Thailand s UHC development. National Health Security Office 23 June 2014

Transcription

1 Welcome to NHSO

2 Thailand s UHC development National Health Security Office 23 June 2014

3 Thailand: country profiles Population - 64 million GNI 2012 US$5,090 per capita UHC achieved in 2001 under 3 scheme civil servants, social security and UCS Health status Life expectancy at birth 74 years IMR 20/1000 LB, MMR 30/100,000 LB Physicians per capita 5/10,000 Total Health Expenditure (NHA 2011) 4.1% GDP 12.4% out of pocket 3 3

4 Before WCF 1975 LICS 1978 CSMBS 1981 FFS with max ceiling Capitation contract model FFS reimbursement Fee Exemption Type B fee exemption 1998 Health care reform project Capitation for OP DRG weighted global budget for IP 1990 SSS 1991 HCS Traffic Accident Protection Program (TAP) MWS 1999 SIP in 6 provinces Poor people Near poor Uninsured Oct Fund-holding autonomous hospital (1 district) Apr UCS in pilot 6 provinces Apr UCS implemented nationwide Year Private employee Government employee Population covered by Universal Coverage 4 Scheme (UCS)

5 Long march towards universal health coverage in Thailand using National Health Accounts (NHA) data GNI per capita,

6 Health service delivery system in Thailand Specialized hospitals 48 University hospitals 11 Province District Regional hospitals 26 Provincial hospitals 71 District hospitals Other public hospitals 60 Private hospitals 322 Subdistrict Health centers 9,768 MOPH facilities Community Medical Centers 365 LGUs Private clinics 17,671 Pharmacy 11,154

7 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. 7 Rural community hospital with 2-8 doctors cover 30-80,000 population

8 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 General hospital in every province 8 Regional hospital in every region

9 3 main schemes characteristics CSMBS SSS UCS Nature Fringe benefit Mandatory Citizen entitlement Population Government employees, pensioners and their dependants5 Million (8%) Formal-sector private employees, 10 Million (16%) The rest of population who are not covered by SSS and CSMBS Source of finance Management organization Benefit package General tax (~400 US$/Cap) Comptroller general under ministry of finance No preventive care No explicit exclusion Special bed Tripartite rate 1.5% of salary (maximum salary: 500 US$) (health care 106 US$ /Cap, total 397 US$/Cap) Social security office under ministry of labor Small number of limited condition eg. Non medical plastic surgery 47 Million (75%) General tax (84 US$/Cap) National Health Security Office (NHSO) Small number of limited condition Prevention & promotion for all Providers Choice of provider Payment Public provider only, Private in emergency, elective surgery (2011) Free choice public hospitals OP: Fee-for-service IP: DRGs (2007) Public and private hospital more than 100 beds (50% private) Contracted hospital and its network Capitation OP and IP (DRG for IP DRG RW> 2) Public and private contracting unit for primary care(cup), mainly District hospitals Primary care contractor services, plus referral OP: Capitation IP: DRGs with global budget CSMBS = Civil Servant Medical Benefit scheme, SSS = Social Security Scheme, UCS= Universal Coverage Scheme 9

10 Achieving efficiency and equity: role of strategic purchaser

11 Provider payment: efficiency and cost containment Budget Hard budget: annual expenditure exactly equal to budget Provider payment: Closed-end Send strong signal Use generic medicines, appropriate dispensing of medical technologies, Effective prevention of supplier-induced demand LOS stays at 4 in last 7-8 years Risk of under-service provision, counteracted by Complaint management through 1330 call centre, Quality assurance, accreditation, medical audit Setting separated payments for high cost previously underprovided services.

12 Benefit package designs Benefit package Initial package: historical precedence, no application of cost effectiveness Later inclusion guided by evidence Benefit Package Sub-committee, NHSO Key platform for decision on what new medical intervention is included into the package National capacity (HITAP and IHPP) to generate evidence on Cost effectiveness, incremental cost effectiveness ratio ICER: not more than one GNI per capita for a QALY gain Catastrophic prevention Medium to long term budget impact assessment Ethical concerns Supply side capacity to scale up new interventions 12

13 Increase fiscal space & deepen financial risk protection NHSO [single purchaser from multiple sellers] Bargaining power over price, quantity and quality of products and services, e.g. Central purchasing of assured quality products or constraint fee» Hemo-dialysis, down from US$ 67 to US$ 50 per session, approx 1 million sessions per annum, saving US$ 170 million per annum» Cataract soft lens, down from US$130 to US$90 with assured quality, saving US$ 40 million per annum» Erythropoietin, down from US$ 21 to US$ 8, saving US$ 12 million per annum» Drug coated Stent for coronary artery, down from US$2,700 to US$ 600, saving US$ 21 million per annum

14 Service management: PHC orientation District health system is a typical contractor provider network Gate keeping role for OP and IP Patient bypassing contractor provider network without referral are liable for full payment Rationale use of service by level: lower unit cost Better access: lower transport cost shouldered by patients Better outcome: continuity of NCD control, DM, HT Referral backups Provincial hospitals with specialists Regional excellent centres strengthened for sub-specialty care e.g. heart, cancer, trauma, premature newborns 14

