RESEARCH EXCHANGE PROGRAMM BETWEEN UNIVERSITY OF HYDERABAD AND MAHASARKHAM UNIVERSITY

RESEARCH REPORT Healthcare Delivery Management To Improve The Primary Healthcare Services And Universal Health Care In Thailand

MAHASARKHAM UNIVERSITY, THAILAND

UNIVERSITY OF HYDERABAD, INDIA
RESEARCH REPORT SUBMITTED TO THE MAHASARKHAM UNIVERSITY, KHAMRIANG, KANTARAWICHAI, MAHASARKHAM 44150 SUBMITTED BY NENAVATH SREENU, SCHOOL OF MANAGEMENT STUDIES, UNIVERSITY OF HYDERABAD, UNDER THE SUPERVISION OF Dr. SOMSAOWANUCH CHAMUSRI

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RESEARCH EXCHANGE PROGRAMM BETWEEN UNIVERSITY OF HYDERABAD AND MAHASARKHAM UNIVERSITY RESEARCH REPORT Healthcare Delivery Management To Improve The Primary Healthcare Services And Universal Health Care In Thailand

RESEARCH REPORT SUBMITTED TO THE MAHASARKHAM UNIVERSITY,

SUBMITTED BY NENAVATH SREENU, SCHOOL OF MANAGEMENT STUDIES, UNIVERSITY OF HYDERABAD, INDIA

Vic president For Planning And Internationa Relations………………………………………

Dean ……………………………………….

Supervisor………………………………….

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CONTENTS
1. INTRODUCTION

1.1 Definition of health care system in Thailand 1.2 Vision of People’s Health Development. 1.3 Overview of health care system in Thailand
2. DEVELOPMENT OF THE HEALTH CARE SYSTEM

2.1 Health policies and strategies
3. HEALTH CARE DELIVERY MANAGEMENT

3.1 healthcare delivery management developments 3.2 healthcare delivery services 3.2.1 Self-Care Level 3.2.2 Primary Health Care Level 3.2.3 Primary Care Level: 3.2.4 Secondary Care Level: 3.2.5 Tertiary Care 3.2.6 The world healthcare system frame work
4. .HEALTHCARE FINANCING MANAGEMENT IN THAILAND

4.1 financial resources for health care in Thailand
5. ORGANIZATION OF THE HEALTH SYSTEM IN THAILAND 6. PRIMARY HEALTHCARE MANAGEMENT ROLE IN THAILAND

6.1 Conceptual Model of the Primary Healthcare in Thailand 6.2 Management Model
7. STRATEGIES FOR IMPLEMENTING PRIMARY HEALTH CARE

7.1 Community Oriented Primary Healthcare 7.2 Uniting Stake holder’s through Partnership
8. Financing Primary Healthcare Services in Thailand

8.1 Strategies to Improve Primary Healthcare Services 8.2 Supporting Primary Healthcare Research
9. PRIMARY HEALTHCARE EFFICIENCY

9.1 Primary healthcare equity
10. Changing of health service administrative structure 11. CHALLENGES FOR THE FUTURE OF PRIMARY HEALTH CARE

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12. HEALTH SYSTEM STRENGTHENING USING PRIMARY HEALTH CARE APPROACH 13. FINANCING POLICIES TO ACHIEVE UNIVERSAL HEALTH CARE

13.1 Public Health Care and Protection Strategy in the 2001-2010 13.2 Universal Health Care Coverage Policy (30-baht Policy) 13.3 Implementation of the Universal Health Care Policy 13.4 Challenges for 30-baht Policy 13.5 Achievements of the UC Scheme 13.5.1 Beneficiaries of the UC Scheme 13.5.2 Improving access to healthcare 13.5.3 Prevention of medical impoverishment 13.5.4 Promoting equity in health
14 CHALLENGES AND STRATEGIES UNIVERSAL COVERAGE FOR HEALTH CARE

14.1 Aligning pluralistic public health protection system 14.2 Appropriate payment mechanism 14.3 Long-term financial sustainability 14.4 Improve equity, quality and efficiency 14.5 Recent Changes in the Thailand Health Care System 15. CONCLUSION

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Healthcare Delivery Management To Improve The Primary Healthcare Services And Universal Health Care In Thailand 1. INTRODUCTION The health services systems in Thailand has evolved from self-reliance, in the past, by utilizing local wisdom for curative care and health promotion, to the system of modern bio-medical emphasis. In serving the new health care system, numerous health personnel in response to various health disciplines have been produced, including the procurement and development of health technologies. There is a clear picture of role designation of providers and recipients, as well as more systematic health services system. In the pluralistic health services system, the main service providers are rendered by the public sector, while the private for-profit and non-profit sectors are also involved. Nonetheless, many Thai people are still accustomed to traditional way of self-care. Components of the health services system include (1) Health resources, (2) Management, (3) Organizational structures, (4) Financing, and (5) Health services The Structure of Health Service Systems Health services Categories Levels Specialized/general Management Policy and Plan Law Monitoring Information Organizational Structures Public /APO Private Social security Financing Social security Tax Individual Business

