[Show abstract][Hide abstract] ABSTRACT: Strategic purchasing is one of the key policy instruments to achieve the universal health coverage (UHC) goals of improved and equitable access and financial risk protection. Given favourable outcomes of Universal Coverage Scheme (UCS), this study synthesized strategic purchasing experiences in the National Health Security Office (NHSO) responsible for the UCS in contributing to achieving UHC goals. The UCS applied the purchaser-provider split concept where NHSO, as a purchaser, is in a good position to enforce accountability by public and private providers to the UCS beneficiaries, through active purchasing. A comprehensive benefit package resulted in high level of financial risk protection as reflected by low incidence of catastrophic health spending and impoverished households. The NHSO contracted the District Health System (DHS) network, to provide outpatient, health promotion and disease prevention services to the whole district population, based on an annual age-adjusted capitation payment. In most cases, the DHS was the only provider in a district without competitors. Geographical monopoly hampered the NHSO to introduce a competitive contractual agreement, but a durable, mutually dependent relationship based on trust was gradually evolved, while accreditation is an important channel for quality improvement. Strategic purchasing services from DHS achieved a pro-poor utilization due to geographical proximity, where travel time and costs were minimal. Inpatient services paid by Diagnostic Related Group within a global budget ceiling, which is estimated based on unit costs, admission rates and admission profiles, contained cost effectively. To prevent potential under-provisions of the services, some high cost interventions were unbundled from closed end payment and paid on an agreed fee schedule. Executing monopsonistic purchasing power by NHSO brought down price of services given assured quality. Cost saving resulted in more patients served within a finite annual budget.
Health Policy and Planning 11/2014; DOI:10.1093/heapol/czu120 · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Walaiporn Patcharanarumol and colleagues illustrate progress towards UHC and its monitoring and evaluation in Thailand.
Please see later in the article for the Editors' Summary
PLoS Medicine 09/2014; 11(9):e1001726. DOI:10.1371/journal.pmed.1001726 · 14.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the 1970s, Thailand was a low-income country with poor health indicators and low health service coverage. The local health infrastructure was especially weak.
In the 1980s, measures were initiated to reduce geographical barriers to health service access, improve the health infrastructure at the district level, make essential medicines more widely available and develop a competent, committed health workforce willing to service rural areas. To ensure service accessibility, financial risk protection schemes were expanded.
In Thailand, district hospitals were practically non-existent in the 1960s. Expansion of primary health care (PHC), especially in poor rural areas, was considered essential for attaining universal health coverage (UHC). Nationwide reforms led to important changes in a few decades.
Over the past 30 years, the availability and distribution of health workers, as well as their skills and competencies, have greatly improved, along with national health indicators. Between 1980 and 2000 coverage with maternal and child health services increased substantially. By 2002, Thailand had attained UHC. Overall health system development, particularly an expanded health workforce, resulted in a functioning PHC system.
A competent, committed health workforce helped strengthen the PHC system at the district level. Keeping the policy focus on the development of human resources for health (HRH) for an extended period was essential, together with a holistic approach to the development of HRH, characterized by the integration of different kinds of HRH interventions and the linking of these interventions with broader efforts to strengthen other health system domains.
Bulletin of the World Health Organisation 11/2013; 91(11):874-880. DOI:10.2471/BLT.13.120774 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Though 85% of financing HIV/AIDS program was domestic resources, Global Fund (GF) programs played a significant role in prevention interventions and treatment for non-Thai Key Affected Populations (KAP) and migrants. As upper-middle income country, Thailand is not eligible for GF support. This study identified the remaining challenges and funding for prevention interventions for Thai and non-Thai KAP and migrants if GF supports were to curtail.
Qualitative method was applied including document review and in-depth interviews of 21 key informants who were Principal Recipients, Sub-recipients, provincial level program implementers and policy makers in health financing agencies. A multi-stakeholder consultation workshop was convened to discuss recommendations.
