Liturature Review of CVA (stroke) in Thailand by mhf39s



                                                Journal Club:
 International Health Policy Program

                                                The Policy Formulation Process of Universal
International Health Policy Program -Thailand

                                                Health Coverage in Thailand (Book Section)

                                                Source: Pitayarangsarit, S. (2010) Universal Coverage of
                                                Health Care Policy in Thailand: Policy Responses.

                                                                                            Jiraboon Tosanguan
                                                                             International Health Policy Program
                                                                                              22nd October 2010
                                                • Introduction- The Policy Elites

                                                • Organisation Structure of the policy
                                                  formulation process
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                                                • Influence of Actors on important issues of UC
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                                                  1.   Source of Financing
                                                  2.   Budget requirement
                                                  3.   Allocation methods to provinces
                                                  4.   Provider payment methods
                                                  5.   Service delivery system
                                                       •   Primary care as ‘Gatekeeper’
                                                       •   Private provider collaboration
                                                • Conclusion
                                                • Policy Elites: The dominant actors

                                                  – Government/Politicians
                                                     •   PM (The Agenda Setter)
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                                                     •   Health Minister (Policy Ambassador)
                                                     •   Deputy Health Minister (Policy Selector)
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                                                     •   The other relevant Ministers
                                                  – TOP civil servants
                                                     • Permanent Secretary of MOPH
                                                     • Secretary General of NESDB
                                                     Organization Structure of the policy
                                                            formulation process
                                                Communication during Jan-May 2001

                                                Periods and        Participants                   Issues of meeting
                                                Jan-Feb 2001       7 high level MoPH staff        To design model and pace of
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                                                (weekly)           chaired by Health PS           implementation
                                                2-4 Mar 01         60 MoPH officials chaired by   To seek opinion on system
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                                                                   Health PS                      design and to prepare design
                                                                                                  details for national workshop
                                                Mar-May 2001       Approx. 30 MoPH                Alternative formulation and
                                                (twice a month)    ‘Headquarter’ Officials        discussion on UC designs for
                                                17 and 22 Mar      111 members from 8             Consultation with various
                                                                   ministries, providers, and     stakeholders and making
                                                                   consumers- chaired by PM       decisions on several details
                                                                   (17th) and Health Minister
                                                Mar-May 2001       10 working groups from         To develop the operational
                                                (average- 2x per   several stakeholders           guidelines for the policy
                                                group)                                            implementation
                                                       Influence of actors and the events
                                                      occurring on important issues of UC
                                                Many aspects of UC were discussed during

                                                policy formulation but the important issues
                                                raised were:
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                                                1. Source of Financing
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                                                2. Budget requirement
                                                3. Allocation methods to provinces
                                                4. Provider payment methods
                                                5. Service delivery system
                                                  –    Primary care as ‘Gatekeeper’
                                                  –    Private provider collaboration
                                                             Source of Financing
                                                Pre 2001

                                                • Mixed financing system
                                                  –   Contributions for employees in formal sector (SSS)
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                                                  –   General tax for welfare scheme for the poor
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                                                  –   Health cards (contribution)
                                                  –   Civil Servant Medical Benefit Scheme (CSMBS)
                                                         Source of Financing (2)

                                                Roles of TRT
                                                • Initially a mixed system of contribution (Bt100
                                                  per mth per capita) and copayment at point of
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                                                  service was proposed
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                                                • However, collection of contribution in the
                                                  informal sector could be difficult and may prove
                                                  to be ‘unacceptable’ to the public
                                                • Consequently, the contribution part was
                                                  dropped, the campaign became “30 baht treats
                                                  all” & The scheme to be financed by general
                                                  tax revenue
                                                   Reaction to tax-based financing
                                                • Academics:

                                                  – Contribution is a more sustainable source of
                                                    financing – no good suggestion on how to collect
                                                    contribution based on ability to pay
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                                                  – Thai tax system was regressive and so
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                                                    inappropriate to be used to expand coverage
                                                  – The economic crisis may hamper the
                                                    government’s ability to afford the scheme

                                                However, their fragmented views meant that
                                                  each idea had little weight
                                                 Reaction to tax-based financing (2)
                                                • Bureaucrats:

                                                  – The increased burden on the government budget
                                                    was a major concern-
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                                                     • Budget expected to rise by Bt4billion in 2003
                                                     • Level of public debt was already high (56% of GDP in
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                                                       2001) and expected to increase further.
                                                  – Bureau of Budget suggested that revenue from
                                                    private hospital room and board should be used to
                                                    supplement the increased demand on the budget