Health resources Body of Knowledge Medical supplies Health facilities/equipment Manpower APO: Autonomous Public Organization

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Social security has become an issue of serious public concern now that Thailand has climbed higher on the development ladder and its population is attaining higher levels of education. Health-care services comprise one of the major forms of social security agreed by the public as a priority. After Thailand’s major reform of the healthcare system in 2001, it is obvious that both the public and the government are paying more attention to the country’s health-care system. Thailand has developed three main public healthcare schemes, the first of which covers government officials and dependents (Civil Servants Medical Benefit Scheme, or CSMBS) and state enterprise employees and dependents. The CSMBS provides subsidized healthcare coverage and is considered by the public as a generous attractive fringe benefit for government officials. The scheme is financed from government budget through the Comptroller-General’s Office. Healthcare coverage for state enterprise employees is not inferior to that offered under CSMBS. Each state enterprise has its own package of health-care benefits. The second health-care scheme, the Social Security Scheme, covers private employees in the non-agriculture sector. To receive health-care benefits and other benefits, private employees and their employers must first pay contributions into the scheme. This healthcare scheme is subsidized by the government through its contributions to the Social Security Fund. The third scheme is the 30-Baht Healthcare Scheme, which covers residents of Thailand not covered by the first two schemes. The name “30 Baht” is derived from the user fee of 30 baht (about 75 US cents) per visit, for a wide range of outpatient or inpatient hospital care. This scheme is now four years old. Government expenditures on these three healthcare schemes in 2003 totaled 68.3 billion baht,1 which represents approximately 6 percent of total government spending. The 30-Baht Health-care Scheme accounts for 59 percent of the expenditures on the three health-care schemes. Even with such very high expenditures on the 30-Baht scheme, many stakeholders have raised the issue of inadequate budget allocation to the program needed to achieve the standard quality of health care. Many hospitals insist that they have gone into debt because of the program and, if prosperous enough, some of them would use their own savings to keep the hospitals running effectively. Many doctors and health-care professionals complain about their workload, which has increased because the 30-Baht Health-care Scheme increases health-care utilization. The arguments pro and con concerning the program have been around for four years; however, there is consensus among the stakeholders that the program is under funded. The purpose of this study is to review 6

the expenditures on the 30-Baht Health-care Scheme to analyze how much more budget the government should allocate to the program and to provide recommendation on possible sources of funding. And deliver of healthcare management to improve the primary healthcare 1.1 Definition of health care system in Thailand “ A proactive health system that emphasizes health promotion of the people, in parallel with a satisfactory health insurance system, so that the people will have access to health care that is solicitous and of good quality when necessary; whereas all sectors of society at all levels have potential and participate in the creation and management of the health system according to the sufficiency economy philosophy, through learning and utilization of Thai and international wisdom in a well-informed manner, so as to make Thai society survive in a self-reliance and healthy manner in the global society that is interconnected and extensively influential to each other” 1.2 Vision of People’s Health Development. All Thai citizens have security to live a happy life in a healthy condition, with access to health care in an equitable manner, in a family, community and society that is selfsufficient in terms of health, with potential, learning and participation in managing health problems, using international and Thai wisdom in a well-informed manner.้ 1.3 Overview of health care system in Thailand Health care system in Thailand is an entrepreneurial health system with public and private providers. Public health facilities were rapidly expanded nationwide since 1961 when Thailand launched the first five-year National Economic and Social Development Plans (1961-1966). Private hospitals also play role in health services. However, they are mostly in Bangkok and urban area. There are also wide spread of private clinics and polyclinics in urban areas, most of them are owned and running out of hour by public physicians. Since 1994, the numbers of hospitals and beds have been remarkably increasing Bed to population ratio came up to 1:469 in 2004. While the doctor to bed ratio has dropped from 1: 15.3 in 1991 to 1: 7 in 2004. Average bed occupancy ratio was 73%, Number of health care personal i.e., Doctors, dentists, pharmacists, and nurses has trended to gradually mount every year due to the strategy to increase emphasis on training of qualified health care personnel in the national plans. Nevertheless the distribution of health personnel still is one of major problems in Thailand. There was significant different between Bangkok, the Capital of Thailand, and other provinces. There are more doctors in Bangkok. The workload was 7

