Health Care

1
Health Care
Reform in Thailand
2

Health Problems
? Passive VS. Proactive ( health
repairing VS. Health building )
? 25 of population - not covered by any
health benefit schemes.
? Health - related inequalities (discrepancy
index, Kakwani index, concentration index)
? High health care cost
3
Table Health benefit coverage ( of total
population) from 1991 to 1997
1991
1993
1995
1996
1997
Schemes
Urban
Rural
Rural
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
Urban
10
23
7
11
11
10
18
8
11
CSMB state
enterprise
6
7
7
13
4
7
Social Security



Low income
17
2
20
27
44
30
32
19
41
public welfare
9
0
2
Health card
2
2
5
8
15
19
scheme
na
na
1
Private
na
2
7
-
-
-
Employee
benefits
1
1
1
2
Private
0
2
3
na
2
Insurance and
others
Not covered
37
35
32
68
68
68
49
28
45
TOTAL
100
100
100
100
100
100
100
100
100
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Table Distribution of hospital beds from 1981
to 1993 (beds/1,000 population)
Public
1993
Private
1981
1986
1.7
3.3
2.9
4.1
2.4
Bangkok
2.1
2.2
2.1
1.6
0.4
Central
1.2
1.3
1.3
0.2
1.5
North
Northeast
0.8
0.9
0.9
1.0
0.1
1.4
0.2
South
1.7
1.7
1.5
TOTAL
1.5
1.9
1.6
0.4
1.5
Sources 1981-1986 - The Thai Government(1988)
1993-Pannarunothai (1994)
5
Table Inpatient workload of doctors and nurses
in 1992
Bed/RN
IP/RN/day
Bed/Dr
IP/Dr/day
Provinces
2.32
2.02
MOPH
9.99
11.48
Bangkok
6.53
5.17
2.26
1.79
Other
Provinces
5.83
1.27
3.13
2.37
2.85
1.19
1.40
0.59
Ministries
Bangkok
4.50
1.74
3.13
Private
8.08
Provinces Bangkok
3.65
2.12
1.86
1.08
Source Health Policy and Plan Bureau (1994) in
Pannarunothai (1996) RN registered nurse
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(No Transcript)
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Scheme characteristics



Free Contractual basis Contractual basis Free Free
- cash benefit - cash benefit No No Yes Yes Yes No Usually no
Inclusive conditions Inclusive conditions All All Non-work Related illness, injuries, except 15 conditions Non-work Related illness, injuries, except 15 conditions Work-related illness and injuries All As stated in the contracts
-Maternity benefit -Maternity benefit Yes Yes Yes Yes No Yes Varies
- Annual physical checkup - Annual physical checkup No Yes No No No Possible Varies
- Promotion preventive - Promotion preventive Very limited Yes Health education and immunisation Health education and immunisation No Possible Varies
- Services not covered - Services not covered Private bed, special nurse, eye glasses Special nurse Private bed, special nurse Private bed, special nurse No Private bed Varies
Low income And public welfare
Private insurance
Health Card
CSMBS
SSS
WCS
Benefit package

• Ambulatory
• Services

Only public designated
Public private
Public private
Public private
Public (MOPH)
Public only
- Inpatient services
Public (MOPH)
Public private
Public private
Public private
Public private
Public only

