This document summarizes Borwornsom Leerapan's lecture on creating and managing new models of care in Thailand. It discusses Thailand's health systems and financing, including the three main public insurance schemes (CSMBS, SSS, UCS), private insurance, and out-of-pocket payments. It also reviews levels of the health system including primary care, chronic care, palliative care, and long-term care. Key challenges addressed are rapidly rising costs, coverage only while employed, and inadequate budgets for public schemes. The lecture aims to provide lessons for improving Thailand's future health care system.

1. Wrap-up: Creating & Managing
New Models of Care in Thailand
Borwornsom Leerapan, MD PhD
MGMG 548: Health Service Systems and Health Systems
CMMU, Mahidol University
Aug 10, 2014
Pix source: ra.mahidol.ac.th

2. Format
F/U
Pix source: online.wsj.com
Mini-lecture
Presentation
Discussion
Q&A
Wrap
up
To-do
list

3. Pix source: online.wsj.com
Housekeeping Issues
1) Guest lecturer on Aug 10th (week 13):
– Thaworn Sakunphanit. MD, MSc (Social Policy Financing),
Director of Health Insurance System Research Office (HISRO)
2) Course papers will be due on Aug 17th (week 14)
– Both of your writing and your presentation will be graded.
– More importantly, it’d be better to aim for sharing your learning
experiences with your classmates and providing constructive feedbacks
to your classmates. Hopefully, each of your course papers will provide
valuable lessons to your future careers.

4. Outline for Today
• How has Thailand financed and organized
health services?
• How has Thai health systems performed?
• How would Thai healthcare system in the
future look like?
• What would be “our” lessons learned for the
whole course?
• Discussions/Q&A
Pix source: online.wsj.com

5. Course Description
MGMG 548
• Major issues in the organization of a health services system
• The role of values in the development of health care policy
• Methods for assessing the health status of populations
• Analysis of need for, access to and use of services; current supply
and distribution of health resources
• Analysis of health care costs and expenditures
• Sociopolitical, economic, and moral/ethical issues confronting the
public health and medical care system
• Trends in service provision, human resources, financing and health
services organization, and implications for the public’s health.
Source Prattana Punnakitikashem. PhD; Pix source: online.wsj.com

6. Up and Down the Ladder of Abstraction
Abstract:
• Concepts
• Theories
• Principles
• Strategies
Concrete:
• Case studies
• Data, Evidence
• Analysis, Synthesis
• Presentations

7. What Level of Our Learning?
Wisdom • Why
Knowledge • How
Information • What, Who, When, Where
Data • Number, Text, Picture, Sound, etc.

8. Pretest
(in-class exam, no grade)
Pix source: online.wsj.com

9. Considering the provided VDO presentation, please give
your best answers to these two following questions:
1. What “health systems issues” are dominated in the
provided VDO presentation? (Please describe.)
2. As a (future) administrators in your healthcare
organizations, what could you do to address such
issues? (Elaborate more on what, why, and how.)
(30 min)
Pre-test Exam

10. “How could we improve
our health & healthcare systems?”
Pix source: online.wsj.com

11. Source: WHO (2000). The World Health Report 2000. Pix source: buelahman.files.wordpress.com

12. Health System’s Performance
Pix source: WHO (2000). World Health Report 2000.

13. The Commonwealth Fund’s Ranking of Healthcare Systems:
EXHIBIT ES-1. OVERALL RANKING
Overall Ranking (2014)
AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
COUNTRY RANKINGS
Top 2*
Middle
Bottom 2*
OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11
Quality Care 2 9 8 7 5 4 11 10 3 1 5
Effective Care 4 7 9 6 5 2 11 10 8 1 3
Safe Care 3 10 2 6 7 9 11 5 4 1 7
Coordinated Care 4 8 9 10 5 2 7 11 3 1 6
Patient-Centered Care
5 8 10 7 3 6 11 9 2 1 4
Access 8 9 11 2 4 7 6 4 2 1 9
Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11
Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5
Efficiency 4 10 8 9 7 3 4 2 6 1 11
Equity 5 9 7 4 8 10 6 1 2 2 11
Healthy Lives
4 8 1 7 5 9 6 2 3 10 11
Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508
Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.
Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health
Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).
Pix source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

14. “Health System”
• “The Six Building Blocks” and their interconnections
Pix source: WHO’s framework for action. (2007)

15. WHO’s Health System Building Blocks
Pix source: WHO’s framework for action. (2007)

16. Social Determinants of Health
• Health is not merely the absence of disease or infirmity.
• Health promotion and disease prevention
• Health promotion strategies have to go beyond health services
sector.
Pix source: greenpeace.org; twirlit.com; who.int/bulletin; cha-amcity.go.th

