APO The Kingdom of Thailand Health System Review (Health in Transition)

Health Systems in Transition
The Kingdom of Thailand
Health System Review

Health Systems in Transition:
Thailand Health System Review
2
Authors:
Editors:
Viroj Tangcharoensathien
Pongpisut Jongudomsuk Samrit Srithamrongsawat
Walaiporn Patcharanarumol Supon Limwattananon
Supasit Pannarunothai Patama Vapatanavong
Krisada Sawaengdee Pinij Fahamnuaypol
Note: Updated with data from Legido-Quigley H, Asgari-Jirhandeh N, editors. Resilient and people-centred health systems: Progress,
challenges and future directions in Asia. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018
Suggested citation: Jongudomsuk P, Srithamrongsawat S, Patcharanarumol W, Limwattananon S, Pannarunothai S, Vapatanavong
P, et al. The Kingdom of Thailand Health System Review. Vol.5 No.5. Manila: World Health Organization, Regional Office for the
Western Pacific, 2015.

Thailand: Socio-demographic profile
 Overview of health system
 Service delivery network
 Governance and administration
 Health financing
 Infrastructure
 Human Resources
 Major reforms
 Main findings
 Progress made
 Remaining challenges
 Future prospects
3
Presentation outline:
This map is an approximation of actual country borders
Source: https://www.who.int/countries/tha/en/

4
Socio-demographic profile
Area 513 115 sq. km
Third largest country in
mainland South-East Asia
Population • 69.0 Million (2017)
• 56.6% Rural population
• 1.4 TFR (2016)
Life expectancy at
birth m/f
71.6/79.1 (2016)
GDP per capita: $6593.8 (2017, USD)
HDI 83
Expenditure on
health % GDP
3.8 (2015)
Source: World Bank 2018a
Socioeconomic indicators, selected years

5
Universal Health Coverage (2002)
1.Standard public health services – guaranteed by the Constitution of Thailand (and
other similar social services)
2.Government control and regulation
3.Ministry of Public Health – core agency in the Thai public health system
4.Implementation – provincial and local administration agencies
5.Primary healthcare focus
6.Majority public health funding
7.Infrastructure and human resources well-distributed
8.Generally free health services: CSMBS outpatients have fee-for-service
9.Minimal NGO and external donor involvement
Overview: Health system

Overview: Service delivery
Patient pathways: Able to choose any health service if they can pay for it.
Insurance schemes: Universal Coverage Scheme (UCS) and Social Health Insurance
Scheme (SHI): must register with providers as first point of contact; Civil Servant
Medical Benefit Scheme (CSMBS): any public facility and certain private facilities.
Outpatient care:
Health centres offer primary health care services.
Secondary and tertiary hospitals provide primary care and prevention under UCS
contracts but also offer more specialized care
Inpatient care
MOPH hospitals the backbone of health system: 70% of beds, distribution based
on population catchment
Increasing trend of admitting patients who can be treated as outpatients
Hospital and health center integration:
UCS contract facilities to provide essential health services with primary health
care networks emerging through hospital and health center partnerships
6

7
Central
• MOPH: central authority on health system governance, implementation
• Interdependent health system: Semiautonomous and autonomous
health agencies introduced
Local (Provincial, District)
• Provincial Health Offices: Oversight, support for local health offices,
health service delivery, limited regulatory powers
• District Health Offices oversee, manages & delivers health services
Other
• Professional Associations: Responsible for respective national license
examinations
NGOs: Play increasing roles in health policy development, funding and
implementation of services
• Private sector: Mostly curative services, urban concentration
Overview: Governance and Administration

8
Overview: Health Financing – Medical insurance
Characteristics of insurance schemes in Thailand
• Public health insurance (UCH -2002)
• Civil servants: Civil Servant Medical
Benefit Scheme (CSMBS)
• Private sector: Social Health
Insurance Scheme (SHI)
• Others: Universal Coverage Scheme
(UCS).
• All three provide comprehensive yet
similar benefits to their target
populations
• CSMBS and UCS are government funded,
SHI requires government, employer and
employee contributions

9
Overview: Health Financing – Payment mechanisms
• UHC established in 2002 along with
three purchasers of services: CGD,
SSO and NHSO
• Supply-side financing
operations switched to
demand-side financing
• Purchaser-provider split: main form
of payment is contractual
• MOPH owns majority of health-care
facilities and receives majority of
revenue through such contracts
Health financing and service provision in Thailand

Capital investment budget
Overview: Infrastructure
Source: Bureau of Policy and Strategy, MOPH
• Government investment has led to hospital distribution by population catchment
• 75% and 79% of hospitals and beds are in the public sector
• No long term care facilities
• 22 beds/10000 population, double the South-East Asian average of 11
10

