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Lessons from the Thai Universal Heatlh Coverage (July. 2017)

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Experiences of Thailand towards Universal Health Coverage to Strengthen the Health Systems

Lecture by Dr. Viroj Tangcharoensathien, summarized and edited by Ms. HAYASHI Kagumi, AHI

 

  Dr. Viroj Tangcharoensathien, is now the secretary general of the International Health Policy Program Foundation, after his 35 years of service for the Ministry of Health in Thailand. He is one of the former AHI participants who joined in its International Training Course in 1985, who Dr, Vimj has been working for the Universal Health Coverage(UHC) in Thailand. He came to Nagoya in December 2016, being invited by the
School of Nursing, Nagoya City University, and gave the lectures to share Thai’s experiences and his thoughts for UHC. The succeeding part is the summary of his lectures.

 

1. What have been done


In Thailand, Health is to be secured with everyone under the National Health Security Act 2002. Its Chapter l states that the Thai population shall be entitled to a health service with such standards and efficiency as prescribed in this Act.
 

There are two essential components to achieve UHC. One, is to build the solid platform for UHC, which means the development of health delivery and health workforce. Human development of health personnel is primarily important. In Thailand, the population per doctor has been decreased to less than 2,500 by focusing on human resource development of medical doctors and nurses. The local health care facilities have been developed as well. Each of the district hospitals with 30 to 120 beds covers 30,000 to 80,000 population. Under them, one health center serves 2,000 to 5,000 population being managed by three to six health personnel.

 

The other, is nancial risk protection. In Thailand, there are three different schemes such as l) the Civil Servant Medical Benefit Scheme (CSMBS) which covers the public servants since 1980,

2) the Social Health Insurance (SHI), which covers the employees of corporations that started in 1990, and 3) the Universal Coverage Scheme (UCS), which was established in 2002 to cover the informal sectors, that comprised 75% of the total population. It includes farmers, day wage workers and others who do not work at corporations, including self-employed who are engaged in micro-business. When the UCS was realized, Thailand has achieved 100% universal health coverage for its population.

 

 

There are two essential components to achieve UHC. One, is to build the solid platform for UHC, which means the development of health delivery and health workforce. Human development of health personnel is primarily important. In Thailand, the population per doctor has been decreased to less than 2,500 by focusing on human resource development of medical doctors and nurses. The local health care facilities have been developed as well. Each of the district hospitals with 30 to 120 beds covers 30,000 to 80,000 population. Under them, one health center serves 2,000 to 5,000 population being managed by three to six health personnel.

 

The other, is financial risk protection. In Thailand,there are three different schemes such as l) the Civil Servant Medical Benefit Scheme (CSMBS) which covers the public servants since 1980, 2) the Social Health Insurance (SHI), which covers the employees of corporations that started in 1990, and 3) the Universal Coverage Scheme (UCS), which was established in 2002 to cover the informal sectors, that comprised 75% of the total population. It includes farmers, day wage workers and others who do not work at corporations, including self-employed who are engaged in micro-business. When the UCS was realized, Thailand has achieved 100% universal health coverage for its population.

 

When UHC is discussed, only the aspect of financial risk protection is oftentimes emphasized. Yet the Thai experience shows the synergies between health system development and financial risk protection expansion.

 

 

After UHC was realized, other financial resources has been mobilized for health. “Sin Tax” on tobacco and alcohol has mobilized approximately US$116 million in 2014 so as to strengthen health promotion activities.

 

It is also important to save cost for health services. The National Health Security Office (NHSO),which manages the UHC, is a big purchaser of medicine and medical supplies, and negotiates the prices. The strategic purchasing, including effective management and strategic payment mechanism is very essential. Thus, “More money for health,and More health for money.”
 

 

2. What have been achieved

 


The top change is the increase in accessing medical care, especially primary care delivered in the rural health centers. In 2010, 54% of the patients received health services in the rural health center, while 33.4% in district hospitals, and 12.6% in regional/general hospitals. The research shows health care delivered in rural health centers has become far accessible than before.

 

Public health expense of the national budget has increased from 5% in the 1980s to 14% in 2013.The total health expenditure has increased by 3.3% of the GDP in 2001 (before UHC) to 4.6% in 2014.

The most important change is the reduction of health impoverishment. UHC is very powerful in reducing poverty due to heavy financial burden.

 

 

3. Remaining challenges


Three different health schemes have different benefit packages, delivery systems, payment mechanisms and budget, resulting in different financial contributions and burdens. There is still coverage gap between low and high socio-economic groups as well as rural and urban.
 

Another challenge is financial sustainability. At present, the national health expenditure is still less than 6% of the GDP. However, financial sustainability is very challenging. Due to technology development, increasing demand and expectation for better and advanced health services, as well as aging population increase drove the health expenditure up to 14% of the total government budget. With limited fiscal space, efficiency needs to be improved through the Health Intervention and Technology Assessment (HITA), pooled procurement and cost control measures. Co-payment (self-payment at health service delivery) might arise in the future.

Dr. Viroj summarized UHC into three points:


・UHC does not mean only financial protection, but more on universal access to comprehensive essential quality health services.
・Achievements and sustainability of UHC depend more on the committed spirits of health workers, the ownership by the people, and the good governance systems than money.
・It is context specific. You can learn from others and adapt, not copy, based on your own situation.