17. Social Entrepreneurship & Health
• Health is among “social values” that are the common
missions of social entrepreneurs or social
enterprises.
• Social values in health systems:
– To providing quality of care in an efficient and equitable
fashion to people with health needs.
(“Health Services/Healthcare”)
– To create social values that lead to healthy behaviors,
healthy lifestyle, and ultimately a better health of people.
(“Health Promotion”)

19. Control Knobs Framework
for Health Reform
Source: Adapted from Roberts et al. (2003).

20. “What exactly should we aim for?”
Pix source: online.wsj.com

21. Characteristics of Desirable Healthcare
• A great health services system should be:
1. Equitable
2. Efficient
3. Safe
4. Timely
5. Effective
6. Patient-centered
Source: Adapted from IOM (2001)
Quality
“STEEEP”

22. Integrated Healthcare Quality Management
“The Constraints Management window is like
looking at the forest from a hot air balloon
and selecting the best tree from which to pick
fruit. The Lean window shows the simplest
way to pick the low-hanging fruits as well as
the fruit on the floor with very little effort.
And the Six Sigma window shows how to
consistently pick the bulk of the sweeter fruits,
without bruising them,
at higher,
difficult-to-reach
branches of the tree.”
Source: Inuzu et al. (2012); Pix source: magic-mural-factory.com

23. Technical vs. Allocative Efficiency
• Two approaches to improve efficiency:
1. Technical efficiency
2. Allocative efficiency

24. Health Technology Assessment
• Health technology assessment (HTA): “a structured analysis
of health technology, a set of related technologies, or a
technology-related issue that is performed for the purpose of
providing input to a policy decision” (Goodman 2004).
• Economic evaluation is a part of health technology assessment
Pix source: http://ecsphysics.webs.com/
HTA
Decision
making
Scientific
Evidence

25. Types of Economic Evaluation
• All costs are in the same monetary unit.
• Type of outcomes determines type of analyses:
Health Outcomes Type of
Analysis
Findings
Clinical/Health effects CEA ICER
Utility/Quality of life CUA ICER
Monetary benefits CBA Net benefits, or
Benefit-cost ratio
Health effects in non-aggregated
format
CCA Lists of health
effects gained/lost
and resources used
Source: Adapted from Brouselle and Lessard (2011)

26. Equity vs. Equality
• Equity means equality of opportunity (“justice as fairness”).
• Equality is not always justice.
Pix source: twicsy.com/i/TwC76c
Equality Equity

27. Contrasting Paradigms of Justice
Source: Aday et al. (2004). Table 6.1, p.192

28. Contrasting Paradigms of Justice
Source: Aday et al. (2004). Table 6.1, p.192

29. Integrating Equity into “STEEEP”
Source: Adapted from Mayberry et. al (2006)

30. “How should we organize healthcare
for certain populations?”
Pix source: online.wsj.com

31. Disability-Adjusted Year Lost (2004)
Injury
NCD
Infec/on
0-­‐4
5-­‐14
15-­‐29
30-­‐44
45-­‐59
60-­‐69
70-­‐79
80+
0-­‐4
5-­‐14
15-­‐29
30-­‐44
45-­‐59
60-­‐69
70-­‐79
80+
Males
Females
1,600
1,400
1,200
1,000
800
600
400
200
0
Sour
Source: Adapted from: WHO (2008), http://www.who.int/healthinfo/global_burden_disease

32. Dealing with the Care Cycle
32
Source: Tishihiko Hasegawa (2013)

33. Concepts in Palliative Care
33
Care provided based on patient & family needs & goals and independent of prognosis

34. Managing Chronic Care
Figure
Source:
www.improvingchroniccare.org

35. Managing Palliative Care
35
Hospice care & End-of-the-life care
Pix source: www.politico.com

36. Managing Long-term Care
4) Supportive services
5) Care Management
Source: Adapted from Feldman, Nadash & Gursen (2008)
36
1) Chronic Care
2) Palliative Care
3) Rehabilitative Services
• Activities of Daily Living (ADL)
• Instrumental Activities of Daily Living (IADL)
• Care plans, appointment arrangement
• Coordination between providers & patients-caregivers
• Logistics and supply of necessities

37. Managing Acute Care
37
Source: Hirshon et al. (2013)

38. Managing Emergency Care
PrevenFon
&
Public
EducaFon
Pix
source:
adapted
from
www.ems.gov/wha/sems.htm
Prehospital
care
Emergency
care
Specialty
care
&
RehabilitaFon

