4. ประเทศต่างๆ ทั่วโลกมีแนวโน้ม ในการพัฒนาระบบ
สาธารณสุขด ้วยสร ้างหลักประกันสุขภาพถ้วนหน้า
ให ้แก่ประชากรของตน
• Pooled funds can be used
• to extend coverage to
those individuals who
previously were not
covered,
• to services that previously
were not covered
• or to reduce the direct
payments needed for each
service.
ที่มา WHO, Health financing for universal coverage: universal coverage-three
dimensions, http://www.who.int/health_financing/strategy/dimensions/en/
• The path to universal health coverage involves important policy choices
and inevitable trade-offs.
กลยุทธ 3 มิติ
5. หลักประกันสุขภาพ “ถ ้วนหน้า” ในระบบสาธารณสุข
4 ผลลัพธ์ ที่ต ้องการ
• Benefit package in a desirable universal health coverage should include health
services from health promotion, disease prevention, curation, and rehabilitation.
• However, extending these health service coverage will affect coverage of the
other dimensions.
• It is difficult to cover 100% of these dimensions.
• Therefore, some services may not cover or require co-payment.
• In order to balance the coverage of these dimensions, four related dimension of
effectiveness outcomes may be considered.
6. 3 ผู้เล่นที่สาคัญ ในการสร ้างหลักประกันสุขภาพถ ้วนหน้า
Universal Health Coverage (UHC)
• Towards UHC implementations are not only using financial mechanisms
to extend coverage but also promoting new relationship of key
stakeholders in UHC.
• Roles of purchasers include to reimburse health care cost to service
providers according to service agreements, to prepare optimal benefit
packages to be able to promote effective outcomes and remove
financial risks from the beneficiaries, to ensure appropriate distribution
of services between regions.
• Consumer right protections and stakeholder participations are also
important to promote good relationship with stakeholders.
8. 8
8
• Population - 64 million
• GNI 2012 US$5,090 per capita, Gini 42.5
• UHC achieved in 2002 under 3 schemes
• civil servants, social security, and UCS
• Health status
Life expectancy at birth 75 years (2012)
female 79 (2012)
male 71 (2012)
IMR 20/1000 LB, MMR 30/100,000 LB
Physicians per capita 5/10,000
ANC & hospital delivery 99-100% (2009)
• Total Health Expenditure
US$300 per capita, 6% GDP
Half from public , 14% of National budget
Less than 40% out of pocket
ภาพรวมทางด ้านเศรษฐกิจ สังคม
และปัจจัยการออกแบบระบบ
More information:
1. Thailand health profile, http://www.moph.go.th/ops/thp/thp/en/index.php
2. World Health Report,
http://www.who.int/gho/publications/world_health_statistics/2014/en/
9. 9
ข ้อมูลประชากร เศรษฐกิจและสังคม
Year
Crude birth rate (per 1000 population) 2012 10.5
Crude death rate (per 1000 population) 2012 7.5
Total fertility rate (per woman) 2012 1.41
Civil registration coverage of births (%) 2005-2006 99.4
Most recent census (year) 2010 2010
Civil registration coverage of cause-of-death (%) 2006 74.5
Ill-defined causes in cause-of-death registration (%) 2006 44.9
Literacy rate among adults aged >= 15 years (%), 2005
93.5
*World Health Statistics 2014, accessed July 2014
10. World Health Statistics 2014,
accessed July 2014
