Chalermpol CHAMCHAN

“Impacts and Constraints of Universal Coverage (UC) in Thailand’s Public Health System” Chalermpol CHAMCHAN Doctor of Area Studies, Graduate School of Asian and African Area Studies (ASAFAS), Kyoto University At Faculty of Economics, TU

I. Background • The UC policy incorporated • 1) Financial reforms with closed-end provider payment method – the capitation method – and • 2) Strengthened primary care network with more attention on health promotion and disease prevention works (PP) – a concept of “Primary Care Unit (PCU)” under “Contracted Unit of Primary Care” (CUP) structure. • Major strategic policies: สร้างนำซ่อม(SNS: health promotion and prevention (PP) ahead curative health care) andใกล้บ้านใกล้ใจ (KBKJ: health facility near dwelling) At Faculty of Economics, TU

At Faculty of Economics, TU

Primary Care Unit (PCU)/ Sub-district level Upper-Secondary and Tertiary Care/ General Hosp. Provincial level (in Provincial city) Secondary Care/ Community Hosp. District level Provincial public care network and referral system At Faculty of Economics, TU 6

Other provincial Hosp. in neighborhood Kalasin Hosp. Khonkaen Hosp. (General and Regional Hosp.) Other provincial Hosp. in neighborhood Regional IP care-referral system At Faculty of Economics, TU 7

CUP structure and main constituent parts I. Background These changes, both of the financing and structural reforms of health service delivery, have affected providers from managing staffs to health practitioners in the country. At Faculty of Economics, TU

I. Background Study questions: • Q.1 How are performances of UC and its impacts on public health system? • Q.2 What are crucial constraints and critical obstacles to the sustainability of UC and the health system? At Faculty of Economics, TU

I. Background Field surveys: Khonkaen and Kalasin provinces of the northeast region Areas in the northeast region were selected as, • hosting the largest number of population - comparatively poorer than those in other regions - but equipped and provided public health resources the least advantage. • tentatively the most affected by the switching of salary subtraction of the capitation budget from at the provincial level to the national level At Faculty of Economics, TU

I. Background At Faculty of Economics, TU Respondents: Providers at facilities in 9 districts, with care referral network from Primary and Secondary levels to Tertiary level 11

II. Providers’ Views of the UC Implementation • General Expressions • agree with the concept of the 30 Baht Scheme and good wills of the government in implementing UC. • Budget management and allocation - more flexible, and clearly defined with concrete strategy, policies and expected outcome to the providers. However, • Database of population and costs of health service - not properly developed. • System and health workers - not prepared to the changes. • Structure of public health organization – PPHO, DPHO, hospitals and PCUs/HCs – not yet properly reorganized---- Confusions! • Too much exploited for political benefitsand popularity At Faculty of Economics, TU

II. Providers’ Views of the UC Implementation At Faculty of Economics, TU B) Views respecting Impacts i. Workloads(by policy changes and higher rate of care utilization) ii. Care over-utilizations(Patient’s rights & Responsibilities) → Risks of malpractice → Work Depressions iii. Structural changes of heath service system and financing iv.Relationship Issues: (Patients & Providers, Providers & Providers) 13

Workloads and Service Utilization At Faculty of Economics, TU

Structural changes: Structure of CUP and Cooperation of the Hospital, PCUs/HCs and the DPHO At Faculty of Economics, TU

Relationship Issues Providers& Patients – Medical malpractice & Suings by patients The problem of malpractice sues by patients is suggested to be managed by, • Hospital qualification/Hospital Accreditation (HA) process • Social recognition about “rights” with “responsibilities” of patients • Risk management and patient monitoring system of the hospital • Social embedment of the hospital in the community, regarding trusts of people toward health practitioners Profession group & Profession group – Structure of returns and welfare At Faculty of Economics, TU

III. Constraints and Consequences in Public Health Service System • Based on the designed structure of medical care and referral network of the UC implementation, we found that impacts and failures of the policy intentions caused by constraints and difficulties, both physically and financially, at each level of health facility systematically affected and were affected as a cycle in the whole public health system. • As of this argument, three components are described to highlight the causes, the consequences and the linkages of the systematic problems, which determinate effectiveness and performances of UC, and as well were impacted by the UC implementation, in the public health service system. At Faculty of Economics, TU

At Faculty of Economics, TU Systematic constraints and negative cyclic consequences in care provision system are drawn out Concerning, • Primary Constraints • Linking Consequences • Secondary constraints 19

1. Primary Constraints At Faculty of Economics, TU • Shortages and Misdistributions of health personnel (across the country, and levels of health facilities in the area) + Resignations and Drains of Health Workers from the Public Sector • Under-estimated and under-approved UC budget • Inconsistency between health strategies and public recognitions towards UC Primary Consequences • Workloads and Poor performances 20