                                                They were against the increased budget for UC
                                                  but the concerns were ignored.
                                                 Reaction to tax-based financing (3)
                                                • Opposition politicians

                                                  – The scheme, referred to as a ‘welfare system’
                                                    would create a burden on the government budget
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                                                  – There was not enough money to run the program
                                                    and other source of financing should also be
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                                                  – “The project use government budget to help the

                                                Despite urging the government to reconsider
                                                  many times, their call were ineffective
                                                 Reaction to tax-based financing (4)
                                                • General Public

                                                  – Villagers agreed that the scheme should protect
                                                    all, and not just the poor.
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                                                  – Some villagers regretted that the rich might have
                                                    more opportunities to use public resources than
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                                                    the poor.

                                                Generally, people seemed to support the policy,
                                                  as reflected in the poll.
                                                           Budget requirement
                                                • Roles of TRT

                                                  – Mobilisation and merging of sources from other
                                                    insurance schemes were proposed but there was a
                                                    lot of resistance from the MoL, MoF & the Civil
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                                                    Servant Commission, and so in the end, only the
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                                                    internal MoPH budget was merged
                                                  – They also want to know: “How Much?”
                                                            Budget requirement
                                                • Roles of Academics

                                                  – In order to estimate budget, cost per capita was
                                                    calculated. 3 numbers were proposed based on 3
                                                    different studies
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                                                  1. Bt900 (Pitayarangsarit et al, 2001)
                                                     •   Too specific, estimated from a special type of hospital
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                                                  2. Bt1,500 (Siamwalla, 2001)
                                                     •   Overestimate & no consideration for Gov fiscal
                                                  3. Bt1,202 (Tangcharoensathien, 2001)
                                                     •   Unweighted & no consideration for cost of teaching
                                                Bt1,202 was adopted for 2002. However, in 2003,
                                                   all stakeholders were invited to participate in
                                                   the 2003 cost calculation workgroup
                                                   Allocation methods to provinces
                                                • Moved towards population base allocation

                                                  from health service-based
                                                • There were 3 main policy issues considered
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                                                  1. Flat rate as transitional model or Ultimate model?
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                                                  2. Should capitation inclusive of staff salary or not?
                                                  3. Same or different allocation criteria (between
                                                     large and small hospitals)?
                                                 Allocation methods to provinces (2)
                                                Unweighted capitation as transitional

                                                  model or Ultimate model?
                                                • A technical working group did propose a capitation
                                                  model in 2002 which take into account the different
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                                                  health needs BUT it was rejected
                                                   – No consideration for provider risk from size of population.
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                                                   – When the above was corrected, it was too complex to
                                                     explain to the providers and public.
                                                • In 2003, another model was proposed but there was
                                                  political pressure against this from bureaucrats in
                                                  order to protect the staff wage.

                                                Flat rate was adopted which led to financial difficulties
                                                   in a number of hospitals
                                                 Allocation methods to provinces (3)
                                                Should capitation inclusive of staff salary or

                                                • There were attempts to try to exclude salary from
                                                  capitation by the civil servants.
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                                                • Material budget was proposed as a way to reduce
                                                  extra budget and to provide incentive for improving
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                                                  efficiency BUT it was rejected because of the
                                                  difficulty of the dual system management (full
                                                  capitation system vs. capitation + salary system)

                                                MoPH Permanent Secretary with support from health
                                                  economists and the Health Minister decided to
                                                  include salary cost in the 2002 budget to accelerate
                                                  reform. However, in 2003, MoPH changed to
                                                  capitation on top of salary budget.
                                                 Allocation methods to provinces (4)
                                                Allocation criteria for large and small

                                                • PS agreed to the Provincial Hospital Society
                                                  proposal that budget for provincial and regional
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                                                  hospital should be separated from capitation and
                                                  the supply-side based system should be re-
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                                                  adopted (Oct 2001)
                                                • However, TRT wanted to achieve equitable
                                                  resource allocation in order to reform the whole
                                                  health system which the demand-side system
                                                  would better serve
                                                • The Rural Doctor Society also supported this
                                                  policy direction
                                                        Provider payment methods
                                                • Inclusive vs Exclusive

