international health policy program -thailand phusit prakongsai, md. phd. international health...
TRANSCRIPT
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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
StrategiesHotel Victoria, Glion sur Montreux
14-15 July 2010
Thailand’s system of accountability:Institutional mechanisms to support
M&E
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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 /strengtheningA general framework
Data sources
Indicatordomains
Analysis & synthesis
Communication & use
Administrative sourcesFinancial tracking system; NHADatabases and records: HR, infrastructure, medicines etc.Policy data
Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness
Clinical reporting systemsService 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
Fina
ncin
gInfrastructure
/ ICT
Health workforce
Supply chain
Information
Interventionaccess & services
readiness
Interventionquality, safety and efficiency
Coverage of interventions
Prevalence risk behaviours &
factors
Gov
erna
nce
Inputs & processes Outputs Outcomes Impact
Data availability for M&E system in Thailand (1)Data availability for M&E system in Thailand (1)
Input Output Outcome Impact
HCF HRH
Infra struct
ure
Gover
nance
Med/Health tech
HIS access
quality
safety
efficienc
y
Interven
coverage
Risk factor
s
H outco
me
Responsive
Equity
Finan prote
ction
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)Data availability for M&E system in Thailand (2)
Input Output Outcome Impact
HCF
HRH Infra structu
re
Gover
nance
Med/Health
tech
HIS access
quality
safety
efficiency
Interven coverage
Risk factors
H outco
me
Responsive
Equity Finan protect
ion
Facility-based report
H resource survey
HIS electronic IP database
Dis surveillance
Behavioral H survey
Sero-sentinelSurvey
Specific dis registration
Quality assurance (HA)
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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
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Scheme beneficiaries by income quintiles, 2004
4% 1%
25%7%
5%
25%
11% 14%
23%
26% 31%
17%52% 49%
10%
0%
20%
40%
60%
80%
100%
CSMBS SSS UC
Q1 (poorest) Q2 Q3 Q4 Q5 (the richest)
Source: Analysis from the 2004 Household Health and Welfare Survey (HWS) conducted by NSO.
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Declining of catastrophic health expenditure
from 2000 to 2006
0
1
2
3
4
5
6%
ho
use
ho
ld
2000 2002 2004 2006
Quintile 1 Quintile 5 All
Note: Catastrophic health expenditure refers to household out-of-pocket payments exceeding 10% of household income
Source: Socio-Economic Survey 2000 - 2006 conducted by NSO.
10
0
1
2
3
4
5
6
7
8
9
Decile
1
Decile
2
Decile
3
Decile
4
Decile
5
Decile
6
Decile
7
Decile
8
Decile
9
Decile
10
Income Deciles
% in
com
e sp
ent
on h
ealt
h
19921994199619982000200220042006
Improved fairness of financial contributions Out of pocket payments,
1992-2006
Source: Household Socio-Economic Survey 1992 - 2006 conducted by NSO.
Dec
linin
g of
gap
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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 0.9057 0.1868– Indirect tax 0.5776 0.3155– Social insurance 0.5760 0.0582– Private insurance 0.3995 0.0668– Direct payments 0.4864 0.3728– Total Health Financing 0.5929
– General Tax 0.6996
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
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Equity in utilization: Concentration Indexes of OP service by
level 2001 to 2007
Facility levels 2001 2003 2004 2005 2006 2007
Health centers -0.294 -0.365 -0.345 -0.380 -0.267
-0.292
District hospitals -0.270 -0.320 -0.285 -0.300 -0.256
-0.246
Provincial and regional hospitals -0.037 -
0.080 -0.119 -0.100 0.028 0.013
Private hospitals 0.431 0.348 0.389 0.372 0.516 0.528
Overall -0.090 -0.139 -0.163 -0.177 -0.054
-0.041
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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).
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Equity in health service use: Concentration indexes of IP service by level
2001 to 2007
Types of health facilities
2001 200320
0
4
20
0
5
20
0
6
20
0
7
Community hospitals -0.316 -0.293 -029
4
-02.66
-02.4
2
-02.93
Provincial and regional hospitals -0.069 -0.138
-011
4
-01.5
6
-00.4
9
-011
4
Private hospitals 0.320 0.309 02.5
4
03
6
6
03.9
8
04.6
4
Overall -0.079 -0.121
-0.127
-0.114
-0.051
-0.080
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Who benefits from government subsidies for health?
Benefit incidence analysis (BIA) 2001 and 2003A comparison of percent distribution of net government health subsidies among different
income quintiles in 2001 and 2003
28
20
17 17 18
31
22
1516
15
0
5
10
15
20
25
30
35
Q1 Q2 Q3 Q4 Q5
Income quintile
perc
ent
2001
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 -0.044 and in 2003 was -0.123
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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
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Increased access to particular servicesafter introduction of appropriate provider
payments
0
2,000
4,000
6,000
8,000
10,000
2004 2005 2006 2007 2008
Open heart
0
50,000
100,000
150,000
200,000
250,000
2004 2005 2006 2007 2008
Chemo
0100,000200,000300,000400,000500,000
2003
2004
2005
2006
2007
2008
ALS BLS FR
0
20,000
40,000
60,000
2004 2005 2006 2007 2008
Cataract
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More equitable geographical access to open-heart surgery between
2004-2007
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Less than 21.06
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21.06 – 42.12
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Financial sustainability:Total health expenditure 1994-2005
0
50,000
100,000
150,000
200,000
250,000
300,000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Mil
. B
aht
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
%G
DP
public private %GDP
Total health expenditures, 2003-2005: 3.55 – 3.49% of GDP, THE per capita approx 100 USD
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Long-term budget impact (million
USD) from providing
treatment for all women with
osteoporosis in Thailand
Years Alendronate(million USD)
2009 15.6
2010 22.8
2011 26.3
2012 29.4
2013 27.7
2014 27.5
2015 26.9
2016 23.2
2017 21.8
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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
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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.
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Structure of Health Information System Development and Networking in Thailand
MOPH
Thai Health Promotion Foundation
Health System Research Institute (HSRI)
Health Information System DevelopmentPlan 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 developmentfor improving health information system
Data qualityassessment
Reviews for health information systems
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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
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Acknowledgement
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• 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