The "public financed public services model" where Principal and Agents were the same entities resulted in less accountability than the "contractual agreement" in GF programs where the Principal Recipients, as the Agents were more accountable to the GF as Principal through results based financing. If GF supports were to curtail, impacts on the current programs would be varied from low to high degree of negative consequences. Scale down the scope and targets, while keeping the most critical components were common coping mechanisms. All three, except one, Principal Recipients had difficulties in fund mobilization. Prevention among non-Thai KAP and migrants were identified as the remaining challenge.
A pooled funding mechanism from multiple domestic sources was proposed. Replacing the conventional public-financed-public-service by a contractual model was preferable. The GF should continue funding the non-Thai KAP and migrant as transition mechanism. Multi-countries or regional programs especially at the border areas were priorities.
BMC Public Health 10/2013; 13(1):1008. DOI:10.1186/1471-2458-13-1008 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Empirical evidence demonstrates that the Thai Universal Coverage Scheme (UCS) has improved equity of health financing and provided a relatively high level of financial risk protection. Several UCS design features contribute to these outcomes: a tax-financed scheme, a comprehensive benefit package and gradual extension of coverage to illnesses that can lead to catastrophic household costs, and capacity of the National Health Security Office (NHSO) to mobilise adequate resources. This study assesses the policy processes related to making decisions on these features.
The study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources.
Continued political and financial commitments to the UCS, despite political rivalry, played a key role. The Thai Rak Thai (TRT)-led coalition government introduced UCS; staying in power 8 of the 11 years between 2001 and 2011 was long enough to nurture and strengthen the UCS and overcome resistance from various opponents. Prime Minister Surayud's government, replacing the ousted TRT government, introduced universal renal replacement therapy, which deepened financial risk protection.Commitment to their manifesto and fiscal capacity pushed the TRT to adopt a general tax-financed universal scheme; collecting premiums from people engaged in the informal sector was neither politically palatable nor technically feasible. The relatively stable tenure of NHSO Secretary Generals and the chairs of the Financing and the Benefit Package subcommittees provided a platform for continued deepening of financial risk protection. NHSO exerted monopsonistic purchasing power to control prices, resulting in greater patient access and better systems efficiency than might have been the case with a different design.The approach of proposing an annual per capita budget changed the conventional line-item programme budgeting system by basing negotiations between the Bureau of Budget, the NHSO and other stakeholders on evidence of service utilization and unit costs.
Future success of Thai UCS requires coverage of effective interventions that address primary and secondary prevention of non-communicable diseases and long-term care policies in view of epidemiologic and demographic transitions. Lessons for other countries include the importance of continued political support, evidence informed decisions, and a capable purchaser organization.
Health Research Policy and Systems 08/2013; 11(1):25. DOI:10.1186/1478-4505-11-25 · 1.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.
The Lancet 04/2013; 381(9883). DOI:10.1016/S0140-6736(12)62000-5 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to estimate household costs (direct medical, direct non-medical and opportunity costs) associated with outpatient consultations and inpatient admissions at three tertiary hospitals in Lao PDR (national, university and regional hospitals). Revolving drug funds are the main sources of revenue for the facilities. We used outpatient exit interviews and interviews with discharged inpatients to obtain data. A total of 280 outpatients and 149 patients discharged from internal medicine wards were interviewed. The average cost for the outpatient services was USD16.0 per patient. Direct medical costs accounted for more than half the amount. Patient interviews revealed it was common for the hospital to require patients to come back the following day to obtain the results of ancillary services which will result in higher transportation and opportunity costs to the patient. The average cost for inpatient admission was USD292; this ranged from USD118 (regional hospital) to USD407 (national hospital). Direct medical costs accounted for 60% and 35% at those two facilities, respectively. Revolving drug funds as a provider payment method at tertiary hospitals were regressive. An uninsured patient faced higher outpatient costs than an insured patient. With the limited number of people currently insured in Lao PDR (8% of the total population in 2009), these results suggest the need to rapidly scale up effective risk protection schemes.
