International Health Policy Program -Thailand Phusit Prakongsai, MD. PhD. International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the technical meeting on Strengthening M&E of National Health Plan and Strategies Hotel Victoria, Glion sur Montreux July 2010 Thailand’s system of accountability: Institutional mechanisms to support M&E

International Health Policy Program -Thailand 2 HIS for M&E in Thailand The HIS in Thailand is not a single system, but it consists of multiple sub-systems of health information with involvement of many key stakeholders in and outside the health sector: – Vital registration from Ministry of Interior (MOI); – Community-based household surveys from National Statistical Office (NSO), MOPH, research institutes; – Facility-based data from several Departments of MOPH, National Health Security Office (NHSO), CGD; – Disease surveillance from Department of Disease Control of MOPH; – NHA and DRGs data from research institutes –IHPP, CHEM, etc. Main financing sources for HIS – Regular government budget, – 2% earmarked tax fund from tobacco and alcohol consumption through Thai Health Promotion Foundation, – Direct payments from data users, either public or private organizations.

Monitoring & Evaluation of health systems reform /strengthening A general framework Data sources Indicator domains Analysis & synthesis Communication & use 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 Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Targeted and comprehensive reporting; Regular country review processes; Global reporting Improved health outcomes & equity Social and financial risk protection Responsiveness Financing Infrastructure / ICT Health workforce Supply chain Information Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Governance Inputs & processesOutputsOutcomesImpact

Data availability for M&E system in Thailand (1) InputOutputOutcomeImpact HCFHR H Infra struct ure Gov er nan ce Med/ Healt h tech HISacc ess qual ity safe ty effic ienc y Interve n coverag e Risk factor s H outco me Re sp on siv e Equit y Finan prote ct 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 M&E system in Thailand (2) InputOutputOutcomeImpact HC F HRHInfra structu re Gove r nanc e Med/ Health tech HISacc ess quali ty safet y effici ency Interven coverage Risk factors H outco me Res pon sive EquityFinan 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)

International Health Policy Program -Thailand 6 Case study on assessing the impact of achieving universal coverage (UC) in 2002 Key characteristics of the UC policy in Thailand – Introducing a tax-funded health insurance schemes to cover 47 million (or 75%) of population who were neither civil servant and social health insurance (SHI) beneficiaries, – Promote the use of primary care as the main contractor and gate keepers, – Changing resource allocation from historical basis to capitation contracting model and performance-based payments, – Removal of financial barriers to health services. Five key questions on assessing the impact of the UC policy – Financial risk protection from catastrophic health expenditure, – Equity in access to and utilization of health services, – Who benefits from government subsidies for health? – Who pays for health care? – Financial sustainability of the government health budget

Characteristics of three public health insurance schemes, after achieving UC, 2002

International Health Policy Program -Thailand 88 Scheme beneficiaries by income quintiles, 2004 Source: Analysis from the 2004 Household Health and Welfare Survey (HWS) conducted by NSO.

International Health Policy Program -Thailand 99 Declining of catastrophic health expenditure from 2000 to 2006 Note: Catastrophic health expenditure refers to household out-of-pocket payments exceeding 10% of household income Source: Socio-Economic Survey conducted by NSO.

10 Improved fairness of financial contributions Out of pocket payments, Source: Household Socio-Economic Survey conducted by NSO. Declining of gap

International Health Policy Program -Thailand 11 Equity in health care finance: Financial Incidence Analysis Subsequent studies indicate the Concentration Index of various sources of healthcare finance – Thailand 2002 (O’Donnell et al 2005) CI weight NHA – Direct tax – Indirect tax – Social insurance – Private insurance – Direct payments – Total Health Financing – General Tax Note: CI, an index of the distribution of payments, ranges (-1 to 1), a positive (negative) value indicates the rich (poor) contributes a larger share than the poor (rich), a value of zero is everyone pays the same irrespective of ability to pay

International Health Policy Program -Thailand 12 Equity in utilization: Concentration Indexes of OP service by level 2001 to 2007 Facility levels Health centers District hospitals Provincial and regional hospitals Private hospitals Overall 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).

