Thailand’s system of accountability: Institutional mechanisms to support M&E

1. Thailand’s system of accountability:Institutional mechanisms to support M&E Phusit Prakongsai, MD. PhD.International Health Policy Program (IHPP)Ministry of Public Health, ThailandPresentation to the technical meeting on Strengthening M&E of National Health Plan and StrategiesHotel Victoria, Glion sur Montreux 14-15 July 2010

2. HIS for M&E in Thailand • The HIS in Thailand is not a single system, but it consists of multiple sub-systems of health information with involvement of many key stakeholders in and outside the health sector: • Vital registration from Ministry of Interior (MOI); • Community-based household surveys from National Statistical Office (NSO), MOPH, research institutes; • Facility-based data from several Departments of MOPH, National Health Security Office (NHSO), CGD; • Disease surveillance from Department of Disease Control of MOPH; • NHA and DRGs data from research institutes –IHPP, CHEM, etc. • Main financing sources for HIS • Regular government budget, • 2% earmarked tax fund from tobacco and alcohol consumption through Thai Health Promotion Foundation, • Direct payments from data users, either public or private organizations.

3. Inputs & processes Outputs Outcomes Impact Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Improved health outcomes & equity Social and financial risk protection Responsiveness Infrastructure / ICT Health workforce Supply chain Information Financing Governance Population-based surveys Coverage, health status, equity, risk protection, responsiveness Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Clinical reporting systems Service readiness, quality, coverage, health status Vital registration Monitoring & Evaluation of health systems reform /strengthening A general framework Indicator domains Data sources Analysis & synthesis Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Communication & use Targeted and comprehensive reporting; Regular country review processes; Global reporting

4. Data availability for M&E system in Thailand (1) Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey, MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes

5. Data availability for M&E system in Thailand (2)

6. Case study on assessing the impact of achieving universal coverage (UC) in 2002 • Key characteristics of the UC policy in Thailand • Introducing a tax-funded health insurance schemes to cover 47 million (or 75%) of population who were neither civil servant and social health insurance (SHI) beneficiaries, • Promote the use of primary care as the main contractor and gate keepers, • Changing resource allocation from historical basis to capitation contracting model and performance-based payments, • Removal of financial barriers to health services. • Five key questions on assessing the impact of the UC policy • Financial risk protection from catastrophic health expenditure, • Equity in access to and utilization of health services, • Who benefits from government subsidies for health? • Who pays for health care? • Financial sustainability of the government health budget

7. Scheme beneficiaries by income quintiles, 2004 Source: Analysis from the 2004 Household Health and Welfare Survey (HWS) conducted by NSO. 8

8. Declining of catastrophic health expenditurefrom 2000 to 2006 Source: Socio-Economic Survey 2000 - 2006 conducted by NSO. Note: Catastrophic health expenditure refers to household out-of-pocket payments exceeding 10% of household income 9

9. Improved fairness of financial contributions Out of pocket payments, 1992-2006 Declining of gap Source: Household Socio-Economic Survey 1992 - 2006 conducted by NSO. 10

10. Equity in health care finance:Financial Incidence Analysis Subsequent studies indicate the Concentration Index of various sources of healthcare finance – Thailand 2002 (O’Donnell et al 2005) CI weight NHA Direct tax 0.9057 0.1868 Indirect tax 0.5776 0.3155 Social insurance 0.57600.0582 Private insurance 0.3995 0.0668 Direct payments 0.4864 0.3728 Total Health Financing 0.5929 General Tax 0.6996 Note: CI, an index of the distribution of payments, ranges (-1 to 1), a positive (negative) value indicates the rich (poor) contributes a larger share than the poor (rich), a value of zero is everyone pays the same irrespective of ability to pay 11

11. Equity in utilization: Concentration Indexes of OP service by level 2001 to 2007 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). 12 12

12. Equity in health service use: Concentration indexes of IP service by level2001 to 2007 13 13

13. Who benefits from government subsidies for health? Benefit incidence analysis (BIA) 2001 and 2003 • Note: • Overall net government health subsidies in 2001 were approximately 58,733 million Baht, and in 2003 were 80,678 million Baht (in 2001-value) • The concentration index of government health subsidies in 2001 was -0.044 and in 2003 was -0.123 14