The Southeast Asian journal of tropical medicine and public health 11/2012; 43(6):1521-36. · 0.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thailand achieved universal health coverage by 2002 with three public health insurance schemes covering the entire population. Of these, the Social Health Insurance scheme for private sector employees has been run on a capitation contract model since 1991. The Universal Coverage Scheme followed its example, with capitation payments for outpatient services and a global budget with diagnosis-related group-based payments for inpatient care. There are several arguments in favour of this closed-end payment system such as administrative simplicity, efficiency, prevention of supplier-induced demand and long-term cost containment.
[Show abstract][Hide abstract] ABSTRACT: In recent years there has been a growth in the number of independent health policy analysis institutes in low- and middle-income countries which has occurred in response to the limitation of government analytical capacity and pressures associated with democratization. This study aimed to: (i) investigate the contribution made by health policy analysis institutes in low- and middle-income countries to health policy agenda setting, formulation, implementation and monitoring and evaluation; and (ii) assess which factors, including organizational form and structure, support the role of health policy analysis institutes in low- and middle-income countries in terms of positively contributing to health policy. Six case studies of health policy analysis institutes in Bangladesh, Ghana, India, South Africa, Uganda and Vietnam were conducted including two NGOs, two university and two government-owned policy analysis institutes. Case studies drew on document review, analysis of financial information, semi-structured interviews with staff and other stakeholders, and iterative feedback of draft findings. Some of the institutes had made major contributions to policy development in their respective countries. All of the institutes were actively engaged in providing policy advice and most undertook policy-relevant research. Relatively few were engaged in conducting policy dialogues, or systematic reviews, or commissioning research. Much of the work undertaken by institutes was driven by requests from government or donors, and the primary outputs for most institutes were research reports, frequently combined with verbal briefings. Several factors were critical in supporting effective policy engagement. These included a supportive policy environment, some degree of independence in governance and financing, and strong links to policy makers that facilitate trust and influence. While the formal relationship of the institute to government was not found to be critical, units within government faced considerable difficulties.
Health Policy and Planning 05/2011; 27(3):194-203. DOI:10.1093/heapol/czr035 · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged-contributory arrangements and tax-financed schemes-with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.
The Lancet 03/2011; 377(9768):863-73. DOI:10.1016/S0140-6736(10)61890-9 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bringing together analysis across different sectors, we review the implementation and achievements of the MDGs to date to identify cross cutting strengths and weaknesses as a basis for considering how they might be developed or replaced after 2015. Working from this and a definition of development as a dynamic process involving sustainable and equitable access to improved wellbeing, five interwoven guiding principles are proposed for a post 2015 development project: holism, equity, sustainability, ownership, and global obligation. These principles and their possible implications in application are expanded and explored. The paper concludes with an illustrative discussion of how these principles might be applied in the health sector.
The Lancet 09/2010; 376(9745):991-1023. DOI:10.1016/S0140-6736(10)61196-8 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The 2010 health financing review describes the configuration, and assesses health financing arrangements in Thailand in order to respond the following six major questions: a) how much is spent on health of Thai population and on what services‘ b) who are covered and what are their benefits or entitlements‘ c) where does the health system’s money come from‘ d) how is money pooling, allocated and purchased‘ e) who spends the money‘ f) how different services and health personnel are paid for, based on various models of payment.‘After UC was successfully achieved by 2002, the whole population of Thais have been covered by one of the three public insurance scheme, as well as voluntary private health insurance. The financing healthcare is dominated by general tax revenue, which is one of the most progressive sources of funding. The level of THE, as percent of GDP, is modest; this is within the fiscal capacity of the country to afford in long term, see long term projection of total health expenditure by 2020. One of the strengths of healthcare financing is strategic purchasing, with the application of capitation contracting model as major mode of provider payment for SHI and UC Schemes. Compared to fee for service reimbursement model, capitation contracting model has better prospect of long term cost containment. Benefit package provided by the three public insurance schemes is generous and comprehensive, almost all health services including high cost care are included; though a few items of negative exclusion list are excluded such as cosmetic surgery. Comprehensive coverage where services are provided free of charge results in extremely low prevalence of catastrophic health spending and impoverishment; the poor resided in rural areas had better access and use of health services from the district health provider network which serves as a “close to client service” results in pro-poor public budget subsidies. The administrative costs of the UC and SHI schemes are very low as NHSO relies on annual budget approval through the Budget Act processes, and SSO collects revenue from mandatory monthly wire transfer from the employers. The purchasing functions when apply the capitation contract model, the administrative cost is much less where there is no need to review and approve claims as is the case of CSMBS fee for service reimbursement model. Benefit package was harmonized across three public insurance schemes facilitate movement of members from one to another scheme, provider payment is better harmonized between SHI and UC scheme, while CSMBS is still outstanding when it applies fee for service direct disbursement for OP services, although CSMBS applies DRG systems for hospitalization similar to that of the UC Scheme.
