Special Symposium "Celebrating The Legacy of HRH Prince Mahidol of Songkla: A Century of Progress in Public Health and Medicine in Thailand", presented at Harvard University 2016.8.25

1. Celebrating The Legacy of
HRH Prince Mahidol of Songkla:
A Century of Progress in Public Health
and Medicine in Thailand
Strengthening Health Systems:
Lessons Learned from 2nd Decade of Thailand’s UHC
Borwornsom Leerapan, MD PhD
Present at Countway Library of Medicine, Harvard University
25 August 2016
Pix source: student.mahidol.ac.th

2. Outline
Pix source: online.wsj.com
1. Thailand’s health systems development before and after
Universal Health Coverage (UHC)
2. Lessons learned from Thai UHC
3. Implications for the future of UHC

3. Q1: What had been the progress of
Thailand’s health systems development?
Pix source: online.wsj.com

4. Source: WHO (2000). The World Health Report 2000; Pix source: Modified from: buelahman.files.wordpress.com
The World Health Report 2000:
• The WHO’s first major analysis of the world’s healthcare systems.
• Health systems of all member states were analyzed and ranked by eight measures that
explain how health systems perform.
• Thailand was ranked the 47th on the overall health systems performance.
Japan
(10th)
Thailand
(47th)
China
(144th)
Germany
(25th)
Japan
(10th)
Canada
(30th)
USA
(37th)
UK
(18th)
Swiss
(20th)
Mexico
(61th)
France
(1st)
India
(144th)
Israel
(28th)
Italy
(2nd) Australia
(32nd)

5. Timeline
PM received
Certificate in
Public Health
from Harvard
(1921)
The "people's constitution”
promulgated and widely hailed
as a landmark in democratic
political reform
(1997)
Socioeconomic and Political Contexts
Era of the Beginning of Modern Medicine and Public Health
Asian Financial Crisis or
"Tom Yum Goong Crisis”
(1997)
UHC officially started
with the National
Health Security Act
(2002)
Small pox
vaccination
ended
(1980)
Era of the Cold War
Primary
Health Care
Declaration of
Alma-Ata
(1978)
PM was the
Director-General of
the University
Department,
Ministry of
Education
(1923)
Kingdom of Siam
changed from
absolute monarchy
to constitutional
monarchy
(June 24, 1932)
PM received
M.D.(cum laude)
and was elected
a member of the
Alpha Omega
Alpha
(1928)
PM was liaising with
the Rockefeller
Foundation for
financial and technical
aid to improve
Thailand's medical
and public health
education
(1916-1923)
PM died at the
age of 37 years
(24 Sep 1929)
Having built one
provincial hospital in
every province in
Thailand
(1957)
HRH Prince Mahidol
(PM) resigned from
the Royal Thai Navy
to pursue his
conviction by
studying at Harvard
(1916)
Thailand
joined WHO
(1947)
Starting the policy to
build a community
hospital in every
district nationwide
(1974)
Timeline of Health Systems Development in Siam/Thailand
Ministry of
Public Health
established
(1942)
The first
HIV/AIDS
patient
found in
Thailand
(1984)
Medical Welfare
Scheme started
(1975)
Era of Primary Health Care towards UHC
National Essential
Drug List started
(1981)
Healthcare
Accreditation
Institute
established
(1999)
The National
Health Act
(2007)
The Health
Promotion Act
(2001)
Data source: Thailand Health Profile 2008-2010; Pix source: www.en.psu.ac.th/about-psu/introduction/27-history/224-biography-of-his-royal-highness-prince-mahidol-adulyadej.html
Restructuring University of Medical Sciences
(currently Mahidol University)
out of Ministry of Public Health
(1959)
The whole class of
medical graduates
from CMU moved
to the USA
(1965)
Siam was
renamed Thailand
(24 June 1939)
The 1st National
Economic and Social
Development Plan
(1961-1966)