International Health Policy Program -Thailand 13 Equity in health service use: Concentration indexes of IP service by level 2001 to 2007 Types of health facilities Community hospitals Provincial and regional hospitals Private hospitals Overall

International Health Policy Program -Thailand 14 Who benefits from government subsidies for health? Benefit incidence analysis (BIA) 2001 and 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 and in 2003 was

International Health Policy Program -Thailand 15 Using evidence to develop appropriate provider payments during the UC era Increase equitable access by – A separation of payment for high cost services – Developing underserved services: Excellence centers (trauma, cardiac, cancer, stroke fast tract, STEMI), EMS, Community rehabilitation – Expansion of benefit package: universal access to ARV, RRT – Compulsory licensing of high cost drugs: chemotherapy for cancer patients. Improve quality & effectiveness of services – Disease management program: DM, TB

International Health Policy Program -Thailand 16 Increased access to particular services after introduction of appropriate provider payments

17 More equitable geographical access to open-heart surgery between

Financial sustainability: Total health expenditure Total health expenditures, : 3.55 – 3.49% of GDP, THE per capita approx 100 USD

International Health Policy Program -Thailand 19 Long-term budget impact (million USD) from providing treatment for all women with osteoporosis in Thailand YearsAlendronate (million USD) Source: Maleewong U, Kingkaew P, Ngarmukos C, Teerawattananon Y. ECONOMIC EVALUATION OF SCREENING AND TREATMENT STRATEGIES FOR POSTMENOPAUSAL OSTEOPOROSIS: EVIDENCE TO INFORM DECISION MAKERS FOR SELECTION TO THE NATIONAL LIST OF ESSENTIAL MEDICINES IN THAILAND. HITAP 2008 Using evidence for decision making on the benefit package of the UC scheme

How equity and efficiency were achieved? 1. Long term financial sustainability 2. Technical efficiency, rational use of services at primary health care Functioning primary health care at district level, wide geographical coverage of services, referral back up to tertiary care where needed, close-to-client services with minimum traveling cost In-feasible for informal sector (equally 25% belong to Q1 and Q2) to adopt contributory scheme 1. Equity in financial contribution Tax financed scheme, adequate financing of primary healthcare 2. Minimum catastrophic health expenditure 3. Minimum level of impoverishment Breadth and depth coverage, comprehensive benefit package, free at point of services 4. Equity in use of services 5. Equity in government subsidies Provider payment method: capitation contract model and global budget + DRG EQUITY GOALS EFFICIENCY GOALS

International Health Policy Program -Thailand 21 Key factors contributing to institutionalization of M&E in Thailand Gradual evolving culture among policy makers in using evidence for decision making, Demand from users  e.g. policymakers, health strategic planners, directors of policy and planning division, health system and policy researchers, etc. Adequate financing and skilful human resources for HIS development, Long-term capacity building and skills in data generation, compilation, processing, synthesis & analyses, dissemination, communication to the public and policymakers, Good collaboration and close relationship between data producers and data users, and policymakers, Networking with key stakeholders at sub-national, national, and international levels.

International Health Policy Program -Thailand 22 Structure of Health Information System Development and Networking in Thailand MOPH Thai Health Promotion Foundation Health System Research Institute (HSRI) Health Information System Development Plan and Networking NHSO NESDB Civil societies NGOs Professionals NSO Academics Data owners Steering committee Management office

Network and coordination Reviews for HIS Demands and indicators Data analysis and synthesis for report production and publication Utilization mechanism Research and development for improving health information system Data quality assessment Reviews for health information systems

International Health Policy Program -Thailand 24 Remaining key challenges in institutionalizing HIS in Thailand Many HIS institutes/organizations are responsible for different components of M&E  duplication, inefficiency, and difficulties in networking and standardization, Gaps in data quality and availability, particularly data of the private sector, Despite adequate financing, more investment in HIS – both human and financial resources is needed, Variations in level of technical capacity in data generation, compilation, data processing, data analysis & synthesis, and communication, in responsible institutes, Problems in standardization of data generation, collection, and analyses, Low utilization of evidence by some policymakers, Need long term capacity building and champions in HIS for M&E

International Health Policy Program -Thailand 25 Acknowledgement 25 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) WHO long-term fellowship program of WHO-SEA region Department of Health Statistics and Informatics, WHO-HQ