10
Infant mortality rate (probability of dying between
birth and age 1 per 1,000 live births)
• Year 2010 2012
• Global 37 35
• Upper-middle-income 18 16
• South East Asia 42 39
• Thailand 12 11
11. World Health Statistics 2014,
accessed July 2014
11
Neonatal mortality rate (per 1,000 live births)
• Year 2010 2012
• Global 22 21
• Upper-middle-income 11 10
• South East Asia 29 27
• Thailand 9 8
12. World Health Statistics 2014,
accessed July 2014
12
Under-five mortality rate (probability of dying by
age 5 per 1,000 live births)
• Year 2010 2012
• Global 52 48
• South East Asia 54 50
• Thailand 14 13
13. World Health Statistics 2014,
accessed July 2014
13
Care of children aged <5 years, 2006-2013
14. World Health Statistics 2014,
accessed July 2014
14
Maternal mortality rate (per 100,000 live births)
• Year 2010 2013
• Global 230 210
• South East Asia 210 190
• Thailand 20 26
15. World Health Statistics 2014,
accessed July 2014
15
Adult mortality rate (probability of dying
between 15 and 60 years per 1000 population)
Male Female Both Sexes
• Minimum 55 34 51
• Maximum 560 503 528
• Median 187 106.5 147.5
• Thailand 182 90 136
16. World Health Statistics 2014,
accessed July 2014
16
Distribution of life years lost by broader causes (%)
Communicabel Non-communicable
Injuries
• Minimum 3 8 3
• Maximum 90 88 50
• Median 26 56 13
• Thailand 24 55 22
17. World Health Statistics 2014,
accessed July 2014
Thailand: Distribution of causes of death among
children aged < 5 years (%), aged 0-4 years
18. World Health Statistics 2014,
accessed July 2014
18
Thailand: Distribution of causes of death among
children aged < 5 years (%), aged 1 - 59 months
19. World Health Statistics 2014,
accessed July 2014
19
Deaths due to tuberculosis among HIV-negative
people (per 100 000 population)
• Year 2011 2012
• Global 14 13
• Upper-middle-income 5.5 5.1
• South East Asia 26 25
• Thailand 14 14
20. World Health Statistics 2014,
accessed July 2014
20
Incidence of tuberculosis
(per 100 000 population per year)
• Year 2011 2012
• Global 125 122
• Upper-middle-income 88 86
• South East Asia 191 187
• Thailand 124 119
21. World Health Statistics 2014,
accessed July 2014
21
Prevalence of tuberculosis
(per 100 000 population)
• Year 2011 2012
• Global 176 169
• Upper-middle-income 111 107
• South East Asia 278 264
• Thailand 168 159
27. World Health Statistics 2014,
accessed July 2014
27
Reproductive healthcare among girls
aged 15-19 years, Thailand
Year 2006
Contraceptive prevalence, among girls aged 15-19
(%)
66.4
Antenatal care coverage - at least one visit, among
girls aged 15-19 (%)
96.4
Births attended by skilled health personnel, among
girls aged 15-19 (%)
98.1
28. ความดันโลหิตสูง เบาหวาน ภาวะโรคอ ้วน ภาวะคุกคามระบบ
สาธารณสุข : ความเหลื่อมล้าที่ซ่อนเงื่อน
World Health Statistics 2014,
accessed July 2014
29. World Health Statistics 2014,
accessed July 2014
29
การบริโภคเครื่องดื่มแอลกอฮอลล์ :
การตลาดโลกาภิวัฒน์ ความเหลื่อมล้าไม่เท่าเทียมของข ้อมูล
30. World Health Statistics 2014,
accessed July 2014
30
ประเทศไทยมีมาตรการควบคุมการบริโภคบุหรี่ และรณรงค์ที่ดี
แต่...