[Show abstract][Hide abstract] ABSTRACT: Thailand achieved universal coverage in access to health care in 2002. Since then, there has been a dramatic reduction in the prevalence of catastrophic health expenditures reflecting the capacity of the main public health insurance schemes to protect their members against financial risk from medical care costs. This policy brief draws on evidence from a recent study of the Social Health Insurance (SHI) and Universal Coverage (UC) schemes, identifying the key features of these schemes which have contributed to the reduction in catastrophic expenditures. Qualitative approaches were applied including documentary reviews and in-depth interviews conducted with three groups of stakeholders: purchasers, providers and patients. Conclusions: The combination of deepening coverage from the comprehensive package to include high cost services, and a provider payment system which reduces the incentives for providers to avoid high cost patients, appear to have been key factors in ensuring that UC and SHI members are protected from the risk of financial catastrophe from health care payments. This predominance of the policy objectives of financial risk protection and equity across schemes is illustrated by the recent decision to extend coverage to include RRT, an intervention that does not pass the conventional cost-effectiveness threshold, but which has been shown to have an impoverishing impact on households. Having a clear policy direction on financial risk protection, a comprehensive benefit package, and an active purchasing function based on evidence and clinical monitoring capacities, together provide an important foundation for successful financial risk protection.
[Show abstract][Hide abstract] ABSTRACT: The establishment of universal social security systems has been one of the cornerstones of OECD countries' successful economic and social development and has contributed to reducing poverty and fostering social inclusion in today's rich countries. It is increasingly recognized that universal social security systems have an enormous potential for low income countries which has not yet been sufficiently explored. Recognizing that economic and social development are inextricably intertwined across countries, new international strategies are required to design appropriate social security policies which would effectively help to reduce poverty and productively contribute to economic and social development.This paper describes and analyses the policy processes of reforms towards UC including the reform content, roles of public actors and the contextual environment. The paper also further describes the systems design, which addresses deficiencies in order to ensure equity, efficiency and long-term financial sustainability. However, the outcomes of the universal coverage policy in terms of equity and efficiency achievements are published elsewhere.
[Show abstract][Hide abstract] ABSTRACT: This paper synthesizes financing health care in general and health promotion in particular, and reviews experiences of innovative financing of health promotion in selected countries that have a specific dedicated tax for health promotion. The paper also draws on lessons from an in-depth case study in Thailand, a lower-middle income country, of the Thai Health Promotion Foundation which has been established since 2001, focusing on innovative financing and a multisectoral and multidisciplinary approach to health promotion. Results show that there is no innovative financing model for health promotion in low-income countries. The historical evolution of innovative financing for health promotion reveals a close link with existing strong tobacco control measures, especially in price increases and dedicated taxes for health promotion, as in Australia, the U.S., and Thailand. Another financing source is earmarking from social health insurance premiums which are quite limited in low-income countries. It is concluded that achieving success in effective financing of health promotion requires legislation to endorse a fund, and often an independent agency with greater flexibility in the organization and management of funding health promotion projects.
[Show abstract][Hide abstract] ABSTRACT: This paper aims to review whether earmarking can mobilize and sustain resources for the health sector. It starts from reviewing the impact of Global Health Initiatives to health care systems of developing countries, experiences in using specific tax on goods and services such as sin taxes from tobacco and alcohol, and additional levy on airline tickets. Then, pros and cons of earmarking are summarized. Finally, this paper concludes that earmarked taxes on harmful products have high potential in mobilizing and sustaining resources to health, although they require strong political leadership and social consensus. Amounts generated, even if they are small, can play catalytic roles towards active health promotion. No matter what the sources, efficient and transparent governance is required to manage these funds towards the country's public health goals.