 


Dr. Viroj’s Sharing: A Single Hero Never Wins

 

I participated in the AHI-ILDC in 1985, when I was the director of the district hospital in Ubonrajthani, Thailand. Int he rural province, I needed to fight in order to save people’s lives. In the villages, it was very difficult to bring patients to the referral hospital, because of the physical distance. I even donated my blood to the patients, when they were in such an urgent and serious condition. Family members are sometimes reluctant to bring the patients due to their anxiety as well as required financial burden. And it is not sure if the patient can fully recover to come back home after spending so much money for the treatment.
 

 

The Thai culture does not traditionally allow to take a dead body cruising villages. So, I needed to promise to the patients’ families that I would take the dead body back to their home during night time. I do remember well the case of the farmer, who was taken to a larger hospital, uncertain if the patient can fully recover to come back home after spending so much for the treatment, but unfortunately passed away. I took him back to his village. When I carried the dead body into his house, I saw almost nothing (like furniture), except a kerosene lamp and an old pillow. The life of the village people was so difficult. Once they get sick, they needed to spend so much that sometimes they get heavily in debt. These experiences are still deeply engraved in my mind.

 

In 1987, I got a scholarship and studied in the U.K. I finished my PhD in health planning, financing and economics in 1990. My experiences in rural hospital made me work for the health system and financial mechanism, that assured every poor person access to appropriate health services when he/she is in need.

When I came back to Thailand after my study, I started to think it would be very important to build a good organization and a strong linkage among different people in health and other sectors, so as to change health policies and systems.

“The study in the U.K. has changed my life. Before that, I was working like a soldier fighting alone everyday in a battlefield. I may win today, but I might loose tomorrow. A single hero could never change the situation. A strong troop would be essential.”

I worked hard being a role model, and tried to get people with commitment in their works. In 1998, the International Health Policy Program (IHPP), Thailand was established within the Ministry of Public Health. I am one of the three people when it started. Currently, it has more than 70 staff. IHPP conducts researches on various health related issues. With those results as evidence, we do advocacy. Research results need to be reflected in the national health systems and policy.

Advocacy and negotiation are not easy. We often need to confront with some related industries. resist against the policy that affects or controls their marketing. We need to mobilize more people and train them on health policy research. For example, when we launched taxation over sugar, which could negatively affect one’s health. Industries such as softdrinks resources in order to establish a firm structure and more effective strategies to negotiate with the opposers. We have generated good policies, and will do more collectively involving more committed people organizations like IHPP.

 

 

International Migration of Health Personnel: One’s Right or What?

 

Dr. Viroj chaired the negotiations of the World Health Organization’s (WHO) Global Code of Practice on the International Recruitment of Health Personnel. This was adopted at the World Health Assembly in May 2010.

 

The Code is voluntary, unlike convention. member States and other stakeholders are yet strongly encouraged to use the Code. The Code is to promote the ethical international recruitment. Below is the summary of his lecture.

 

The Article 3 of the Code describes the guiding principles as follows.
The specific needs and special circumstances of countries especially those developing countries and countries with economies in transition that are particularly vulnerable to health workforce shortages and/or have limited capacity to implement the recommendations of this Code, should be considered. Developed countries should, to the
extent possible, provide technical and financial assistance to developing countries and countries with economies in transition aimed at strengthening health systems, including health personnel development.” “Member States should take into account the right to the highest attainable standard of health of the populations of source countries, individual rights of health personnel to leave any country in accordance with applicable laws, in order to mitigate the negative effects and maximize the positive effects of migration on the health systems of the source countries.

 

 In Thailand, although facing shortage and maldistribution of health workforce especially doctors, dentists and nurses, along with the medical hub policy in the ASEAN region, the international recruitment concern is not among the major issues.
The Ministry of Public Health of Thailand is yet very active in implementing the Code as well as raising social awareness. The National Health Commission, being chaired by the Deputy Prime Minister is responsible for the implementation.

The Code was translated into Thai Language in 2010. Since then, its contents have been
disseminated in terms of recruitment and migration of health work force not only with health sector, but across multi-sectors nationally and locally.

 

Meetings with private are organized so as to establish good practice guideline for internationalrecruitment of health personnel. The Thai Nurses Association and Nursing Council annually recognizes the forum for nursing students to create awareness of the Code, rights of migrant nurses and fair practices, balancing their rights to migrate and social responsibilities in their motherland.

In accordance to Article 4, the Thailand Labor Act assures that the international health personnel enjoy the same legal rights and responsibilities on employment as those domestically trained. On the other hand, all health practitioners have to pass national licensing examination in Thai languages, as being required by health professional councils.

The Ministry of Public Health has its policy focus in strengthening health system, specially for health work force planning, health professional education and retention strategy. Its strategic plan for 2016 to 2025 has its goals, including producing quality workforce distributing them equally with right numbers, right skills and on right time, and improving work environment which promotes retention performance of health workforce. To strengthen rural retention, different measures need to be taken such as increasing the provision of financial and non-financial incentives, implementing rural recruitment, local training and hometown placement.

Dr. Viroj concluded that the national capacity to manage is a pre-requisite in discussing international recruitment of health personnel, and international cooperation is needed so as to promote sharing good practices of managing HWF mobility.
 

 

 

 

 

 

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