41. 41
4141
การพัฒนาบริการที่ใกล ้บ ้าน
“ระบบบริการปฐมภูมิ หมอครอบครัว”
ความร่วมมือรัฐ กับคลินิกเอกชน เป็นทิศทางการพัฒนา
Source: Bureau of Plan and Strategy, Ministry of Public Health, June 2014
http://203.157.10.8/hcode/query_02.php
42. 42
42
48.7% 47.7% 47.6% 48.0%
39.6% 40.1% 40.4% 40.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2553 2554 2555 2556
In-patient service under the UCS scheme classified by hospital types, FY2010 – 2013
โรงพยาบาลเอกชน
โรงพยาบาลรัฐอื่น
โรงพยาบาลของมหาวิทยาลัย
โรงพยาบาลศูนย์/โรงพยาบาลทั่วไป
โรงพยาบาลชุมชน
2010 2011 2012 2013
2010 2011 2012 2013
การเข้ารับบริการแบบผู้ป่ วยนอก , FY2010-2013
In-patient service under the UCS scheme classified by hospital types, FY2010-2013
43. 43
การลงทุนในเตียงบริการในโรงพยาบาลภาครัฐ ยังไม่มี
อัตราเพิ่ม ทั้งที่โรคมีความรุนแรง เทคโนโลยีก ้าวหน้าขึ้น
Hospital bed by ownership, 1973-2008
68 64 67 70 66 65 60 64 66 63 67
7 9
10 10
11 15 23 21 20 22 21
22 23 19 17 19 16 14 12 11 13 11
0%
25%
50%
75%
100%
1973 1977 1981 1985 1989 1993 1997 2001 2005 2007 2008
MOPH Private Other Govt Other (LGU, SE)
Key message: public sector especially MOPH and its district hospitals
are dominant in service provision, private sector has limited role, only
one fifths of total bed share
LGU=Local government unit, SE= State enterprise
43
44. 44
การผลิตกาลังคนด ้านสุขภาพ กรณี พยาบาล แพทย์
• All public medical schools produce medical students from “Collaborative
Program for increasing rural doctors” (CPIDR) and One District One Doctor
(ODOD).
• The second private medical school will be operated soon.
Public Private Total % of private
1. Nursing school 57 21 78 26.9%
Ministry of Education 23 21 44
Ministry of Public Health 29 29
Other Public school 0
Ministry of defense 3 3
Police Bureau 1 1
Bangkok Metropolitan 1 1
2. Medical Schools 18 1 19 5.3%
44
45. 45
คุณภาพ ตลาดแรงงานบุคลากรวิชาชีพ AEC และ
แนวโน้มการพัฒนาระบบสาธารณสุข
Source: The 2011 survey by Human Resources for Health Research and Development
Office, MOPH and Thai Medical Council
45
49. 49
1945
2000
2002
Universal
Coverage
of Health Care
Expand
Prepayment
Establish
Prepayment
Exemption
1990
First Social Security Act (not implemented)
1974 Workmen Compensation Fund
1975 Free Medical Care for the Poor
1980 CSMBS
1983 Health Card Project for near poor
1990 Social Security Act
1970
User fees
1962-76
Provincial
hospital
1977-86
district hospitals
and health centers
Health
Infrastructure
ประวัติศาสตร์การพัฒนาประกันสุขภาพในประเทศไทย
Legislation
1993 - Free care for children,
1995 – for elderly
2000 - Total health
insurance coverage
= 71 %
52. 52
Public Assistance
Civil Servant Medical Benefits Scheme (CSMBS)
Social Security Scheme (SSS)
Voluntary health insurance
People with no health insurance cover
การเปลี่ยนผ่านของประกันสุขภาพถ ้วนหน้าในประเทศไทย
Universal Coverage Scheme (UCS)
27.5 M.
(43.7%)
5.2 M.
(8.2%)
15.2 M.
(24.1%)
8.5 M.
(13.5%)
47 M.
(74.60%)
8 M.
(12.7%)