39. Managing Primary Care
“Anatomy of Primary Care” “Physiology of Primary Care”
— Structure & Organizations
of primary care system
(in urban settings)
• Patient Care Teams
• PCUs/Clinics
• Systems/Networks
• Governance policies
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
— Four Cardinal Functions
of primary care services
(in urban settings)
• First Contact/Access
• Continuity
• Coordination
• Comprehensiveness

40. “How our healthcare should be
financed & organized?”
Pix source: online.wsj.com

41. Major Mechanisms of
Healthcare Financing
Healthcare
Regulator(s)
2) Taxes
Payers
3) Individual
private
health
insurance
4) Employer-based
private
health
insurance
1) Out-of-pocket
Payments
Hospitals
Medical
Specialists
Ambulatory
Facilities
Generalists
& PCPs
Payment Mechanisms:
Salary, Fee-for-Service,
Global Budget,
Capitation, etc.

42. British National Health Service System
(the model after recent reforms)
Most Providers
in the Public Sector
Taxes
Payers
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach

43. Canadian National Health Insurance System
Most Providers
in the Private Sector
Taxes
Payers
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach

44. German National Health Insurance System
Employer-based
private
health
insurance
Most Providers
in the Private Sector
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach

45. US Healthcare System
Federal
Government
(e.g. Medicare,
VA, Indian)
Taxes Payers
Individual
private
health
insurance
Employer-based
private
health
insurance
Hospitals
Medical
Specialists
Generalists
& PCPs
State
Government
(Medicaid,
CHIP)
Uninsured Patients paying out-of-pocket
Ambulatory
Facilities
Payment Mechanisms:
Salary, Fee-for-Service,
Global Budget,
Capitation, DRGs, etc.
Most Providers
in the Private Sector
Commercial
Health Plans/
HMOs
(private health
insurance
companies)

46. Taiwanese Healthcare System
Most Providers
in the Public Sector
Taxes
Payers
Govt-run,
Single fund,
National
Health
Insurance

47. Japanese Healthcare System
Most providers are in the
private sector, most small
facilities are private,
but large facilities are
in the public sector.
Employers
Employees
Taxes
Payers
Corporates
Central govt.
Local govt.
Negotiated standardized
payment rates
(e.g. FFS, per diem)
&
Retirees & (ex-employers)
Self-employed, Farmers,
Fishermen, etc.
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach

48. Compulsory
Savings
Scheme
(Employees
&
Employers)
Individual
Insurers
Taxes
payers
“Corporatized”
public hospitals
& Private
hospitals
Medical
Specialists
Generalists
& PCPs
Patients paying out-of-pocket
Ambulatory
Facilities
Singaporean Healthcare Systems
Providers in
Public & Private Sector
Central Provident Fund(CPF)
Medical Saving
Accounts
(Medisave)
Catastrophic
insurance
program
(Medishield)
Public assistant
program
(Medifund)
Severe disability
insurance program
(Eldershield)
“3M”, “Means-testing”

49. Thai Healthcare Systems
CGD
(CSMBS),
NHSO
(UCS)
Taxes Payers
Employer-based
private health
insurance
Individual &
Employer’s
private health
insurance
(Voluntary)
Hospitals
Medical
Specialists
Generalists
& PCPs
Social
Security
Office (SSS)
Patients paying out-of-pocket
Ambulatory
Facilities
Payment Mechanisms:
Salary, Fee-for-Service,
Global Budget,
Capitation, DRGs, etc.
Providers in
Public & Private Sector
Commercial
Insurance
Companies
Motor vehicle’s owners
(Mandatory by the Motor
Vehicle Victim Protection Law)

50. Financing of Thai Healthcare System
CSMBS SSS UCS Motor Vehicle
Victim
Protection
Law
Private Health
Insurance
Feature State/Employer
welfare
Compulsory
heath insurance
with state
subsidies
State welfare Compulsory
heath insurance
for vehicle
owners
Voluntary health
insurance
Targeted groups
of beneficiaries
Civil servants,
state enterprise
employees and
dependents
Employees in
private sector and
temporary
employees in
public sector
Thai citizens
without the
coverage of
CSMBS & SSS
Victims of
vehicle accidents
General public
Source of
financing
Govt. budget
Tri-party
(Employee,
employer and
govt. budget)
Govt. budget
Vehicle owners Household
Method of
payment to
health facilities
Fee-for-service Capitation and
Fee-for-service
Capitation and
Fee-for-service
Fee-for-service Fee-for-service
Major problems Rapidly and
constantly rising
costs
Covering while
being employed
only
Inadequate
budget
Redundant
eligibility and
slow
disbursement
Redundant
eligibility and
slow
disbursement
Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.

