Pattaraporn Khongboon

1. I I HPP HPP Thailand Thailand Regulation in Health Service Delivery System Viroj Tangcharoensathien, Supon Limwattananon, Walaiporn Patcharanarumol, Chitpranee Vasavid, Phusit Prakongsai,Suladda Pongutta @ JOURNAL CLUB July 2, 2010 PattarapornKhongboon Prince Mahidol Award Foundation under the Royal Patronage

2. Increasingthe role of private sector in service provision, • Cost-escalation, (overcharging, unnecessary high tech. equipment, etc) • low standard of care, (medical malpractice, etc.) • low effective health regulation Rationale • To understand the global issue of private healthcare sector, challenges & opportunities with respect to health regulation objectives • To better understand the government regulatory capacity Review both published & gray literatures methods An assessment of performance of health regulation Self-administered questionnaire survey to 105 countries on September 2008

3. Outlines Overview 1. Regulatory measures 1.1 Direct command-and-control 1.2 Incentive-based measures 1.3 Self-regulation 2. Government stewardship & governance 3. The role of consumers 4. Characteristics of survey response countries 5. Survey results 6. Conclusions 7. Recommendations

4. Overview Five key regulators in health system Regulate private health sectors price, quantity, quality, & distribution & information 4 3 Qualification professions, control for entry to market Accreditation, quality improvement certification HA agencies Professional councils Competitive contracting, financial incentive Watch dog role, media to ensure consumer voice heard 2 5 Command & control, registration, licensing, inspection, sanction non-compliance NGO, consumer protection agencies Financingagencies Gov. agencies 1 Political, administrative, information constraints Figure 1 Five key regulators & their regulatory measures operated under three main constraints

5. 1. Regulation 1.1 Command-and-control measures • LMIC the legislation on health facilities < health practitioners • Regulatory requirement in LMIC less demand than HIC • Low enforcement & its effectiveness (Asiimwe et al., 1993; Mujinja et al., 1993; Yesudian 1994). • Developing countries remains unimplemented, weakly implemented due to lack of regulatory capacity or being perverted by powerful vested interests( Bennett et al., 2005). Countries experiences: • Bureaucratic & very rigid regulatory control may unexpected results or failed.(Pakistan, China, India) • Multi-faceted strategy; inspection, education, enforcement. (Lao, Thailand, Vietnam)

6. 1.2 Incentive-based measures • To change the behaviour in delivering & utilizing HC services • Both financial & non-financial forms (Kumaranayake, 1997) • Result-based financing and service contracting • LMIC experiences suggest, contractual agreements on HC services are more like a long-term relational contracting rather than a formally enforced, written contract as in the developed countries • Doing the private business: LIC imposed the regulatory procedures on the business more than HIC Number of procedures risks of corruption

7. 1.3 Self-regulation • Accreditation is a voluntary process of institutional self-regulation, an explicit standards are required • The process-oriented regulation of service quality may include: • accreditation (re-accreditation) of health facilities, educations for health personnel, • certification (re-certification) of practice specialties. Countries experiences: • Self-serving in favor of the interests (USA) • Slow productivity in early phase due to lack of incentive (Zambia) • Inactive bodies (India, Thailand, Zimbabwe)

8. 2. Government stewardship & governance Objectives of the system Functions the system performs Stewardship (oversight) Responsiveness (to people’s non-medical expectations) Creating resources (investment & training) Delivering services (provision) Health Fair (financial) contribution Financing (collecting, pooling & purchasing) Relationship between functions & objectives of a health system Source: Musgrove et al. (2000) The GOV. has a fundamental responsibility to set the rules of engagement for all actors in public & private sectors in the systems.

9. Worldwide Governance Indicators (WGI) Measure of country’s governance, developed by WB since 1996 Six dimensions: (1) government effectiveness, (2) regulatory quality, (3) rule of law, (4) control of corruption, (5) voice &accountability, (6) political stability & absence of violence • Country-level analyses revealed a significant link between the population health outcomes and the health expenditure a country spent (Filmer et al., 1999; Wagstaff, 2002; Bokhari et al., 2007). • Government effectiveness, regulatory quality, rule of law, have linearly positive link with economic status. • Might be HIC is in a better position to invest in human resources and social capital

10. 3. The role of consumers Consumers are important in bringing to light information on the functioning of the HC system • In developed countries, market mechanism places the high priority to civil society involvement, such as public information, and local initiatives to strengthen citizens’ voices. • In developing countries, consumer information & disclosure as a regulatory intervention are less implemented than other measures. Countries experiences: • Educating consumers is a powerful way to make people well aware of their rights and what is the good health care. • In Zimbabwe, campaigns against excessive injections and prescriptions have thought to be successful (WHO, 1991). • In India, consumer groups taking the case to court (Mudur, 1995) • In Nigeria, campaigns increase public awareness of the rights to quality health service. (Fatusi et al., 2006)

11. 4. Characteristics of survey response countries Table 1 Survey response rateby world region , a The World Bank’s classification of world regions • The sample countries are relatively poorer • the sample countries are better in term of governance performance than the group average of WGI. • MIC-L, the difference is obvious, the samples are better performed in term of regulatory quality, rule of law, government effectiveness & control of corruption. • LIC, have better overall governance, despite poorer & lower health spending compared to the group average.

12. 5. Survey results Three major regulatory constraints (1) Political constraints & regulatory capture (2) Administrative constraints: (3) Informational constraints: • LIC, high administrative constraint across five regulators. • MIC, pattern not clear • The GOV. regulatory agency has relative higher levels of all three constraints than other key regulators. •  NGO & CSO had the least though high level of political constraints especially in LIC group where 36% reported high level of constraints. • Evidence from the self-assessment on different levels of three constraints prompts to policy interventions • The administrative& informationconstraints are relatively easy to be implemented thanpoliticalconstraints. • The institutional capacity to implement health regulation tends to be strongest for the rule setting > enforcement > monitoring.

13. 6. Conclusions 1. Private health sectors had a major role in terms of magnitude of service provision & household direct expenditure on their service. 2. LIC & MIC-L, government regulatory capacity are weak. 3. Administrative & information constraints seems to be more easy to solve than political constraints 4. LIC & MIC-L, three phases of regulations, rule setting, enforcing and monitoring compliances. Rule setting is strongest. 5. Challenging pre-requisite of increased gov. capacity to better regulate.

14. 7. Recommendations • 1. Administrative & informationconstraints are not too difficult to solve. Targeting the professional councils, government regulation agencies who provide licensing professionals & registering medical premises. • 2. Political constraint can be solved by • More developed Social Health insurance & pre-payment schemes • The better the capacity of gov. to steer private health sector • 3. Good governance through the potential role of NGO & CSO as a watch dog (?)

15. 7. Recommendations (cont.) 4. Beyond rule setting, strengthening capacity on enforcement & monitoring of compliance are needed. 5. Establishing or expanding financial schemes are needed for longer term. In the future, Health insurance system can play an increasing role through contracting & purchasing functions. 6. Accreditation & quality assurance mechanisms require more sophisticated health systems benchmarking and capacity on continued quality improvement.