Overview: Human resources for Health
 Ability to produce an adequate,
qualified workforce supports - UHC
and basic health care
 2.8 physicians, nurses and
midwives/1000 population: higher
than WHO threshold of 2.28
 Compulsory three year medical
service on graduation
 Over 1 million village health
volunteers supporting community
health activities: significant
contribution to NCD management
11
Doctors, dentists, pharmacists and professional nurses
Source: Thailand Health Profile (2008-2010), Office of the National
Economic and Social Development Board on mid year population (1979-
2009)

Overview: Major reforms
2001: Establishment of sin tax health promotion fund
2002: Establishment of UHC system
2007: Enactment of the National Health Act and
institutionalization of national health assembly and
movements on health in all policies
2007: Constitutional change guaranteeing citizen health rights
2008: Establishment of emergency medical services
2010: Extension of health coverage to stateless population
12

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Achievements and progress made
Improved life expectancy and lower mortality rate
Successful reversal of HIV/AIDS epidemic
Universal health coverage
Maternal and child health drastically improved

14
Achievements and progress made: Maternal and
child health
• Maternal mortality rates have halved while infant and under-5 mortality rates have
decreased significantly
• Child vaccination coverage at 90% and 99% for measles, hepatitis B vaccine
• First country in Asia to eliminate mother-to-child transmission of HIV and syphilis
Source: World Bank, 2018a
Maternal, child and adolescent health indicators, 1990-2016

15
Achievements & progress: Equity focused reforms
Strong political commitment to health equity
Universal health coverage
Participatory consultation
Rural health focus
Pro-poor MOPH technocrats drive reforms

16
Achievements & progress: Decreased OOPE
Direct payments for health as a percentage of THE
Source: Analysis of NSO Socioeconomic Survey (SES).
• OOP decreased from 44.5% to 11.6%
• Most services covered by UCS and
SHI are free. CSMBS provides some
free services
• Reductions in OOP payments health
care have occurred across richest
and poorest quintiles

17
Achievements & progress: Health information, security
and technology
• Population-based HIS: Household Socioeconomic and Health and Welfare Surveys assist
in measuring policy impact| National HIV sentinel surveillance survey contributed to
effective intervention in response to HIV/AIDS epidemic
• Facility based HIS: Health record information generation to support clinicians and public
health personnel
• Hospital information technology:
• Contributes to effective insurance scheme implementation including determining
patient entitlements
• Reimbursement of patient costs
• Health System Research Institute: Supports MOPH on evidence-based policy
development
• Health security: Thailand implements IHR to address infectious disease threats including
MERS-CoV and Influenza A

18
Remaining challenges: NCDs and risk factors
Major causes of death by percentage, 2016
Source: WHO, 2018b
• 74% of deaths and the 75% of
DALYs (2009) are due to NCDs
• Adequate competence and skill
mix to address chronic NCDs
lacking
• Road injuries the most serious
problem contributing to DALYs
due to ineffective law
enforcement
• Risk factors contributing to
DALYs:
• In 2016, the population
smoking rate was 21% and
physical inactivity was 25%
• High-body mass index 44%
increase between 2005
and 2016

19
Remaining challenges: Rural-urban disparities
Rehabilitation
services mostly
in urban areas
Limited medical
equipment in
rural areas
Low health
workforce in
rural areas
Weak municipal
health systems
Urban PHC
inadequate

20
Remaining challenges: Pharmaceutical care
Expenditure
• Medicine mark up being an income source incentivises dispensing of
items
• Irrational use of medicines rampant at all levels of health care
• Pharmaceutical expenditure higher than OECD countries.
Regulation
• Increases in direct sale, mail-order and internet pharmacies difficult to
regulate
• National List of Essential Medicines not adhered to in private facilities,
leading to high OOP mark-ups
• Outpatient drug spending for CSMBS is five times that of UCS due to a
change from retrospective reimbursement to direct reimbursement

21
• Thailand fast becoming an ageing society
• Increased need for long-term care:
majority of care currently informal with
limited, yet expensive private for-profit
care
• Ageing and disability population often
lack access to rehabilitation services
causing permanent disability
• No specific organization to deliver
palliative care
• Mental health: 0.4 beds/100000
population in regional hospitals | 0.01
psychiatrist and 0.02 psychologist, social
worker or occupational therapist per bed
Remaining challenges: Specializations
Mental health
Rehabilitation
Long term and palliative
Growing demand for specialist services

22
Remaining challenges: Human resources
• Post-UHC reform: freeze on public
sector staff led to contract roles for
nurses and pharmacists, push to
private sector employment
• Increasing number of specialist
doctors: 3% in 1971 to 85% in 2009 |
Led to weakening of primary health
care in urban areas with limited
family physicians
The proportion of general and specialist doctors
Source: Thai Medical Council, various years

23
Future prospects: Thailand
Harmonizing
of health
insurance
Cost
containment
of drugs
LTC
Specialized
care
Thailand 4.0
Essential supports
• Financial investment
• Health workers
• Community-oriented

Based on the Health Systems in Transition
Kingdom of Thailand Health Systems Review, 2015
24

http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/hit_thailand/en/
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APO The Kingdom of Thailand Health System Review (Health in Transition)

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