Shortage of health workforces At Faculty of Economics, TU

Drains of health workforces At Faculty of Economics, TU

Drains of doctors • Disadvantageous returns in comparison with the returns offered by private hospitals or clinics[1]. • Workplace and location of the public hospital. • Workloads at the public hospital. • Personal and family factors. [1] Na-ranong (1992) pointed out an evidence from a case study in community hospitals of the MOPH that the determinant of the resignation of a doctor from the public sector were mostly the financial factors, respecting disadvantageous salary level and returns. At Faculty of Economics, TU

Resignations of nurses • Two points of the issue were expressed i) “public post” and “workloads” and ii) “location of the hospital” • Draining to Sub-district Local Government Organization (SLGO) Drains of the PHO group at the PCU/HC level At Faculty of Economics, TU

Under-estimated and under-approved UC budget At Faculty of Economics, TU

Adequacy of the capitation rates and UC budget “Adequacy” ---- survival of the health facility and its financing----enough and the hospital could survive, even with some financial deficits and debts. However, “Adequacy” ---- in relation to assigned work tasks and expected outcomes by the NHSO, the MOPH and the patients----hardly enough and inadequate to have the facility achieving at the quality levels At Faculty of Economics, TU

Adequacy of the capitation rates and UC budget • “Investments” for long-term development and quality improvement of services provided ---- said to be forgotten, due to the limitations and inadequacy of the budget----affects not only the sustainability of the facilities themselves but also of the whole health service provision system. • “Salary subtraction” of the UC budget at the national level & at the provincial level • “The co-payment”: The fixed 30 baht/visit At Faculty of Economics, TU

2. Linking consequences: At Faculty of Economics, TU From PCUs to Secondary and Tertiary level hospitals • Failures of strategies to strengthen service provisions at primary care level, and health promotion and prevention (PP)---Failures of the SNS and KBKJ strategies From Secondary level hospitals to Tertiary level hospital • Over-referring of In-Patient cases 28

สร้างนำซ่อม andใกล้บ้านใกล้ใจ Strategy • Even if PP work is perceived to have been given more attention from the health policy agenda with more purposeful work plans, the implementation is facing many difficulties and constraints from both the nature of PP work itself, and the unsupportive workforce and budget, specifically at the PCU/HC level. A. The Nature of PP Work B. Inadequate Workforce with Heavy Workloads C. Unsupportive UC Budget for PP Work At Faculty of Economics, TU

3. Secondary Constraints At Faculty of Economics, TU Backward from Tertiary level hospitals to Secondary level hospitals • Infeasible reallocations of health personnel from provincial cities to rural districts Secondary care level hospital to PCUs • Infeasible strengthening primary care network 30

Primary Constraints at Facilities in Primary Care Level + Impacts of the UC implementation Workloads and Poor performances of service provisions at the primary care level Infeasible to strengthen Primary care network Consequences of Failures at primary care level Primary Constraints at Facilities in Secondary Care Level + Impacts of the UC implementation Workloads and Poor performances of service provisions at the secondary care level Consequences of Over-referring of In-Patient cases Infeasible Reallocation of health personnel in the province Primary Constraints at Facilities in Tertiary Care Level + Impacts of the UC implementation Workloads and Poor performances of service provisions at the primary care level 1) Primary Constraints 2) Linking Consequences 3) Secondary Constraints Figure 6 Systematic Constraints and Cyclic Consequences in Public Health Service System at the Provincial Level PCUs (Primary Care Units) Community Hosp. (Secondary Care level) General/Regional Hosp. (Upper-Secondary and Tertiary Care level) At Faculty of Economics, TU

“…where shortages (and inequitable distributions) of health workforces are still prevalence in many areas and sufficient budget funding are not yet acquired, the public health care system (and UC) as a whole is vulnerable and might not be sustainable in the long-run At Faculty of Economics, TU

(1) Assuring universal and comprehensive health insurance coverage. (2) Ensuring adequate and equitable access to needed health service. (3) Increasing the effectiveness and sustainability of health system Source: Docteur et al. 2003 Conclusions Thailand’s health system has achieved intermediate goal but not yet the final one of the UC policy. • ‘Universal inclusion’ is to be achieved, but • “Universal access” is still not ensured that it is equitable to all insured population • UC system is insufficiently provided with health resources, and as a result ineffectively functioning and vulnerable At Faculty of Economics, TU

Policy Suggestions • To empower Primary Care Unit (PCU) and enhance its staffs • To put forward a concrete agenda to relieve shortages of health workforce and its misdistribution nationwide • To adjust financing mechanism of UC in term of fund sourcing and budget managements • To promote better community participation and patients’ responsibilities At Faculty of Economics, TU

Thank you,ขอบคุณครับ At Faculty of Economics, TU

Chalermpol CHAMCHAN

Chalermpol CHAMCHAN

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