15 Expanding benefit package 2013 (B.E.2556) - Expand target group for seasoning influenza vaccines - stem cell transplantation in Leukemia and lymphoma with indication - Strategic plan for long-term care in frail elderly in Home care and community care 2012 (B.E.2555) - Liver transplantation in patient age <18 years - Heart transplantation 2009 (B.E.2552) - High cost drug in J2-National drug lists - Seasoning Influenza drug list 2010 (B.E.2553) - Orphan drug, Thai traditional medicines - Psychosis admission without limitation 2007 (B.E.2550) - Thai traditional medicine services 2008 (B.E.2551) - Renal replacement therapy (CAPD, HD, KT) - Methadone drug as a replacement drug in drug addicts 2005 (B.E. 2548) Benefit package for HIV/AIDS include ARV, Laboratory, counseling, Voluntary Counseling and Testing (VCT), condoms (B.E. 2545) Universal health coverage for Thai citizen including health promotion, disease prevention, diagnosis, treatment, dental care, drug listed in national drug list, rehabilitation 15

16 UCS institutional arrangements Fund and system manager provider

17 Head Quarter & Branch Address of NHSO

18 NHSO Office of the secretariat Bureau of Audit Cluster of Strategy and evaluation Cluster of Fund administration Cluster of Universal health care services delivery management Cluster of Office administration Cluster of Branch office mission and participation Bureua of Strategic management Bureau of Planning and evaluation Bureau of Quality and health outcome monitoring Bureau of Executive information administration Bureau of International universal health coverage Bureau of Registration administration Bureau of Fund allocation and reimbursement Bureau of Finance and accounting for universal health care fund Bureau of Medical audit Bureau of primary health care promotion Bureau of Medicines, medical supplies and vaccines management Bureau of secondary, tertiary and specifics cares HIV/AIDS and tuberculosis Program Chronic diseases and special diseases Program Renal diseases Program Bureau of General administration Bureau of Legal affairs Bureau of Finance and accounting for administrative fund Bureau of Health insurance information technology management Bureau of Human resources and change management Bureau of Quality and good governanace development Bureau of Public and private participation promotion Bureau of Customer services and right protection Bureau of Regional support and coordination NHSO Region 1-13

19 Administration for UC budgeting 13 Branch offices NHSO Central headquarter Timetable for budget subsidies plan Bureau of the budget Approved annual budget Submit a request for annual budget recommendation Preliminary approved annual budget suggestion Submit annual government budget plan Recommendation Preliminary approved annual budget 1 2 Financial sub-board Submit the approved annual budget request National health security board The Cabinet Apply annual budget request The Parliament 3 Main scheme MOF MOPH 19

20 Timetable for UC budgeting, FY Branch offices Sep NHSO Feb Central headquarter Timetable for budget subsidies plan Bureau of the budget Submit Nov. a request for annual budget 2011 Approved annual budget recommendation Preliminary approved annual budget Apr suggestion Submit Apr. annual government 2012 budget plan Recommendation Preliminary approved annual budget 1 2 Financial sub-board Submit the approved Feb. annual budget 2012 request National health security board Apr The Cabinet Apply annual budget Mar. request 2012 May 2012 The Parliament 20

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22 Outcomes of UC Scheme

23 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) 23

24 Outcome: increased government health spending Thailand THE , ,000 UHC achieved 5.0% 4.0% Mil Baht 300, , % 2.0% 100, % GDP 1.0% 0.0% Year Government spending non-government spending THE, %GDP Source: NHA

25 Outcome: Protection against health impoverishment UHC achieved

26 Outcome: health impoverishment sub national 1996 to 2008 Per 100 households Per 100 households Per 100 households Per 100 households Per 100 households Per 100 households Per 100 households Per 100 households

27 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% 27 Source: NSO 2009 Panel SES, application of OECD unmet need definitions

28 Changes in utilization: primary secondary and tertiary % (5.5) 24% (2.9) 29% (3.5) 27% (11.0) 35% (14.6) 38% (15.7) 18.2% (20.4) 35.7% (40.2) 46.1% (51.8) 12.6% (18.1) 33.4% (33.4) 54.0% (78.0) Regional H./General H. Community H. Rural Health Centres Regional H./General H. Community H. Rural Health Centres Regional H./General H. Community H. Rural Health Centres Regional H./General H. Community H. Rural Health Centres

29 Challenges for further reforms Harmonization of the three main schemes is challenging as individual fund has its own legal framework and governing board Burden Of Disease challenges Increased diseases burden from chronic NCD Little success in controlling traffic injuries Health systems capacity to cope with Increased workload and very strained health workforces Decentralization context threats and opportunities Public private dialogues, better trust and collaboration Medical tourism and internal brain drains Long term financial sustainability Aging society 29

30 Thank you for your attention