51. Four Major Types of Healthcare Systems
US
Singapore
Germany
Japan
Canada
Taiwan
UK
Cuba
The least!
market interventions"
-Private financing "
-Private providers "
Source: Adapted from Roemer (1993).
Socialist !
Health Systems"
Entrepreneurial
Health Systems"
Comprehensive !
Health Systems"
Welfare-oriented !
Health Systems"
The most !
market interventions"
-Public financing "
-Public providers "

52. “Why should we concern about
health & healthcare systems?”
Pix source: online.wsj.com

53. Simple, Complicated, Complex Problems
Source: Glouberman and Zimmerman (2002)

54. “Simple Logic Model”
Source: W.K. Kellogg Foundation (2004)

55. Source: Patricia Roger (2008)
“Complicated Systems”

56. Source: Patricia Roger (2008)
“Complex Systems”

57. Health Systems as
An Example of Complex Adaptive Systems
Pix source: Don de Savigny and Taghreed Adam (2009).

58. Decision-making in Healthcare
Source: Gilson, editor (2012). Health Policy and Systems Research: A Methodology Reader.

59. Decision-makers in Healthcare
Macro
Source: Adapted from: Lessard et a. (2009)
• Policy level
• Policymakers
Meso
• Administrative level
• Organizational administrators
Micro
• Clinical practices level
• Clinicians

60. Pix
source:
Strategic
Analysis
hMp://hbr.org/2008/01/the-­‐five-­‐compe//ve-­‐forces-­‐that-­‐shape-­‐strategy/ar/1

61. Stakeholder
Analysis
Pix
source:
Start
and
Hovland
(2004)
Tools
for
Policy
Impact:
A
Handbook
for
Researchers

62. Force
Field
Analysis

63. Gap
Analysis
Pix
source:
www2.ifm.eng.cam.ac.uk/

64. PosiFve
NegaFve
Strengths
Advantages
Financial reserves, likely returns
Qualifications, certifications
Competitive advantages
Capabilities
Location and geography
Innovative aspects
Resources, Assets, People
Processes, systems, IT, communications
Culture, attitudes, behaviours
Management cover, succession
Experience, knowledge, data
Strong brand names
Marketing - reach, distribution, awareness
Unique selling points “USP”
Price, value, quality
Weaknesses
Lack of competitive strength
Gaps in capabilities
Disadvantages of proposition
Weak brand name
Financials
Cash flow, start-up cash-drain
High cost structure
Our vulnerabilities
Timescales, deadlines and pressures
Reliability of data, plan predictability
Continuity, supply chain robustness
Processes and systems, etc
Management cover, succession
Morale, commitment, leadership
Opportunities
Market developments
Competitors vulnerabilities
Niche target markets
New USP's
New markets, vertical, horizontal
Partnerships, agencies, distribution
Geographical, export, import
Unfulfilled customer need
New technologies
Loosening of regulations
Changing of International trade barriers
Business and product development
Seasonal influences
Technology development and innovation
Threats
Environmental effects
Seasonal, weather effects
Economy - home, abroad
Political effects
Legislative effects
Market demand
New technologies, services, ideas
IT developments
Shifts in consumer preferences
Obstacles
Sustainable financial backing
Insurmountable weaknesses
Competitor intentions
New policies or regulations
Emergence of substitute products
External Internal
SWOT
Analysis
Figure
source:
Adapted
from
conceptdraw.com

65. Looking Forward
Pix source: online.wsj.com

66. Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

67. Financing of Healthcare Systems
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

68. Desirable Healthcare Systems
• Systems Thinking
• Focus on quality,
efficiency & equity
• Responsive (esp. to
health needs of certain
disease and certain
populations)
• Good governance in all
level of health system
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

69. Towards a Better Healthcare System
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

70. Towards a Better Healthcare System
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

71. Towards a Better Healthcare System
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.

72. Adult Learning
Ø Learning about health systems: “Experience, not explanation.”
Picture source: commonsenseatheism.com; variety.thaiza.com
EXPERIENCE

73. Food-for-Thought
Pix source: online.wsj.com

74. “If I had asked people what they wanted,
they would have said faster horses.”
--Henry Ford

75. “The best way to predict the future
is to create it.”
Pix source: www.dennisgruending.ca
--Peter F. Drucker

76. Q& A
Discussions
Pix source: online.wsj.com