Bulletin of the World Health Organisation 12/2008; 86(11):898-901. DOI:10.2471/BLT.07.049593 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rationale: In 2001, Thailand achieved universal coverage (UC) in access to health care for the whole population by introducing a tax-financed health insurance scheme to 47 million people (~75% of total population). The UC scheme employs a capitation payment for ambulatory care and a global budget with diagnostic-related group (DRG) for hospitalization. A nominal payment of 30 Baht (~USD 0.75) per ambulatory visit or hospital admission was levied. In rural areas, district health system (DHS) is the main contractor whereby the UC members are required to register with the nearby DHS. In urban areas, public and private hospitals are the main UC contractors. A benefit package of the UC scheme covers outpatient care, hospital admissions, health promotion and disease prevention, as well as a wide range of high-cost care with an additional fee schedule outside the capitation and global budget. The Social Security Scheme (SSS) is a compulsory social health insurance financed by tripartite contributions for 9 million private employees in the formal sector. Payment to health providers rely on a pure capitation basis. The Civil Servant Medical Benefit Scheme (CSMBS) is a non-contributory, tax-funded scheme with free access to a comprehensive service package, but limited to public hospitals without co-payment. Healthcare providers are paid on a conventional fee for service. This results in rapid cost escalation. In 2006, the expenditure per CSMBS member, 5,300 Baht (USD143) was 3.2 times that of per UC member, 1,654 Baht (USD48). Policy makers need to be informed if cost containment from the capitation payment would result in poor quality and welfare loss, and vice versa, if expensive CSMBS would lead to higher level of quality and survival. Objectives: In the context of the close-end payment of UC, the capitation payment of SSS, and the open-ended payment (fee-for-service) of CSMBS, this study explores variations in clinical practice, costs, and outcomes of selected medical interventions provided to members of these three health insurance schemes, in order to inform policy decision if there is any need to fine-tuning payment methods to achieve equity and efficiency objectives. Methods: This study analyzes nationally patient databases of three health interventions provided to UC, SSS, and CSMBS members, and employing literature review to compare costs, intermediate and clinical outcomes among the three different schemes. Results: Evidence from approximately 1.2 million deliveries in hospitals during 2004-2006 indicates that pattern of the deliveries varied substantially across health insurance schemes. There existed an increasing trend in Caesarian section over time. Women covered by the CSMBS underwent the Caesarian section in a much greater proportion than the SSS and UC members. Provincial hospitals performed this expensive procedure more frequently than district hospitals and the rest. The CSMBS members have been admitted to the provincial hospitals for the delivery purpose more often than in the district hospitals when compared with the SSS and UC members. The UC scheme lists leukemia, a life-threatening hematological cancer, as a high-cost care with a separate payment schedule. Empirical evidence from 2003-2005 patient registry indicated more effective but expensive chemotherapies were given to the acute non-lymphoid leukemia (ANLL) patients who were covered by SSS and CSMBS in a greater proportion than UC members. This resulted in better survivals for SSS and CSMBS beneficiaries than for UC members when adjusting for age difference. In 2000-2002, prescribing variation for chronic asthma patients (N=6,176) was observed in 18 provincial hospitals. The UC members who were exempted from the 30-Baht co-pay and SSS members were less likely to get the steroid inhaler treatment which is deemed necessary for asthma control than the CSMBS members even though the underlying difference in asthma severity was taken into account. Conclusions: Determinants of clinical practice variations are complex, and provider payment is one determinant of such variations. Findings from this study indicate that a further investigation is needed for each practice and outcome variation. In addition, there is a need to minimize practice variations through the expansion of clinical practice guidelines and advocate their use, single-out some expensive but cost-effectiveness interventions from capitation payment with additional payment schedule. Using routine report and monitoring practice variations among peers such as caesarean section in Thailand tends to be practical and effective.