-Thailand 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 Overview • Introduction- The Policy Elites -Thailand • Organisation Structure of the policy formulation process International Health Policy Program • Influence of Actors on important issues of UC International Health Policy Program -Thailand 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 Introduction • Policy Elites: The dominant actors -Thailand – Government/Politicians • PM (The Agenda Setter) International Health Policy Program • Health Minister (Policy Ambassador) • Deputy Health Minister (Policy Selector) International Health Policy Program -Thailand • 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 -Thailand Periods and Participants Issues of meeting Frequency Jan-Feb 2001 7 high level MoPH staff To design model and pace of International Health Policy Program (weekly) chaired by Health PS implementation 2-4 Mar 01 60 MoPH officials chaired by To seek opinion on system International Health Policy Program -Thailand 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 implementation 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 (22nd) 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 -Thailand policy formulation but the important issues raised were: International Health Policy Program 1. Source of Financing International Health Policy Program -Thailand 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 -Thailand • Mixed financing system – Contributions for employees in formal sector (SSS) International Health Policy Program – General tax for welfare scheme for the poor International Health Policy Program -Thailand – Health cards (contribution) – Civil Servant Medical Benefit Scheme (CSMBS) (Tax) -Thailand Source of Financing (2) Roles of TRT • Initially a mixed system of contribution (Bt100 per mth per capita) and copayment at point of International Health Policy Program service was proposed International Health Policy Program -Thailand • 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: -Thailand – Contribution is a more sustainable source of financing – no good suggestion on how to collect contribution based on ability to pay International Health Policy Program – Thai tax system was regressive and so International Health Policy Program -Thailand 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: -Thailand – The increased burden on the government budget was a major concern- International Health Policy Program • Budget expected to rise by Bt4billion in 2003 • Level of public debt was already high (56% of GDP in International Health Policy Program -Thailand 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 -Thailand – The scheme, referred to as a ‘welfare system’ would create a burden on the government budget International Health Policy Program – There was not enough money to run the program and other source of financing should also be International Health Policy Program -Thailand considered – “The project use government budget to help the RICH!” Despite urging the government to reconsider many times, their call were ineffective Reaction to tax-based financing (4) • General Public -Thailand – Villagers agreed that the scheme should protect all, and not just the poor. International Health Policy Program – Some villagers regretted that the rich might have more opportunities to use public resources than International Health Policy Program -Thailand the poor. Generally, people seemed to support the policy, as reflected in the poll. Budget requirement • Roles of TRT -Thailand – Mobilisation and merging of sources from other insurance schemes were proposed but there was a lot of resistance from the MoL, MoF & the Civil International Health Policy Program Servant Commission, and so in the end, only the International Health Policy Program -Thailand internal MoPH budget was merged – They also want to know: “How Much?” Budget requirement • Roles of Academics -Thailand – In order to estimate budget, cost per capita was calculated. 3 numbers were proposed based on 3 different studies International Health Policy Program 1. Bt900 (Pitayarangsarit et al, 2001) • Too specific, estimated from a special type of hospital International Health Policy Program -Thailand 2. Bt1,500 (Siamwalla, 2001) • Overestimate & no consideration for Gov fiscal constraint 3. Bt1,202 (Tangcharoensathien, 2001) • Unweighted & no consideration for cost of teaching hospital 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 -Thailand from health service-based • There were 3 main policy issues considered International Health Policy Program 1. Flat rate as transitional model or Ultimate model? International Health Policy Program -Thailand 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 -Thailand model or Ultimate model? • A technical working group did propose a capitation model in 2002 which take into account the different International Health Policy Program health needs BUT it was rejected – No consideration for provider risk from size of population. International Health Policy Program -Thailand – 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 -Thailand not? • There were attempts to try to exclude salary from capitation by the civil servants. International Health Policy Program • Material budget was proposed as a way to reduce extra budget and to provide incentive for improving International Health Policy Program -Thailand 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 -Thailand hospitals • PS agreed to the Provincial Hospital Society proposal that budget for provincial and regional International Health Policy Program hospital should be separated from capitation and the supply-side based system should be re- International Health Policy Program -Thailand 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 -Thailand – ‘For’ inclusive • Low cost of administration (senior MOPH officials) • Familiar & led to expected hospital revenue (Private International Health Policy Program providers) • Anticipation of treatment cost-saving in the future from International Health Policy Program -Thailand 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 academics) • 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 -Thailand – ‘For’ exclusive • Case payment is an incentive to admit patient (Regional & provincial hospitals, some chief provincial medical officers, & some academics) International Health Policy Program – ‘Against’ exclusive International Health Policy Program -Thailand • 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 lacking 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’ -Thailand role instead of TRT which the Health Minister later became a strong supporter of the concept. International Health Policy Program • Pre-2001: International Health Policy Program -Thailand – Health centres had been established covering the whole country, BUT low satisfaction & evidence of bypass – MoPH wanted to improve PCU standard • Increase efficiency • Provide continuity & comprehensive care using holistic approach • An area with population up to 10,000 should have a PCU Primary care as ‘Gatekeeper’ (2) • Reactions to PCU Model -Thailand – Academics perceived that UC reform is the last opportunity to construct primary care in the provider-contract model International Health Policy Program – Private Hospital Association preferred contracting International Health Policy Program -Thailand 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.) -Thailand – Regional & some provincial hospitals saw this as an opportunity to off-load patients and workload to PCU. International Health Policy Program – ‘Front-line’ health workers support this policy as International Health Policy Program -Thailand they wanted to strengthen health promotion. – However, the number of doctors available were seen as the major problem in implementing the model Private provider collaboration • The concept was widely accepted as it would -Thailand encourage competition between public and private providers -> greater efficiency • Private sector was very keen. International Health Policy Program • A number of conditions required International Health Policy Program -Thailand – Registration system and allocation of capitation – Quality assurance system – Patients allowed to register with public provider of their choice So it could take some time before private providers could join Private provider collaboration (2) • Reactions -Thailand – 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. International Health Policy Program – PM was supportive of the concept as the under-utilised private providers could help promoting efficiency. International Health Policy Program -Thailand – 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 provider. – 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 Conclusion • There was a number of policy elites involved in the -Thailand policy formulation process including top-level politicians and high ranking civil servants.The policy formulation ‘circle’ started small but later grew in size International Health Policy Program and number. International Health Policy Program -Thailand • 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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