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Review of current situation in health inequity in Thailand after achieving universal coverage

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.

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Review of current situation in health inequity in Thailand after achieving universal coverage

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  1. 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

  2. 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).

  3. 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.

  4. Conceptual framework of presentation

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

  6. Household OOP for health, % income 1992-2008 Source: Analysis from household socio-economic surveys (SES) in various years 1992-2008, NSO

  7. Incidence of catastrophic health expenditure in Thailand 2000-2006

  8. Kakwani indexes of health care finance and share of health care finance in Thailand from 2000 to 2006

  9. Equity in utilization: Concentration Index OP service by levels: 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). 9 9

  10. Equity in utilization: Concentration Index IP service by levels: 2001 to 2007 10 10

  11. Equity in budget subsidies: BIA, (2001-2007)

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

  13. Increase access to particular services 13

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

  15. Inequity in quality and patterns of health service provision:Percentage of caesarian section to total deliveriesby health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

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

  17. 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

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

  19. Inequity in geographical distribution of Health workforce in 2007 Physicians Dentists 800-3,305 3,306-6,274 6,245-9,272 9,243-12,300 5,500-15,143 15,144-25,767 25,768-36,390 36,391-47,011 Nurses Pharmacists 280 - 652 653 - 904 905 - 1,156 1,157 – 1,408 4,600-8,432 8,433-12,274 12,275-16,115 16,116-19,956

  20. จำนวนปีสุขภาวะที่สูญเสียของประชากรไทยตามกลุ่มของสาเหตุระหว่างพ.ศ. 2542 และพ.ศ. 2547 เพศหญิง เพศชาย

  21. จำนวนปีสุขภาวะที่สูญเสียจากภาระโรค พ.ศ. 2542 และ 2547จำแนกตามกลุ่มอายุ เพศชาย เพศหญิง

  22. ปัจจัยเสี่ยงและจำนวนปีสุขภาวะที่สูญเสียจากภาระโรคของประชากรไทย พ.ศ. 2542 และ 2547 ที่มา โครงการศึกษาภาระโรคและปัจจัยเสี่ยงของประเทศไทย พ.ศ. 2547

  23. แนวโน้มการสูบบุหรี่และการดื่มสุราของประชากรไทยแหล่งข้อมูล สอส. 2544, 2546, 2549

  24. ความชุกของการดื่มสุราในประชากรอายุ 15 ปีขึ้นไปแหล่งข้อมูลสอส. 2544, 2546 และ 2549

  25. Household consumption: tobacco, alcohol and healthMedian household expenditure per month Sources: Analyses from 2006 SES

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

  27. RR = 2.8 (95% CI 2.5-3.0) 55% (39%-68%) reduction RR = 1.8 (95% CI 1.6-2.0) Child mortality by quintile of household economic status from 1990 and 2000 census 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; 369:850-855

  28. 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

  29. 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 30

  30. Thank you for your attention 31

  31. 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

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