14. Using evidence to develop appropriate provider payments during the UC era Increase equitable access by A separation of payment for high cost services Developing underserved services: Excellence centers (trauma, cardiac, cancer, stroke fast tract, STEMI), EMS, Community rehabilitation Expansion of benefit package: universal access to ARV, RRT Compulsory licensing of high cost drugs: chemotherapy for cancer patients. Improve quality & effectiveness of services Disease management program: DM, TB 15

15. Increased access to particular servicesafter introduction of appropriate provider payments 16

16. More equitable geographical access to open-heart surgery between 2004-2007 17

17. Financial sustainability:Total health expenditure 1994-2005 Total health expenditures, 2003-2005: 3.55 – 3.49% of GDP, THE per capita approx 100 USD

18. Using evidence for decision making on the benefit package of the UC scheme Long-term budget impact (million USD) from providing treatment for all women with osteoporosis in Thailand Source: Maleewong U, Kingkaew P, Ngarmukos C, Teerawattananon Y. ECONOMIC EVALUATION OF SCREENING AND TREATMENT STRATEGIES FOR POSTMENOPAUSAL OSTEOPOROSIS: EVIDENCE TO INFORM DECISION MAKERS FOR SELECTION TO THE NATIONAL LIST OF ESSENTIAL MEDICINES IN THAILAND. HITAP 2008 19

19. How equity and efficiency were achieved? Breadth and depth coverage, comprehensive benefit package, free at point of services In-feasible for informal sector (equally 25% belong to Q1 and Q2) to adopt contributory scheme 2. Minimum catastrophic health expenditure 3. Minimum level of impoverishment EQUITY GOALS 4. Equity in use of services 5. Equity in government subsidies 1. Equity in financial contribution Tax financed scheme, adequate financing of primary healthcare Provider payment method: capitation contract model and global budget + DRG 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 1. Long term financial sustainability 2. Technical efficiency, rational use of services at primary health care EFFICIENCY GOALS

20. Key factors contributing to institutionalization of M&E in Thailand • Gradual evolving culture among policy makers in using evidence for decision making, • Demand from users  e.g. policymakers, health strategic planners, directors of policy and planning division, health system and policy researchers, etc. • Adequate financing and skilful human resources for HIS development, • Long-term capacity building and skills in data generation, compilation, processing, synthesis & analyses, dissemination, communication to the public and policymakers, • Good collaboration and close relationship between data producers and data users, and policymakers, • Networking with key stakeholders at sub-national, national, and international levels.

21. Structure of Health Information System Development and Networking in Thailand MOPH Thai Health Promotion Foundation Health System Research Institute (HSRI) NHSO NESDB Health Information System Development Plan and Networking NSO Civil societies Academics Steering committee NGOs Management office Data owners Professionals

22. Network and coordination Data analysis and synthesis for report production and publication Reviews for health information systems Reviews for HIS Demands and indicators Data quality assessment Utilization mechanism Research and development for improving health information system

23. Remaining key challenges in institutionalizing HIS in Thailand • Many HIS institutes/organizations are responsible for different components of M&E  duplication, inefficiency, and difficulties in networking and standardization, • Gaps in data quality and availability, particularly data of the private sector, • Despite adequate financing, more investment in HIS – both human and financial resources is needed, • Variations in level of technical capacity in data generation, compilation, data processing, data analysis & synthesis, and communication, in responsible institutes, • Problems in standardization of data generation, collection, and analyses, • Low utilization of evidence by some policymakers, • Need long term capacity building and champions in HIS for M&E

24. Acknowledgement • Ministry of Public Health (MOPH) of Thailand • National Statistical Office of Thailand (NSO) • Health Systems Research Institute (HSRI) • Health Information System Development Office (HISO) • Thai Health Promotion Foundation (THPF) • National Health Security Office (NHSO) • WHO long-term fellowship program of WHO-SEA region • Department of Health Statistics and Informatics, WHO-HQ 25