Post on 13-Jan-2016
24 June 2009At Faculty of Economics, TU
Chalermpol CHAMCHAN
Doctor of Area Studies, Graduate School of Asian and African Area Studies (ASAFAS), Kyoto University 1
“Impacts and Constraints of Universal Coverage (UC) in Thailand’s Public Health System”
24 June 2009At 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: สร้�างนำ�าซ่อม (SNS: health promotion and prevention (PP) ahead curative health care) and ใกล้�บ้�านำใกล้�ใจ (KBKJ: health facility near dwelling)
24 June 2009At Faculty of Economics, TU
24 June 2009At Faculty of Economics, TU
24 June 2009At Faculty of Economics, TU
24 June 2009At Faculty of Economics, TU 6
Upper-Secondary and Tertiary Care/ General Hosp.
Provincial level (in Provincial city)
Primary Care Unit (PCU)/ Sub-district level
Secondary Care/ Community Hosp.
District level
Provincial public care network and referral system
24 June 2009At Faculty of Economics, TU 7
Regional IP care-referral system
Khonkaen Hosp.(General and Regional Hosp.)
Kalasin Hosp.
Other provincial Hosp.
in neighborhood
Other provincial Hosp.
in neighborhood
24 June 2009At Faculty of Economics, TU
CUP structure and main constituent parts
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.
I. Background
24 June 2009At Faculty of Economics, TU
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?
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I. Background
24 June 2009At Faculty of Economics, TU
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
I. Background
24 June 2009At Faculty of Economics, TU
Respondents: Providers at facilities in 9 districts, with care referral network from Primary and Secondary levels to Tertiary level
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Table 5.1 Summary of the Interviews, by Health Workplaces and Professions
Khonkaen (J uly-August 2005) Kalasin (J anuary-February 2006)
CUP (5) CUP(4) Professions PPHO
(1) DPHO
(5) Hospital
(5) PCU/ HC
(8)
Pri. H. (1)
PPHO (1)
DPHO (4)
Hospital
(4)
PCU/ HC (6)
Total
Director* - - 4 - - - - 3 - 7
Doctor - - 4 - - - - 4 - 8
Nurse - - 7 5 - - - 4 2 18
PHO, Health Academic,
Management Offi cer
1 5 3 4 1 1 4 2 5 26
Total 1 5 18 9 1 1 4 13 7 59
Note: * All directors of the hospitals are doctors. In parentheses are the numbers of visits at each place type.
I. Background
24 June 2009At Faculty of Economics, TU
a) 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 benefits and popularity
II. Providers’ Views of the UC Implementation
24 June 2009At 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)
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II. Providers’ Views of the UC Implementation
24 June 2009At Faculty of Economics, TU
Workloads and Service Utilization
24 June 2009At Faculty of Economics, TU
Workloads and Service Utilization
24 June 2009At Faculty of Economics, TU
Structural changes: Structure of CUP and Cooperation of the Hospital, PCUs/HCs and the DPHO
24 June 2009At Faculty of Economics, TU
Relationship Issues
Providers& Patients – Medical malpractice & Suings by patientsThe 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
24 June 2009At Faculty of Economics, TU
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.
III. Constraints and Consequences in Public Health Service System
24 June 2009At Faculty of Economics, TU
Systematic constraints and negative cyclic consequences in care provision system are
drawn out
Concerning,1. Primary Constraints2. Linking Consequences3. Secondary constraints
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24 June 2009At 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
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1. Primary Constraints
24 June 2009At Faculty of Economics, TU
Shortage of health workforces
24 June 2009At Faculty of Economics, TU
Drains of health workforces
24 June 2009At Faculty of Economics, TU
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.
Drains of doctors
24 June 2009At Faculty of Economics, TU
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)
Resignations of nurses
Drains of the PHO group at the PCU/HC level
24 June 2009At Faculty of Economics, TU
Under-estimated and under-approved UC budget
24 June 2009At Faculty of Economics, TU
“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
Adequacy of the capitation rates and UC budget
24 June 2009At Faculty of Economics, TU
“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
Adequacy of the capitation rates and UC budget
24 June 2009At 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
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2. Linking consequences:
24 June 2009At Faculty of Economics, TU
สร้�างนำ�าซ่อม and ใกล้�บ้�านำใกล้�ใจ 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 WorkB. Inadequate Workforce with Heavy Workloads
C. Unsupportive UC Budget for PP Work
24 June 2009At 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
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3. Secondary Constraints
24 June 2009At Faculty of Economics, TU 31
Figure 6 Systematic Constraints and Cyclic Consequences in Public Health Service System at the Provincial Level
24 June 2009At 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
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24 June 2009At Faculty of Economics, TU
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
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(1) Assuring universal
and comprehe
nsive health
insurance coverage.
(1) Assuring universal
and comprehe
nsive health
insurance coverage.
(2) Ensuring adequate
and equitable access to needed health
service.
(2) Ensuring adequate
and equitable access to needed health
service.
(3) Increasing
the effectiveness and
sustainability of health system
(3) Increasing
the effectiveness and
sustainability of health system
Source: Docteur et al. 2003Source: Docteur et al. 2003
ConclusionsConclusions
24 June 2009 At Faculty of Economics, TU
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
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Policy SuggestionsPolicy Suggestions
24 June 2009At Faculty of Economics, TU 35