6. Source: Patcharanarumol et al. (2011). Why and how did Thailand achieve good health at low cost; Pix source: HISRO (2012).
Thailand’s Path to UHC
Health Systems Development, 1970s-2000s
“Infrastructure has been built over time”

7. Source: Thailand’s National Statistical Office, the Health and Welfare Surveys in 1991, 1996, 2001, 2003.
Pix Source: TDRI; Health Insurance System Research Office (2012).
Thailand’s Path to UHC
Coverage of Health Insurance, 1970s-2000s
21
3
UCS
SSS
(SSS)
(UCS)
(CSMBS)
CSMBS
Long-term drive vs. “Big Bang” reform

8. Data source: http://data.worldbank.org; Pix Source: Health Insurance System Research Office (2012).
Thailand’s Path to UHC
Against GNI per Capita, 1970s-2000s
Long-term drive vs. “Big Bang” reform

9. Thailand’s Path to UHC
Key Features of the UCS Policy
2
1
3
Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

10. Thailand’s Path to UHC
Health Expenditures as % GDP, 1990s-2000s
Total Health Expenditures
General Government
Health Expenditures
(excl. Social Security)
Out-of-Pocket Payment
Private Insurance
Social Security Scheme
Source: International Health Policy Program, the national health account of Thailand 1994-2008.
“Significant increase of health expenditures by the government ”
Others

11. Thailand’s Path to UHC
Service Utilization Rates among UCS members
“Better access and greater utilization of healthcare services”
Source: National Health Security Office (2011)
(Visits/capita/year) (Admissions/capita/year)

12. Thailand’s Path to UHC
Thai Households with Medical Impoverishment
“Prevention of medical impoverishment”
Source: Health Insurance System Research Office (2012)
Before UCS After UCSStarting UCS

13. Thailand’s Path to UHC
Thai Households with Medical Impoverishment
Source: Health Insurance System Research Office (2012).
Before UCS After UCSStarting UCS
“Less medical impoverishment nationwide”

14. Q2: What are the lessons learned
from UHC implementations in Thailand?
Pix source: online.wsj.com

15. Thailand’s Path to UHC
Why the UCS was launched in 2001?
Source: Wasi (2002). “Triangle That Moves The Mountain” and Health Systems Reform Movement in Thailand; HISRO (2012);
Pix source: www.pinterest.com/pin/88594317647694761/
“The Public Health Triumvirate”
• Major political party putting
UHC as one of its priorities in
the 2001 general election (with
“30-baht treats all diseases”
campaign slogan)
• Civil society securing
Parliament’s commitment
to the UHC
1) Creation of Relevant Knowledge
2) Social Movement 3) Political Involvement
• Scholarly assessments showing
the UHC was “financial and
programmatically feasible”

16. What’s Next?
Policy Recommendations at the End of 1st Decade
Ø Two sets of policy recommendations are offered with a view to
sustaining and improving of UHC over the next 10 years (2011-2020):
1) “The Unfinished Agenda”
1. Governance and strategic purchasing
2. Managing the purchaser-provider split
3. Harmonizing the three public health insurance schemes
2) “The Future Agenda”
1. The private sector
2. Decentralization
3. Epidemiological transition and the ageing of the population
4. Quality monitoring, quality assurance and health technology
assessment
Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

17. • Social accountability, transparency, protection against political manipulations
• Relationship between the purchaser (NHSO) and the provider (MOPH)
• Equitable distribution of human resources
Source: HISRO (2012); Pix Source: www.hfocus.com; web.facebook.com/aanuchitn
#1 Governance and Strategic Purchasing
#2 Managing the Purchaser-Provider Split

18. #3 Harmonizing Three Public Health Insurance Schemes
• Reducing inequities in benefits, level of expenditures
• Addressing inefficiencies across the schemes
• Standardizing common features
Source: HISRO (2012). Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years.

