International Health Policy Program -Thailand Review of current situation in health inequity in Thailand after achieving universal coverage Phusit Prakongsai, MD. Ph.D. Vuthiphan Vongmongkol, Warisa Panichkriangkrai International Health Policy Program (IHPP) Ministry of Public Health, Thailand 1 August 2010

International Health Policy Program -Thailand Definition of health inequity The International Society for Equity in Health (ISEqH) defined equity in health as “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically” Inequity in health or ‘health inequity’ is differences in health that are avoidable, unjust, and unfair (Whitehead 1992).

International Health Policy Program -Thailand Objectives To review current situation in health inequity in Thailand after achieving universal coverage for one decade using documentary review and secondary data analysis, To develop inputs for consultation among key stakeholders involving in SDH reduction in Thailand – Health System Research Institute (HSRI), – Thai Health Promotion Foundation (THPF), – Social Research Institute, Chulalongkorn University, – Mahidol University, – National Health Commission Office, – SIR-NET, – Ministry of Public Health.

Conceptual framework of presentation

International Health Policy Program -Thailand Source: Analysis of Health and Welfare Survey 2004 (NSO 2004). CSMBS, SHI covers the rich, 52% and 49% belong to Q5 Scheme beneficiaries by income quintiles, 2004 UC scheme covers mostly the poor, 50% belong to Q1+Q2

Household OOP for health, % income Source: Analysis from household socio-economic surveys (SES) in various years , NSO

Incidence of catastrophic health expenditure in Thailand

Kakwani indexes of health care finance and share of health care finance in Thailand from 2000 to 2006 Type of health payments Kakwani indexesShare of health care finance (%) * Out of pocket payments Direct tax Indirect tax Premium Insurance Na SHI contribution Na Premium insurance & SHI contributionNa na 17.1% Overall Kakwani index

International Health Policy Program -Thailand 9 Equity in utilization: Concentration Index OP service by levels: 2001 to 2007 Facility levels Health centers District hospitals Provincial and regional hospitals Private hospitals Overall 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).

International Health Policy Program -Thailand 10 Equity in utilization: Concentration Index IP service by levels: 2001 to 2007 Types of health facilities Community hospitals Provincial and regional hospitals Private hospitals Overall

Equity in budget subsidies: BIA, ( )

Health service delivery: Better coverage of essential vaccines, ARV and condom use Compulsory licensing Include ART in UC package Generic production of triple ART Percentage of female sex worker consistently use condom when having sex with general client in the past 1 month, 1995 – 2007

International Health Policy Program -Thailand 13 Increase access to particular services

14 More geographical access to open-heart surgery between 2004 – 2007 but don’t know whether they were the rich or the poor

Inequity in quality and patterns of health service provision: Percentage of caesarian section to total deliveries by health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, (N=13,232,393 hospital admissions)

Inequity in quality and patterns of health service provision: Propensity of receiving single source antiplatelets clopidogrel, cilostazol: 6 regional hospitals

Inefficiency of the Thai health care system: CSBMS expenditure from 1989 to 2008, current year price Note: Expenditure for 2008 is extrapolated from 6 months actual spending Source: Ministry of Finance, Comptroller Generals Department, various years

Current situation and challenges of human resources for health in Thailand Thailand Source: World Development Indicator 2002 and World Health Report 2006

Inequity in geographical distribution of Health workforce in 2007 Physicians 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 Pharmacists 4,600-8,432 8,433-12,274 12,275-16,115 16,116-19,956 Nurses ,156 1,157 – 1,408 Dentists 5,500-15,143 15,144-25,767 25,768-36,390 36,391-47,011

จำนวนปีสุขภาวะที่สูญเสียของประชากรไทยตามกลุ่มของสาเหตุ ระหว่างพ.ศ และพ.ศ เพศชาย เพศหญิง

จำนวนปีสุขภาวะที่สูญเสียจากภาระโรค พ.ศ และ 2547 จำแนกตามกลุ่มอายุ เพศชาย เพศหญิง

ปัจจัยเสี่ยงและจำนวนปีสุขภาวะที่สูญเสียจากภาระโรคของประชากร ไทย พ.ศ และ 2547 ที่มา โครงการศึกษาภาระโรคและปัจจัยเสี่ยงของประเทศไทย พ.ศ. 2547

แนวโน้มการสูบบุหรี่และการดื่มสุราของประชากรไทย แหล่งข้อมูล สอส. 2544, 2546, 2549

ความชุกของการดื่มสุราในประชากรอายุ 15 ปีขึ้นไป แหล่งข้อมูล สอส. 2544, 2546 และ 2549

Household consumption: tobacco, alcohol and health Median household expenditure per month Sources: Analyses from 2006 SES

Child mortality in Thailand from various sources of surveys Source: Hill et al. Int J Epidemiol 2007 (with updates)

RR = 2.8 (95% CI ) RR = 1.8 (95% CI ) 55% (39%-68%) reduction Error bars are 95% CIs Source: Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez AD, Lim SS. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369: Child mortality by quintile of household economic status from 1990 and 2000 census

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

International Health Policy Program -Thailand 30 Key challenges and unfinished agenda – BOD challenges Increased diseases burden from chronic NCD Demographic changes in Thailand Little success in controlling traffic injuries Revitalizing HIV prevention in the light of universal ART – Health systems capacity to cope with Increased workload with very strained health workforces Decentralization context –threats and opportunities, don’t’ move fast Public private dialogues, better trust and collaboration Medical tourism and internal brain drains – Long term financial sustainability Universal access to renal replacement therapy-heavy fiscal pressure, cost ineffective, >4X GNI per QALY, but adopted due to catastrophic and inequity across 3 schemes Second and third lines ARV Medical technology advancement-main drivers in OECD

International Health Policy Program -Thailand 31 Thank you for your attention

International Health Policy Program -Thailand Diseases/risk factor priorities in Thailand Significant high disease burden and economic loss – HIV/AIDS – การป้องกันและควบคุมอุบัติเหตุจราจรในประเทศไทย For traffic injuries – การควบคุมการบริโภคแอลกอฮอล์และยาสูบ For prevention of HIV/AIDS, traffic injuries and COPD – การลดภาวะน้ำหนักเกินและโรคอ้วน For DM, CVD and other chronic non-communicable diseases