                                                   – ‘For’ inclusive
                                                       • Low cost of administration (senior MOPH officials)
                                                       • Familiar & led to expected hospital revenue (Private
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                                                       • Anticipation of treatment cost-saving in the future from
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                                                         health promotion (community hospital)
                                                       • This system would increase efficiency- incentive to take
                                                         cost-effectiveness into consideration (SOME academics)
                                                   – ‘Against’ inclusive
                                                       • Disincentive for providers to treat severe cases (some
                                                       • Community hospitals might delay referral (some academics)
                                                       • Community hospitals in area with small population size may
                                                         not be able to bear the cost of referral (some academics)
                                                     Provider payment methods (2)
                                                • Inclusive vs Exclusive

                                                   – ‘For’ exclusive
                                                      • Case payment is an incentive to admit patient (Regional &
                                                        provincial hospitals, some chief provincial medical officers,
                                                        & some academics)
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                                                   – ‘Against’ exclusive
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                                                      • At the time, DRG system was still incomplete and might
                                                        lead to unfair budget allocation (an officer from Health
                                                        Insurance Office, some provinces)
                                                      • Require skills of well trained IT officers which was still

                                                No consensus. Decision was down to the provincial
                                                  committees. Approx. equal no. of provinces
                                                  adopted each PP system.
                                                   Primary care as ‘Gatekeeper’
                                                • MoPH researcher played the ‘Agenda Setter’

                                                  role instead of TRT which the Health Minister
                                                  later became a strong supporter of the
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                                                • Pre-2001:
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                                                  – Health centres had been established covering the
                                                    whole country, BUT low satisfaction & evidence of
                                                  – MoPH wanted to improve PCU standard
                                                     • Increase efficiency
                                                     • Provide continuity & comprehensive care using holistic
                                                     • An area with population up to 10,000 should have a PCU
                                                 Primary care as ‘Gatekeeper’ (2)
                                                • Reactions to PCU Model

                                                  – Academics perceived that UC reform is the last
                                                    opportunity to construct primary care in the
                                                    provider-contract model
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                                                  – Private Hospital Association preferred contracting
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                                                    units to have at least 100 bed. They also would
                                                    like to remove the ‘gatekeeping’ feature of PCU
                                                  – MoPH wanted PCU to be small & easily accessible
                                                    and not bound to large hospitals. It should be the
                                                    smallest contracting unit AND ‘gatekeeping’
                                                    feature must remain.
                                                 Primary care as ‘Gatekeeper’ (3)
                                                • Reactions to PCU Model (cont.)

                                                  – Regional & some provincial hospitals saw this as
                                                    an opportunity to off-load patients and workload
                                                    to PCU.
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                                                  – ‘Front-line’ health workers support this policy as
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                                                    they wanted to strengthen health promotion.
                                                  – However, the number of doctors available were
                                                    seen as the major problem in implementing the
                                                   Private provider collaboration
                                                • The concept was widely accepted as it would

                                                  encourage competition between public and
                                                  private providers -> greater efficiency
                                                • Private sector was very keen.
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                                                • A number of conditions required
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                                                   – Registration system and allocation of capitation
                                                   – Quality assurance system
                                                   – Patients allowed to register with public provider of their

                                                So it could take some time before private providers
                                                  could join
                                                Private provider collaboration (2)
                                                • Reactions

                                                   – Private sector believed that UC would be similar to SSS which
                                                     was their major source of income and wanted to join asap in
                                                     order to utilise their excess capacity. The media was used
                                                     extensively to pressure MoPH for a quick implementation.
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                                                   – PM was supportive of the concept as the under-utilised
                                                     private providers could help promoting efficiency.
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                                                   – MoPH were concerned with the quality assurance process in
                                                     UC as the policy was rapidly implemented. They were also
                                                     worried about the impact on the financial status of the public
                                                   – Rural Doctor Society was against the decision to allow private
                                                     providers to join as main contractor because the public
                                                     providers needed to improve their competitive capacity

                                                The private sector was allowed to joined in June 2001 BUT
                                                  the population size was limited, and the entry of new
                                                  providers were prohibited to join
                                                • There was a number of policy elites involved in the

                                                  policy formulation process including top-level
                                                  politicians and high ranking civil servants.The policy
                                                  formulation ‘circle’ started small but later grew in size
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                                                  and number.
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                                                • TRT was, in many cases, the agenda setter who was
                                                  in a very powerful position and also enjoyed a lot of
                                                  public support for the policy
                                                • There were numerous opposition to some of the
                                                  decisions made by TRT but they were either too
                                                  fragmented, or they could not provide better
                                                  alternative. However, they did not always get what
                                                  they wanted.

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