• Choice of
• provider

Referral line
Referral line
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- Source of fund General tax General tax Tripartite contributions, 1.5 of payroll Employer, 0.2-2 of payroll with experience rating Household purchase 500 bath tax subsidy 500 Premium
- Financing body MOPH Ministry o Finance Ministry of Labour Ministry of Labour MOPH Competitive companies
- Payment mechanism Global budget Fee-for-service reimburse Prospective capitation Fee-for-service reimburse Limited fee-for-service Fee-for-service reimburse
- Copayment No Yes,for IP at private hospital Maternityand emergency services Yes, if beyon the ceiling of 30,000 bath No Almost none
Financing
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Table Total expenditure per capita of selected
health benefit schemes
Private
Government
Expenditure
Discrepancy
Schemes
contributions
Index
budget
Per capita
(million bath)
(million bath)
(bath)
1. Public welfare
0
4,143.1
gt22
1
Low income,elderl
(1995)
161.1
gt 3
Primary school(1995)
0
0
2. Fringe benefit
0
9,954.0
gt 1,780
CSMBS(1994)
8
3. Compulsory insurance
711
3
3,803.7
SSS (1993)
5,553.5
WCS (1993)
921.4
0
96
0
4. Voluntary insurance
Health card (1994)
0
807.4
400
gt 19
SourceSupachutikul (1996) ratio between
expenditure per capita of each scheme and the low
income scheme
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National Health Security Fund
Contract
SSS / WCS
Basic package
Oversee
Contracted providers
National Commission on Health Security
CSMBS
Consumer
Govt. budget / LICS
Choose
Private
Public
VHC
SSS Social Security Scheme
WCS Workmen Compensation Scheme CSMBS
Civil Servant Medical Benefit Scheme VHC
Voluntary Health Card Programe
Figure 1.
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SSS / WCS
Contract
CSMBS
Contract
Common health benefit
coordinate
Contracted providers
National Commission on Health Security
Contract
Govt. budget / LICS
Consumer
Private
Public
VHC
Contract
SSS Social Security Scheme
WCS Workmen Compensation Scheme CSMBS
Civil Servant Medical Benefit Scheme VHC
Voluntary Health Card Programe
Figure 2.
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Ultimate Scenario
? Universal Coverage
? Core Package
? Health Care Service System
? Monetary and Fiscal System
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Universal Coverage
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Core Package
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Health Care Service System
?Primary care gate keeper
? Main contractor neighborhood primary care
? Provider network public private mix
? Health care accreditation system
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Monetary and Fiscal System
? Cost Containment Systems
? Capitation
? Operating areas - adjusted rate
- minimum guarantee
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Monetary and Fiscal System
? Closed ends
a. Inclusive capitation - ambulatory
care - promotive and preventive care
- in-patient care
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Monetary and Fiscal System
? Closed ends
B. Combined method Capitation
- ambulatory care - promotive and
preventive care Global budget -
inpatient care (DRGs)
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Monetary and Fiscal System
? Closed ends
C. Both (a) and (b)
? Performance related payment
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Table The health care insurance system
reformation trends
2002
2003
2004
Expand the coverage
1. Social Security Project
Expend its coverage from the
Integration to form single fund or multiple funds
to be managed by standard beneficial right
and single format payment mechanism
business with over 10 employees
to the insured families,
to the business with 1 or more
raising the coverage
employees, coverage of the
of 10 million to 14-15
Number of the incurred shall rise
million
from 6 million to 9 million
Change payment method to per
Management by new
2. Civil servants welfare project
in term of medical care
person for out-patient service
system and the
incurrence of new
and DRG for in-patient create
information technology for DRG
information
and other systems development
technology of the
in connection with the management
future system
or pre-management by social
security fund or the national health
care security fund
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Table 1 The health care insurance system
reformation trends
2002
2003
2004
Continuing operation
Integrate lower income
3. Public Health Ministry
encouraging areas
cards, health care security
committees to take,
cards and other operating
charge of service
budgets to be managed,
buyers units
administered under
Performance Based
Budgeting System(PBBS)
guidelines and made the
allocation to the provinces
or areas committees in
the from of block grant.
4. Commerce Ministry
Amend the Act covering
Starts transferring
faced cars accident so
money to the national
medical care budget be
health care security
integrated in the national
fund
health care security fund
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Unity
Civil Servants Welfare Fund
Public - private medical care provider network
Core Benefits
Public Health Care Security Board
Tertiary
Social Security Fund
Area Purchaser
Choice of
Secondary
Population
Primary
Low income and public welfare cards, and other
health cards
Payments Format
Satisfaction
Standard Regulation and Certification
Public Health Ministry and Accreditation bodies
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Transitional Period
? Budget - For service - For management
? Operating area - all in October 2001
? Public health care organization reform
- Regulation reform - Autonomous
Organization - Both
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Transitional Period
? Private participation
? Registry
? Accreditation
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? Core Package
W o r k i n g
? Service Standard
? Information Technology
? Public relation and Petition
G r o u p s
? Referral Service System
? Organization Development
? Management System
? Human resource development
? Research and Development
? Monitoring and Evaluation
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Desirable Health Systems
Conceptual Framework of Health Systems Refrom
NEED FOR NATIONAL HEALTH ACT (As a health
constitution for the Thai people)
NEED FOR REFORMOR THE WHOLE
HEALTH SYSTEM AS Policy system
Health promotion system Disease prevention
system Health service system Quality
control system Technology system Human
resources system research system etc.
CURRENT SITUATION Undesired deterioration of
the health of the Thai. High health
expenditure, emphasizing on treatment with low
returns. Much thought but little on health
promotion work. Limited rights,
opportunity, system and support for good health
building.. Many problems with the health
service system. Many Thai people lack health
security.
REFROM THE WAY OF THINKING OF THE THAI PEOPLE
ON HEALTH
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Goals And Strategies Of National Health System
Reform

• Desired Health Systems
• Focus on health building
• Access health service system that is
  efficient, of good quality and justice to all.

• National Health Act
• A health constitution
• Legeslative framework
• National Health Council

Strategies
1. Knowledge generation 2. Partnership
building 3. Public communication 4. Management
(3 years)
(5 years)
Evidence - based social movement - Ministy of
Public Health (all departments, Policy and
Planning Office. Office of The Health Care
Systems Reform) Health Systems Research
institute. - National Health Foundation. -
National Economic and Social Development Board. -
Non Government Organizations. - Private business
organizations. Public sector. - political sector.
- Political organizations. - Professional
organization. - Mass media, etc.
National Health System Reform Commitee (NHSRC)
HSRO (Secretariat)
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Machanism of National Health System Reform
Technical Advice
National Health System Reform Committee (NHSRC)
HSRI Board
Health Systems Research Institute (HSRI)
Partnership building
Knowledge generation
HSRO
Media movement
Drafting NH act
HSRO is set up under HSRI
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Component of Budget
? Capitation 1,200 Baht/Person/yr. 1.
Curative Care (934 Baht/Person/yr.) 1.1
General curative care - OPD 574
Baht/Person/yr. - IPD 303
Baht/Person/yr. 1.2 High cost 32
Baht/Person/yr. 1.3 Emergency 25
Baht/Person/yr. 2. Promotive and Preventive
Care 175 Baht/Person/yr. 3. Investment 91
Baht/Person/yr.
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Component of Budget
? Management 110 Baht/Person/yr. ?
Contingency Fund 110 Baht/Person/yr.
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Budget Management
High cost 32 Baht/Person/yr. Emergency care 25
Baht/Person/yr. Investment 91 Baht/Person/yr. Man
agement 110 Baht/Person/yr. Contingency fund 110
Baht/Person/yr. Medical care with promotive and
preventive care- (8871751,052 Baht/Person/yr.)
Managed by Central Committee
Budget
Refer
Area Purchaser
Tax
Budget for IPD (303 Baht/Person/yr.)
Citizens
Working Committee for monitoring and
control
Budget for OPD, Promotive, Preventive care
(574175749 Baht/Person/yr.)
Secondary Tertiary care
Refer
Primary Health care
Registry and choice of health care
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SAWASDEE