19. #4 The Private Sector
• Establishing a single regulatory system for both public and private providers
• Engaging more with the private sector in the delivery of publicly-funded care,
especially in the urban settings
Source: HISRO (2012); Pix Source: www.bumrungrad.com/en/clinics-and-centers

20. #5 Decentralization
• Exploring local commission of health services
• Balancing centralization and decentralization
Source: HISRO (2012).
Source: HISRO (2012); Pix Source: www.bumrungrad.com/en/clinics-and-centers
Thailand’s 13 Regional Healthcare Governance Structure
(since 2012)

21. #6 Epidemiological Transition and Ageing Population
• Developing appropriate long-term care models—hospital care still dominates
other care models in Thailand
• Greater investment in disease prevention and health promotion
• Addressing social determinants of health
Data source: NSO. Population and Housing Census 1970, 1980, 1990, 2000, 2010; NESDB. National Projections for Thailand 2010-2040.
Pix source: Foundation of Thai Gerontology Research and Development Institute. This report on the situation of Thai elderly 2014.

22. #7 Quality Monitoring, Quality Assurance
and Health Technology Assessment
• Developing methods to routinely collect and assess clinical outcomes
• Building institutional capacity for health technology assessment (HTA)
Source: HISRO (2012); Pix source: www.hitap.net/en/

23. Source: www.ha.or.th; forumhai.com/2016/gallery; www.tqa.or.th/en/

24. AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
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
COUNTRY RANKINGS
Top 2*
Middle
Bottom 2*
EXHIBIT ES-1. OVERALL RANKING
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
The Commonwealth Fund’s Ranking of Healthcare Systems (2014)

25. Q3: What would be the policy implications
for the future of UHC worldwide?
Pix source: online.wsj.com

26. Politics Matters
Four Major Types of Healthcare Systems
Source: Adapted from Roemer (1993). National Health Systems Throughout the World.
US Singapore Germany Japan Canada Taiwan UK Cuba
The least
market interventions
-Private financing
-Private providers
Socialist
Health Systems
Entrepreneurial
Health Systems
Comprehensive
Health Systems
Welfare-oriented
Health Systems
The most
market interventions
-Public financing
-Public providers

27. Coalitions, Elections, Military Coups
Political Turmoil in Thailand, 2000s-2010s
Thaksin Shinawatra
(1st Term)
2001/2-2005/3
Thaksin
Shinawatra
(2nd Term)
2005/2-2006/9
Surayud
Chulanont
2006/10-2008/1
SamakSundravej
SomchaiWongsawat
Abhisit Vejjajiva
2008/12-2011/8
AbhisitVejjajiva
2008/12-2011/8
Yingluck Shinawatra
2011/9-2014/5
Prayut Chan-o-cha
2014/5-present
??
Assuming General Election in late 2017
2001 2002 2003 2004 2005 2006 2006 2008 2009 2010
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
*The dark green shaded boxes represent the coup-appointed governments

28. The National Committee on
Resource Mobilization for
Sustainable UHC (2015)
• Sustainability
• Adequacy
• Fairness
• Efficiency
The National Committee on
the Development of
National Health Security
Systems (2016)
• Sustainability & Adequacy
• Fairness
• Systems Efficiency &
Resource Distribution
• Effectiveness & Efficiency
of Health Services
Source: http://ihppthaigov.net/document/safe/SAFE(ENG)Feb2016.pdf

29. Beyond Healthcare Financing
Control Knobs Framework for Health Reform
Source: Adapted from Roberts et al. (2003).

30. Source: Hoffman et al. (2012). A Review of Conceptual Barriers and Opportunities Facing Health Systems Research to Inform a Strategy from WHO.

31. Summary
Pix source: online.wsj.com
1. Prince Mahidol put forth the foundations of medical
education and public health infrastructure in Thailand.
2. Lesson learned from Thailand is that a long-term health
systems development is required for UHC, including:
v Creation of relevant knowledge
v Social movement
v Political involvement
3. Sustainability of UHC depends on:
v Systems thinking
v Institutional capacities to create and apply relevant knowledge

32. Pix source: Courtesy Akarin Nimmanit, MD