Commencement of the benefits 2002 2004 2009 2010 2012

NHSO allocation Item increase Capitation increase Item increase From: Bureau of policy and planning, NHSO

UHC scheme payment Basic health care ARV drug Population/patient Capitation in OP, DRG with global budget in IP Basic health care Population/patient ARV drug Fee schedule & development plan UC fund Provider RRT Fee schedule & development plan Chronic (DM/HT) Point by no of pt Mental health (Medicine) Medicine supply & development plan

Development of Thai DRGs Version Refined Diagnosis code Procedure code Groups Implement 1 No ICD-10 (WHO) 1992 ICD-9-CM 2000 511 Nov 1998 2 Feb 2001 3 5 levels 1,283 Oct 2003 4 ICD-10 (WHO) 2007 + ICD-10-TM* ICD-9-CM 2007 with extension 1,920 Oct 2007 5 ICD-10 (WHO) 2010 ICD-9-CM HoNOS Barthel index DRG 2,450 TMHCC 54 SNAP 41 Expected on Oct 2011 * Thai Modification for data entry only (not for new classification)

DRG evolution Ver.3 Ver.2 Ver.1 Oct.2007 Oct.2005 Apr.2005 Thai DRGs Reclassification Add group from previous other… Bilateral , Multiple procedures Special care Unbundling Coding: ICD-10-TM (diagnosis) ICD-9-CM 2005 with Extension (Procedure) Oct.2007 Thai DRGs ver. 4 Oct.2005 Thai DRGs Ver. 3.5 Apr.2005 Oct.2003 Thai DRGs Ver. 3.1 Feb.2001 Ver.3 Nov.1999 Reclassification Recalibration Ver.2 Clean up library Unbundling  Additional lists Recalibration (Minor change) Ver.1

Increased utilization, low unmet needs Prevalence of unmet need OP IP National average 1.44% 0.4% Civil Servant Medical Benefit Scheme (CSMBS) 0.8% 0.26% Social Security Scheme (SSS) 0.98% 0.2% Universal Health Coverage Scheme (UCS) 1.61% 0.45% Evidence from national HH surveys and routine reporting system shows improved utilization both outpatient and inpatient services. OP utilization rate increased from 2.4 visits per person per year in 2003 to 3.6 in 2011. Also, hospitalization rate increased significantly from 0.067 admissions per year to 0.119 admissions per capita per year. Another key evidence is on the unmet needs. When we applied OECD standard questionnaire in the panel HH surveys, the unmet needs of Thai people was low, 1.4% of OP and 0.4% of IP, which is similar to good performing OECD countries. Source: NSO 2009 Panel SES, application of OECD unmet need definitions

Increased access to expensive health interventions for heart disease patients among UHC beneficiaries, 2005-2012 This slide shows the increased access to expensive health interventions for heart disease patients which include open heart surgery, PTCA for IHD, and primary PCI for ST-elevated myocardial infarction. You can see the increasing number of patients access to these expensive cardiac interventions, especially poor people in the rural areas of Thailand.

Starting special pay When we assess the impact of special payment for injection of thrombolytic agent in ST-elevation myocardial infarction, we found a significant increase in the infusion rate of thrombolytic agent with reduction in case fatality rate of ST-elevation Myocardial infarction. *54 = estimation from Aug. 2010 – Jul.2011 Source : IP individual record 2005- 2011 , NHSO

Financial risk protection (1) Reducing incidence of catastrophic health spending OOP>10% total consumption expenditure Since the benefit package of the UHC scheme is quite generous and comprehensive, data from national household surveys show that there was a significant reduction in households facing catastrophic health expenditure, particularly among poor households, when we define catastrophic health expenditure as HH out-of-pocket payments for health exceeding 10% of total household expenditure. Source: Analysis of Socio-economic Survey (SES)

Financial risk protection (2) Protection Thai HH against health impoverishment UHC achieved From the analysis of national household surveys, it is clear that in 2009, seven years after we achieved UHC, the UHC policy protected almost 70,000 households from health impoverishment caused by medical care costs. It is clear that the more high cost benefits we cover, the higher reduction of health impoverishment and equitable access to expensive health services. For example, universal access to open heart surgery and PTCA in 2002, and free services for Renal Replacement Therapy (RRT) for ESRD patients in 2006 have clearly further reduce the poverty and household catastrophic health spending.

UHC scheme improved equity in service use Ambulatory care: concentration index

Increasing share of public spending on health with less share of out-of-pocket payments after achieving UHC (Total health expenditure and THE as % of GDP 1994-2010) UHC achieved Data from the National Health Accounts of Thailand show that after achieving UHC in 2002, the share of public financing for health increased from 56% in 2001 to 75% in 2008. Total health expenditure during 2003-2008 which is shown as the line graph ranged from 3.49 to 4% of GDP, and THE per capita in 2010 was 194 USD. Health expenditure for UHC beneficiaries in 2010 was approximately 80 USD per capita. Total health expenditure during 2003-2009 ranged from 3.49 to 4.0% of GDP, THE per capita in 2010 = 194 USD Capitation payment for UC beneficiary in 2010 = 80 USD per capita