63 million 63 million
2 M.
(3.2%)
1997
2002
Before
UCS
After
UCSUCS
53. 53
53
การบริหารเงินกองทุนประกันสุขภาพภาครัฐ ส่วนใหญ่เป็น
tax-financed scheme ด ้วยภาษีทั่วไป
Tax-financedschemes
Tax-financedschemes
Uninsured(informalsector)
Uninsured(informalsector)
Uninsured
(informalsector)
Tax-financedschemes
UCS(mergingLIS+VHCSand
extendingtocoveruninsured)
CSMBS = Civil Servant Medical Benefit Scheme
SSS = Social Security Scheme
UC
S
LIS = Low income scheme
VHCS = Volunteer Health Card Scheme
UCS = Universal Coverage Scheme
54. 54
54
Civil Service Medical
Benefits Scheme
(CSMBS): gov. officers
and dependents
Social security scheme
(SSS):
private formal employees
Universal Coverage
Scheme(UCS):
the rest of Thai citizens
Thai citizens
Safety Net
BudgetBudgeting
Beneficiary Population Financing
Tax
ประเทศไทยมี 3 กองทุนประกันสุขภาพภาครัฐ
จึงมีพลวัตรของการจัดการกองทุน
Tripartite
contribution
Tax
55. 56
ภาพรวมของการประกันสุขภาพถ้วนหน้าของไทย 3 กองทุน
Health insurance
scheme
Target group Administrator office
Civil Servant Medical
Benefit Scheme
(CSMBS)
civil servants and
dependents
Comptroller General’s
Department (CGD),
MOF
Social Security Scheme
(SSS)
private employees in
formal sector
Social Security Office
(SSO), MOL
Universal Coverage
Scheme (UCS)
the rest of citizens
(unemployed, informal
employment)
National Health Security
Office (NHSO), chaired
by the minister of
MOPH
56. 57
รายละเอียดที่แตกต่าง :
ความเหลื่อมล้า ความยั่งยืน ประสิทธิภาพของระบบ
3. patient reimburses
for emergency services
out of service network.
SSS
UCS for
prenancy
Capitation
DRG method
with global
budget for IP
OP and IP
services at
main
contractor or
sub
contractors,
or refer as
need,
except for PP
services
1. no reimbursement for
basic package included
in capitation.
2. reimbursement for IP
and additional vertical
programs
1. Hospitals
2. SSO provincial
branch office
3. SSO
1. patients
2. SSO provincial
branch office
3. SSO
Service cost
reimbursement at
private health
facilities is limited
and only as
needed.
Contributions,
Coverage
Government
4.9 mil.
People
(8%)
Government,
Employers,
and
Employees
9.5 mil.
People
(15%)
Employment
Government
employees and their
dependents (parents,
spouse and up to 3
children < 21 year
old.)
Formal private
employees
Government
47.7 mil.
People
(74%)
+
Non-
registered
qualified
citizens
Unemployed, or other
informal sector
workers
Entry
Condition (s)
-
>= 3-month
of
contributions,
and up to 6-
month after
unemployed
do not have
any other
government
health
benefit.
Health
Insurance
scheme
CSMBS
less than
7-month of
contributions
UCS
Within the first
3-month of
contributions
type of
payment
Fee-for-service
Diagnostic-
related-group
(DRG) method
for inpatient
(IP)
Per item with
ceiling for
outpatient (OP)
Capitation
DRG method
with global
budget for IP
Benefit
package
OP and IP
services at
any public
health care
facilities,
except for PP
services
OP and IP
services at
primary care
contractors,
or refer as
need
Health
promotion
and disease
prevention
(PP)
programs for
all citizens
Claim, reimbursement
1. when direct payment
was set up, Hospital
claim through the
CSMBS
1. no reimbursement for
basic package included
in capitation.
2. reimbursement for IP
and additional vertical
programs
Related
organizations or
systems
2. without direct
payment setup, the
patients can reimburse
through their affiliated
office.
1. Hospitals
2. Central office of
Health Information
(CHI) on some
vertical programs
3. The ministry of
public health
(MOPH) on PP
programs
4. National Health
Security Office
(NHSO)
1. Hospitals
2. Central office of
Health Information
(CHI)
3. CSMBS
1. patients
2. patients’ affiliated
office
3. GFMIS system
4. CSMBS
Note
When they are
eligible to UCS,
the first service is
covered and
register is
requited at the
health facilities.
(only registered
UCS are count
for government
budget
allocation.)
Service cost
reimbursement at
private health
facilities is limited
and only for
accident or
emergency
threaten to life.
UCS All claim and reimbursements are managed under the UCS scheme.
57. 58
สามเหลี่ยมเขยื้อนภูเขา
• A wisdom proposed by Dr. Prawese Wasi, Thai senior citizen.
• The triangle is formed by three elements as follows:
1. To create a powerful wedge to move society by civil society.
2. To generate supporting knowledge of the problem to be solved.
3. To promote the political support within the legislation to resolve the
problem.
