The document discusses health systems in advanced Asian countries and lessons for Thailand. It covers how Japan, Taiwan, and Singapore organize and finance healthcare through social health insurance models. These systems achieve universal coverage and emphasize preventive care. The document suggests Thailand could improve healthcare quality, efficiency and equity by taking a systems approach while strengthening governance.

1. International Health Systems:
The Asian
Borwornsom Leerapan, MD PhD
MGMG 548: Health Service Systems and Health Systems
CMMU, Mahidol University
Aug 3, 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) [Confirmed] Guest lecturer on Aug 10th (week 13):
– Thaworn Sakunphanit. MD, MSc (Social Policy Financing),
Director of Health Insurance System Research Office (HISRO)
2) [Canceled/Postponed] Scheduling a site visit to Ramathibodi
Hospital & Somdech Phra Debaratana Medical Center (SDMC)
– To settle down on your preferred dates
– To prepare a scope of your interviews with the executives

4. Outline for Today
• How do the advanced Asian countries
(e.g. Japan, Taiwan, Singapore) finance and
organize health services?
• How such health systems have performed?
• What would be the lessons learned for
healthcare managers currently working in Thai
healthcare system?
• Discussions/Q&A
Pix source: online.wsj.com

5. Reviewing what we have learned:
Organizing & Financing Healthcare
Pix source: online.wsj.com

6. 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.

7. 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)

8. 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)

9. 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

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

11. 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

12. Comparing Asian Healthcare Systems:
Organizing & Financing Healthcare
Pix source: online.wsj.com

13. 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

14. Japanese Healthcare Systems
Ø “Social Health Insurance” with standard comprehensive benefits, including
payment for hospital and physician services, prescription drugs, maternity care,
and dental care, disable adults with long term insurance and earmarked
income tax.
Healthcare financing mix
Figure source: Wagstaff (2005). World Bank Policy Research Working Paper 3790.

15. 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”

16. Singaporean Healthcare Systems
Ø Govt. subsidies aim to provide all Singaporeans basic health care
defined as “good and affordable medical services”, but not
provide “the latest and best of everything”
Ø Emphasize on greater transparency about costs and prices,
more regulation of insurance company’s prices and policies.
Source: Hsiao (1995); Singapore's Ministry of Health (2003)

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

18. Taiwanese Healthcare Systems
Ø “Consolidated System”: providing everyone equal access to
health care, free choice of doctors, with no waiting time, and
a system that encouraged a lot of competition among medical
providers.
Ø Efficient administrative system: utilization of information
technology, including smart cards, online medical information
systems, and online billing systems.
Figure source: Wagstaff (2005). World Bank Policy Research Working Paper 3790.

19. How have health systems performed?
Pix source: online.wsj.com

20. Health System’s Building Blocks
Pix source: WHO (2007).

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

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

23. What would be your lessons learned
from these comparative health systems?
Pix source: online.wsj.com

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

25. 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 "

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

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

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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

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

35. “The track of the previous cart
is the teacher of the following cart.”
Pix source: en.wikipedia.org/
--A Chinese proverb

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