Key contributing factors Development of health systems: First strand: expansion of strong district health systems both infrastructure and workforces More resource allocation to district and provincial levels, Government bonding “mandatory public health services” by all health-related graduates. The MOPH high level production capacity of nursing and other health-related personnel contributed significantly to the functioning of rural health services. We can say that one of the key contributing factors in achieving UHC is the long-term development of health system. The expansion of strong district health systems both infrastructure and health workforces during the past decades contribute significantly to the achievements of UHC policy in Thailand. 20

District health systems: significant improvement Well equipped building Adequate supplies of medicines and diagnostics Good working environment Housing Transportation Recreation A standard team of HW and equipment list were planned in conjunction with infrastructure development

Education strategies: increase production and rural recruitment Source: Noree & Pagaiya, 2011 1965 1970 1975 1980 1985 1990 1995 2000 2005 External brain drain Rural development HFA/PHC Economic boom crisis Ratio doctor density Between Bangkok to Northeastern region recovery 1974 Rural doctor program (Rural recruitment and hometown placement) 1979 Medical education reform (PHC base, rural training) Collaborative Project to increase production of rural doctor 300-500 /year ODOD project (one district one doctor) 3 year mandatory rural services to all graduates, non-compliance are liable to pay a fine of US$ 10,000 to 50,000 (for ODOD)

Financial incentives Ratio doctor density Between Bangkok to 1965 1970 1975 1980 1985 1990 1995 2000 2005 External brain drain Rural development HFA/PHC Economic boom crisis Ratio doctor density Between Bangkok to Northeastern region recovery Hardship allowance 60-88 USD/mo Non-private practice allowance 250 USD/mo 1997 Increase Hardship allowance Normal 55 USD/mo Remote 250 USD/mo Very remote 500 USD/mo Special allowance >3 yrs work - 125 USD/mo Southern – 250 USD/mo

Four decades of infrastructure and workforce development The advent of district hospitals (1977) First batch of two-year technical nurses (1982) Now fully upgraded to RNs Public service mandate of new MDs (1972) The four decades of health infrastructure and health workforce development greatly contribute to distribution of good quality health services throughout the country. This includes the advent of district hospitals in 1977, mandatory public services of new graduated medical doctors in 1972, and first batch of two year technical nurses in 1982. Source: Health Resource Surveys (various years)

Change in the use of primary health care From reverse to upright triangle: PHC utilization 46% (5.5) 29% (3.5) 24% (2.9) 1977 Regional H./General H. Rural Health Centres Community H. 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) Evidence shows gradual improvement of utilization by level of care, reverse the dominant tertiary care to primary care. By 2010, 54% of OP services were provided by rural health centres, and one thirds by district hospitals.

The Decade of Health Center Development Primary health care development - Thailand Adopted Health For All Policy The Decade of Health Center Development (1992-2001) Starting Primary Care Services Wat Boat Project Universal Coverage Policy Health Centers Community Health Volunteers National Health Act Economic Crisis Traditional Medicine 1932 1964 1968 1975 1978 1981 1985 1992 1996 1997 1999 2001 2002 2007 1950 1966 1974 Rural Doctors Movement Health Care Reform Project Thai Health Fund Stating Rural Health Services Sarapee Project BanPai Expanded Community Hospitals Decentralization Health Card Project Primary Care Development Tropical Diseases Control Programs Lampang Project Samoeng Project Nonetai Project Civil Society Movement Source: Komartra Chungsathiensarp, 2551

hospital accreditation status, 2005-2011 after Pay by quality based pay before Sources : Healthcare Accreditation Institute (Public Organization), 2011. adapted by Bureau of Service Quality Development, NHSO. หมายเหตุ ปี 2554 เป็นข้อมูล ณ ไตรมาส 2

Monitoring & Evaluation of health systems reform /strengthening A general framework Inputs & processes Outputs Outcomes Impact Improved health outcomes & equity Social and financial risk protection Responsiveness Financing Infrastructure / ICT Health workforce Supply chain Information Intervention access & services readiness quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Governance Indicator domains Data sources Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Population-based surveys Coverage, health status, equity, risk protection, responsiveness Clinical reporting systems Service readiness, quality, coverage, health status Vital registration Analysis & synthesis Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Communication & use Targeted and comprehensive reporting; Regular country review processes; Global reporting 28 28

Data availability for M&E system in Thailand 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 From M&E framework, the reviews on existing reports and facility-based data in Thailand show that Thailand has a wide range of household survey data and routine information from many institutes and organizations to assess almost all areas of health system capacity and its performance, except governance and health system responsiveness. These data are conducted by different institutes and organizations in Thailand which require coordination and networking. These data are useful for assessment of health reform policies in Thailand. 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

The principle of “Triangle that moves the mountain” Knowledge power & management Social and civic movement In conclusion, it took us 25 years to achieve UHC based on a gradual and incremental movements. Our successes depend on the inter-connectedness of three important powers, the policy or political power, the social power and the power of wisdom. This concept has been called the strategy of ‘The triangle that moves the mountain’, and has been applied to solve many difficult social problems in Thailand. Political commitment/ Policy linkages

Acknowledgements Ministry of Public Health (MOPH) of Thailand, National Statistical Office (NSO) of Thailand, National Health Security Office (NHSO) of Thailand, Health Systems Research Institute (HSRI), World Health Organization (WHO)