Civil society mobilization
Political commitment
Technical know-how
58. ความมุ่งหมายของการทาให ้มีระบบ
หลักประกันสุขภาพถ ้วนหน้าในประเทศไทย
• improving health of all Thai people by providing
equal access to quality of care in accordance
with health need of population on equitable
basis
• and preventing Thai households from being in
catastrophic situations when facing with high
cost care
59. 60
หลักการที่สาคัญ
• System efficiencies - cost containment
– Close end provider payment methods - capitation
– Rationalize use of health services: promote Primacy
Medical Care
– Provide conducive environment for a fair public
private sector competition
• Equity
– Standardized core package across the two schemes
– Convergence magnitude of financing per
beneficiaries
• Separation role of puchaser and provider
– Reform from “integrate model” towards “contract
model”
• Quality and accreditation
Source: Manual of Universal Coverage 20012
60. สิ่งที่สาคัญในการดาเนินการ
เพื่อสร้างหลักประกันสุขภาพถ้วนหน้า
• Extensive geographical coverage of public healthcare
provision owned by MoPH throughout the country
• Relatively strong research capacity and the well-
established Health Systems Research Institute
• Public administration and MOPH institutional capacity
both at headquarters and provincial health offices were
crucial in implementing and managing the reforms.
• computerized civil registration system used to record all
births and deaths in the country
Source: Bureau of Policy and planning, NHSO
61. 62
• Personal information management
– Thai people that have no or multiple personal
identification numbers (PID)
– Dynamic personal information that may impact
eligibility, such as birth, death, employment status,
migrant status.
ข ้อมูลประชากร ที่เชื่อมโยงกับ
ฐานข ้อมูลทะเบียนราษฎร์ กระทรวงมหาดไทย
64. 65
Government Budgeting for UCS in Thailand
FY2003 FY2013
UCS budget THB56,091 million THB140,609 million
% of gov. budget 5.61% 5.91%
UCS budget per
capita
THB1,202.40 THB2,755.60
UCS budget per
capita included other
vertical programs
THB1,202.40 THB2,921.66
• UCS budget to the overall government budget during
FY2003 – FY2013 is quite steady at the rate from
5.26% to 6.94%.
68. 6969Source: Bureau of Registration Administration, NHSO
Proportion of the government health insurance schemes, FY2013
(10.77mil.people)
(4.98mil.people)
(48.61 mil.people)
(0.49 mil.people)
(0.08 mil.)
(0.10 mil.)
UHC coverage in FY2013 is 99.87%
Most of the coverage are
UCS (74.74%), SSS (16.56%), CSMBS (7.66%),
and the rest are other small government schemes and stateless group
69. 70Source: Bureau of Registration Administration, NHSO
The UCS schemes classified by age groups, FY2013
1,470,134, 2%
9,750,818,
15%
29,937,321,
47%
14,939,648,
23%
7,304,398,
11%
1,123,273, 2%
The UCS schemes classified by age groups, FY2013
ทารก 0-1 ปี
เด็ก 1-15 ปี
ผู้ใหญ่ 15 - 59 ปี
หญิงวัยเจริญพันธ์
ผู้สูงอายุ>60ปี
ผู้พิการ
Newborn 0-1 yr
1-15 yr
15-59 yr
Female, reproductive ages
Elders > 60 yr
Disables
70. National Health Security Fund : categories
Basic health care
• OP
• IP
• HC, AE, Disease management
• P&P
• Rehabilitation
• Capital replacement
• Emergency Medical Service (EMS)
• Thai traditional
• No-fault liability
• ect.
