UHC in developing countries, Health system : Ethical dilemmas. Dr. Peerapol Sutiwisetsak Deputy Secretary General National Health Security Office Thailand.

UHC in developing countries , Health system : Ethical dilemmas.

Dr. Peerapol SutiwisetsakDeputy Secretary General

National Health Security OfficeThailand

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• Population - 64 million

• GNI 2012 US$5,090 per capita, Gini 42.5

• UHC achieved in 2001 under 3 scheme

• civil servants, social security and UC

• Health status

Life expectancy at birth 74 years

IMR 20/1000 LB, MMR 30/100,000 LB

Physicians per capita 5/10,000

ANC & hospital delivery 99-100 (2009)

• Total Health Expenditure

US$300 per capita, 6% GDP

Half from public , 14% of National budget

Less than 40% out of pocket

Thailand: country profiles

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UHC can be started and achieved at low level of income

390

710

760

1490

2,7

00

1,9

00

0

1,000

2,000

3,000

4,000

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

US $

1997: Asian financial crisis

1990 SHI introduced

1980 CSMBS introduced

1983 CBHI introduced

1975 Low Income scheme introduced

2002 Universal Coverage for entire population achieved

2001: 29% of population are uninsured

year

GD

P/c

ap

ita

20%

29%

42%

53%

The children n elderly

71%

100%

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UC 75.27%(48.62Millions)

SSS 15.99%(10.33Millions)

CSMBS 7.69%(4.97 Millions)

None 0.95%(0.65Millions)

Other 0.10%0.07Millions

1 ประกั�นสุ�ขภาพถ้�วนหน�า

2 ประกั�นสุ�งคม

3 ข�าราชกัาร/ร�ฐว�สุาหกั�จ

4 สุ�ทธิ�อื่��นๆ *

5 ผู้��ยั�งไม"ลงทะเบี&ยันสุ�ทธิ�

UC

SSS social security

CSMBS civil servant medical benefit

Others

None

Health Insurance Schemes

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1.Ensure Healthcare for all and poverty reduction

2.The Development of benefit package

3.The Transparency and participatory mechanism.

4.The Strategic purchasing under fiscal constraint

5. The Preliminary assistance for damage or injury caused by any services

6.The 24 hr services of the call center

Ethical point

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6Dr. Suwit Wibulpolprasert, Ministry of Public Health,

Thailand

1.88 2.042.15 2.23 2.27

2.432.73

3.1

1.68

2.42.64

2.9 3 3.013.15

3.68

0

0.5

1

1.5

2

2.5

3

3.5

4

1982 1983 1984 1985 1986 1987 1988 1989

Budg

et (b

illio

n Ba

hts)

Year

Provincial District

Fast tracking rural health

No investment in urban areas for 5 yrs.

1. Ensure availability of quality health care for all

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Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population

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

Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential.

Adequate and appropriately manned rural health facilities

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Medical school hospital

For more complex service, secondary and tertiary hospitals with specialized personnel , highly diagnostic and treatment technology are available . Referral system was set up .

Seamless Health Service Networks

General hospital in every province Regional hospital in every region

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46%(5.5)

29%(3.5)

24%(2.9)1977

Regional H./General H.

Rural Health Centres

District Hospital

27%(11.0)35%

(14.6)38%

(15.7)

1987

Regional H./General H.

District Hospital

Rural Health Centres

200046.1%(51.8)

35.7%(40.2)

18.2%(20.4) Regional H./General H.

District Hospital

Rural Health Centres

201054.0%(78.0)

33.4%(33.4)

12.6%(18.1) Regional H./General H.

District Hospital

Rural Health Centres

( ) : Number of OPD visits (millions)

Source: Rural Health Division, MoPH

1. Healthcare for all : Changes in out-patient utilization:

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UHC is effective for poverty reduction

UHC achieved

Source: Viroj Tangcharoensathien Suwit Wibulpolprasert, MoPH, Thailand

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Evidence base transparent n participatory processes

Life saving non cost-effective treatments but high impoverishment tendency w low budget impact

Increase access at affordable budget by using mix payment methods to control cost and also stimulate demand and services

The use of quality generic medicines, TRIPs flexibilities, and the promotion of rational drug use

2. The Ethic in the benefit packages development

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Use of Lopinavir/Ritonavir (200/50mg)

bottles CL

0

5,000

10,000

15,000

20,000

25,000

UC Scheme

CL

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By law National Health Security board consists of Minister of Health chair the Board, 8 Government Ex-officio 4 Local Government Representatives, 5 representatives selected from 9 NGO constituencies 4 representatives from four Professional Councils, 1 representative from Private Hospital Association, 7 experts appointed by Cabinet [insurance, medical and

public health, traditional medicines, alternative medicines, financing, lawyer and social science],

Secretary General serves as secretary of the Board Public hearing from provider, people every year Annual accounting audit Satisfaction survey every year

3.The Transparency and participatory mechanism

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83.0 83.4 83.2 84.0 83.1 88.3 89.3 89.8 92.8

45.6 39.347.7 50.9 56.5 50.7

60.3 78.866.9

0.010.020.030.040.050.060.070.080.090.0

100.0

2003 2004 2005 2006 2007 2008 2009 2010 2011

UC People provider

Percent

Expand financial incentives

Source: Satisfaction survey NHSO & ABAC University in various years

Satisfaction: UC members and providers

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Close end capitation based budget with mixed payment mechanisms mainly on capitation (OP) and Case Mix (IP) and some FFS and PC as gate keeper

Involvement of the private providers, e.g, providing primary care in the urban areas, emergency medical services, and some specific tertiary care, e.g., cardiac surgery

Central bargaining and purchasing with VMI (Vendor Managed Inventory)

4.Strategic purchasing : Better Value for Money

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5.The Preliminary assistance for damage or injury caused by any service

2004 2005 2006 2007 2008 2009 2010 20110

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

0

100

200

300

400

500

600

700

800

US$ compensate Cases

US$ Numbers

From: NHSO data 2011

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6.The 24 hrs services of the call center 1330

Total call743,744

(3) Information 729,320 (98.35%)

(1)Complaint – quality care

4,386 (0.51%)

(2) Complaint - general

5,758 (0.75%)

(4) Inpatient bed finding

4,280 (0.39%)

96.18%Complete cases

in 30 days

96,45% Complete cases

in 30 day

From : NHSO data 2011

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Three key take home messages UHC is the accesses to health services without

financial barrier, not merely financial protection. It is can be achieved at low level of income and it is effective for poverty reduction

Fiscal spaces and innovative financing are possible with political leadership - resources must be used cost-effectively thru Health Technology Assessment and strategic purchasing

Mechanisms to assure sustainable financing and meeting the emerging challenges are needed and should be developed thru evidence based health systems researches18

Suwit Wibulpolprasert, MoPH, Thailand

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Thank you

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TRIPS flexibilities

TRIPS stands for Trade-Related Aspects of Intellectual Property Rights agreed in DOHA , 2001

Flexibilities : special mechanism is allowed for

developing countries to gain access to essential drugs and or to protect health system

Such as to import some generic drugs aiming to lower ARV cost for HIV patients

The example of flexibilities is CL in ARV drug Thailand,

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MDG 1

The Millennium Development Goals (MDGs) are eight international development goals that were officially established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 193 United Nations member states and at least 23 international organizations have agreed to achieve these goals by the year 2015.

The first goal is : Eradicating extreme

poverty and hunger