International Health Policy Program -Thailand Phusit Prakongsai, MD. PhD. International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the 1 st Global Symposium on Health Systems Research Montreux, Switzerland 17 November 2010 Contributions of health system research to health system performance assessment in Thailand

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

Informal user fee exemption User fees 1-3 rd NHP Provincial hospitals Health Infrastructure extension--wide geographical coverage Historical evolution: Infrastructure development + financial protection extension 1975 LIC 1990 Establishment of prepaymentschemes 1983 CBHI 1980 CSMBS 1990 SSS UniversalCoverage CSMBS 2002 full achieve Universal Coverage SSS LIC  MWS 1994 Pub VHI CSMBS SSS Expansion consolidationof prepayment schemes 4 th -5 th NHP ( ) District hospitals Health centers

Improving production capacity, but still shortage of human resources for health in Thailand Thailand Source: World Development Indicator 2002 and World Health Report 2006

Geographical mal-distribution of health workforce in 2007 Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 Pharmacists 4,600-8,432 8,433-12,274 12,275-16,115 16,116-19,956 Nurses ,156 1,157 – 1,408 Dentists 5,500-15,143 15,144-25,767 25,768-36,390 36,391-47,011

Real term growth GDP versus THE,

Total health expenditure Total health expenditure during ranged from 3.49 to 3.55% of GDP, THE per capita approx 100 USD Achieving UC

Health service delivery: Better coverage of essential vaccines, ARV and condom use Compulsory licensing Include ART in UC package Generic production of triple ART Percentage of female sex worker consistently use condom when having sex with general client in the past 1 month, 1995 – 2007

International Health Policy Program -Thailand 99 Increase access to particular services

More equitable health care use and better distribution of public subsidies on health after achieving universal health coverage (20% poorest) (20% richest) Before UC After UC OP visits Hospital admission

More equitable health financing and better financial risk protection 3. Health impoverishment 2. Catastrophic health payment 1. Out-of-pocket health payment

Child mortality in Thailand from various sources of surveys Source: Hill et al. Int J Epidemiol 2007 (with updates)

International Health Policy Program -Thailand 13 Child mortality by quintile: 1990 and 2000 census Source: Vapattanawong et al. (2007)

International Health Policy Program -Thailand 14 Efficiency in health resource use compared to health outcome Reduction in under 5 mortality rate (U5MR) – The highest level of annual reduction in child mortality during RankAnnual reduction U5MR (1990–2006) U5MR 2006MMR Thailand 8·5% Vietnam 7·1% Indonesia 6·2% Sri Lanka 5·6% Nepal 5·5% Laos 4·9% Bangladesh 4·8% Philippines 4·1% China 3·9% Note: only countries with GNI US$ ≤5,000 per capita; Births ≥ 100,000/year Source: Rohde et al in Lancet 2008

International Health Policy Program -Thailand 15 Health outcome on maternal mortality Maternal mortality rate (MMR per 100,000 live births) Various MMR show steep reduction trend; though problematic MMR: 65% of all deaths occurred outside health facilities, high (40%) ill defined cause of deaths Recent update in Lancet May 2010 by Hogan et al 1980: 115 ( ) 2000: 43 (38-48) 1990: 44 (39-50) 2008: 47 (42-53) Analysis from various sources

Inequitable health service provision: Percentage of caesarian section to total deliveries by health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, (N=13,232,393 hospital admissions)

Inequity in quality and patterns of health service provision: Propensity of receiving single source antiplatelets clopidogrel, cilostazol: 6 regional hospitals

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 spending Source: Ministry of Finance, Comptroller Generals Department, various years

Data availability for M&E system in Thailand 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

Network and Coordination of HIS Reviews for HIS Demands and indicators Data analysis and synthesis for report production and publication Utilization mechanism Research and development for improving HIS, health system and policy research Data quality assessment Reviews for health information systems Health Information System for supporting HSPR in Thailand

International Health Policy Program -Thailand 21 Key challenges in future health system development in Thailand (1) BOD - Increasing disease burden from chronic NCD and rapid demographic changes  aging society, - The pandemic of new emerging infectious disease and unsuccessful control of TB and HIV/AIDS, - Inequitable health risk distribution among different SE groups. Inequity and inefficiency - Mal-distribution and internal brain drain of HRH  external brain drain of nurses in the future, - Inefficiency and inequitable access to good quality of health services among different health insurance schemes, - Require more efficient use of new medical products and health technology. 21

International Health Policy Program -Thailand 22 Key challenges in future health system development in Thailand (2) Governance - Poor governance of the Thai health systems, Contexts - The impact of globalization and international trade agreement on health  import of harmful products e.g. alcohol, tobacco, - Economic recover and growth of the private sector, Financing - Sustainability of health care finance in Thailand. 22

International Health Policy Program -Thailand 23 Lessons learnt from Thailand Need good relationship and collaboration between Data producers Researchers Policy makers To bridge HSPR and HIS to health system performance assessment in Thailand Good quality and timely health information system Skills of researchers to analyze the data, and get research into policy and practice.