Basic health Care (on capitation basis)
ARV drug
Renal replacement therapy
2002
Chronic
(2nd prevention for DM/HT)
Mental health
(medicine)
20112006 2009 2010
Benefit Starting year
(Pilot project in FY2009 and
extend to the whole country in
FY2010)
(Pilot project in FY2010 and extend
to the whole country in FY2011)
(Pilot project in FY2007 and extend to the
whole country in FY2009)
71
71. 72
Items / List Budget saved (฿) %
1. Instrument 2,520,092,092 17.61
2. Medicines and Vaccine 10,861,566,107 75.91
2.1 Negotiating Prices & Central Procurement and VMI 4,768,622,364 100.00
1) Antiretroviral Drug: ARV) 899,214,251 18.86
2) High cost drug in NDL 363,150,805 7.62
3) Influenza Vaccine 96,678,000 2.03
4) EPO and Solution for CAPD (for ESRD patients) 3,409,579,308 71.50
2.2 Compulsory Licensing: CL] (2008 – 2012) 6,092,943,743 100.00
1) EFV, LPV & RTV 4,507,452,140 73.98
2) Some high cost medicines (DOCETAXEL, LETROZOLE) 125,082,359 2.05
3) Clopidogrel 1,460,409,244 23.97
3. Health services : 926,053,000 6.47
- Cataract surgery (central procurement of Lens and
change payment method)
593,532,000 64.09
- ESWL Surgery (2008–2012) (change payment method) 332,521,000 35.91
Sum of budget saved (฿) 14,307,711,199 100
สปสช. มีการจัดการประสิทธิภาพของระบบ ไปพร้อมกับบริหารการประกัน
(central procurement & CL) Fiscal year 2009–2012
73. ประเด็นการเปลี่ยนแปลง และท ้าทายในอนาคต
• Changing in population structure to aging society
• Rapid demographic and epidemiologic transition
– Increased burden of diseases (BOD) from chronic NCD 1999
versus 2004 [Thai WG on BOD]
– Little investment in primary preventions of risk and social
mobilization
• Limited financing role of Thai Health Fund, 2% earmark tax from
tobacco/alcohol
• Increasing concerns on chronic diseases and emerging diseases
• Lacking of health resources both human resource and facilities.
• Relying on government budgets (ภาษีทั่วไป Health financing
sustainability)
• Multi-government health insurance schemes with different benefit
packages
74. ทิศทางในทศวรรษที่สอง
ของการสร ้างหลักประกันสุขภาพถ ้วนหน้า
1. Health
system
related
issues
• Strengthening health system by primary care approach
• Prevention and promotion to reduce cost of treatment
• Long term care for aging society
• Decentralized of service and commissioning
• Human resource distribution
• Quality assurance and Health technology assessment
• Development of a more equitable health facility plan and re-
orientation of existing system to fit with the health facility plan
• Reassuring people about quality of care provided by primary care
provider and the necessity to have a registration system based on
primary care
• Special measures to target and to organize health services for the
marginal and specific groups of Thai citizen (e.g. migrant worker,
solider, taxi- driver, prisoners and etc.)
• Engaging private sector in the provision of health care especially
in urban areas and establish a system for public and private health-
care providers in Thailand
• Developing model to manage epidemiological transition and the
aging of the population
75. ทิศทางในทศวรรษที่สอง
ของการสร ้างหลักประกันสุขภาพถ ้วนหน้า
2. Financing
and
management
issues
• Ensuring long term financial sustainability and equity in
financing of the UCS
• Seeking innovation way to reduce cost of care and
make health security system sustainable
– Harmonization of benefit package and provider payment
methods among public health insurance schemes
– Standardization of provider payment methods and benefit
packages among schemes
– Establishment of active and effective health care
purchaser (central and local)
– Co-finance with community fund
• Using purchasing power to increase quality of care
76. ทิศทางในทศวรรษที่สอง
ของการสร ้างหลักประกันสุขภาพถ ้วนหน้า
3. Stakeholder
and
networking
• Balancing the use of financing mechanism
and other measures to maintain a good
relationship between health care
providers, and between health care
providers and consumers
• Strong network of public and private
participation
77. 78
พัฒนาการของระบบบริการสาธารณสุขสู่อนาคต
Model Goals
Primary care strengthening;
concentrated on long term care for
chronic diseases, health promotion
Promoting accessibility with
Equity
Quality of care
Effectiveness
Safety
Efficiency
Equity of care and effectiveness
including appropriate drug
administration and medical
technology
Harmonization between public health
insurance schemes
Cost control
Responsiveness
Holistic care and communitarian
care model
Human and patient right