lower for the doctors who worked in other ministry hospitals or private hospitals rather than hospitals of the MoPH. 2. DEVELOPMENT OF THE HEALTH CARE SYSTEM 2.1 Health policies and strategies The MOPH is authorized and responsible for the strengthening of the public health and hygiene, preventing and controlling diseases and recovering the energy-level of the population. It has established its goals and a 3-year strategy for pursuing the goals so that the subordinating agencies adhere to the principal goals and their strategy is in operation according to estimates of the public health budget required for achieving the goals. The followings are the target of MOPH’s policies: 1. To improve the organization structure, culture and the operation procedure in order to have good administrative system and to become a learning organization of public health. 2. To develop and provide mechanism in facilitating the involvement of all concerned Parties in monitoring the public health system as a whole. 3. To increase the capability of the medicines, public health and biology of health, in order to be on the front line of world competition. The middle-term goals of the MOPH’s services are following: 1. The important public health problems in different age groups of the population are to be lowered. 2. The people have health security with standard and quality health services, and to Encourage people to take part in taking care of health and the public health environment. 3. The healthcare products and services are to be of the quality and up to the standard of international requirement. 4. To have good governance in the public health administration. The MOPH’s strategies in pursuing the goals according to the policies are: 1. Improving the sanitation behaviour of the people and to prevent and control diseases with involvement of all concerned parties. 2. To increase the varieties and capacity of the research, including bio-medicines, Development, transfer, applications of technology and knowledge.

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3. To develop the system of health security and public health services to be holistically efficient with equal quality services for all. 4. To promote people’s involvement in developing public health, managing public health environment accordingly and efficiently. 5. To encourage innovations, develop mechanism of facilitating innovations of health Products and services, which make use of domestic resources to further enhance the Thai traditional wisdom so that the products and services are of better quality and meet the international standard. 6. To develop and improve the systems and procedures of operations of public health Management to make them better and more efficient. The devising of the public health strategic plan: The strategic plan is very important for the result-oriented management (or Management by Objectives). Therefore, the strategic plan will be designed carefully in order to conform to the desired goal and the strategy of achieving the goal of the superior operation unit, so as to achieve the goal successfully. 3. HEALTH CARE DELIVERY MANAGEMENT Health Policies for continuous improvements of economic growth and for promoting government during the “cold war” period are major drivers for expansion of public health facilities nationwide. Before 1932, main concerns of the Thai Government were only prevention services and controlling communicable diseases. Therefore a few public hospitals were established. The health policy was changed to improve access to modern medical care after Thailand changed from the Absolute monarchy state to a democratic state in 1932. However, the infrastructure of the health care system expanded slowly. In 1942, there were only 15 provincial hospitals and 343 health centers. It was until 1956 that every province had a provincial hospital and there was a regional hospital in each region to act as a referral centre of provincial hospitals. These public health care facilities were financed by government budget which was not enough. For this reason, they were allowed to keep their own revenue for run their own business. Coverage planning for public health care infrastructure was successfully done by using an administrative area approach. There were 217 and 267 grade-I health centers at the end of the first and second plan respectively. Each grade-I health centers had a medical doctor working as a permanent staff member, and took care of people at the district level. In the third plan, grade-I health centers were changed to community hospitals and government set targets to reach “one hospital for 9

every district and one health center for every sub-district (Tambon)”. It took time until the fifth plan that Thai government could achieve districts coverage. In 1993 public health centers were close to people that they could access for services within one hour by walking. However, the problem of maldistribution of health care providers among rural and urban areas still exists, and it affected equity in people’s access to care. In the public sector, the largest agency is the MOPH with two-third of all hospitals and beds across the country. The other public health services are medical school hospitals under the Ministry of University, general hospitals under other ministries (such as Ministry of Interior, Ministry of Defense). In 2004, 68.6 percent of hospitals and 65.4 percent of beds belonged to the MoPH. There are general hospitals (120-500 beds) or regional hospitals (501-1,000 beds) and few special centre/ hospitals in provincial level, community hospitals (10-120 beds) in district level and health centres in sub district areas. Health services in health centers, which mainly concern primary care, are provided by nurses, midwives, and sanitarians. Some of health centers, which are call Community Medical Unit (CMU), now have a doctor work as full time or part time staff. The lowest level is self-care and primary health care which is provided by health volunteers or people take care themselves. Currently, MoPH owns 891 hospitals which cover more than 90% of districts; and 9,762 health centers, which cover every sub-district, Tambon (Wibulpolprasert, 2008). Local governments play very limited role in health services now. However, under the decentralization act the MoPH has to transfer most of their health facilities to local government within 2010. Until now there is no concrete action plan for this decentralization. 3.1 HEALTHCARE DELIVERY MANAGEMENT DEVELOPMENT Thailand has invested to improve all aspects of the health system. This has ensured 4 out of 5 out-patients to use the community health system. However, there are still differences in the quality of the health system, particularly between Bangkok and other parts of the country. The Thai health system has been expanded to provide health care services at all levels from primary to tertiary. At the primary-care level, there are community health facilities which are easily accessed by the community, providing basic medical care, health promotion and prevention of diseases. The coverage of the primary-health care system in Thailand is widely regarded to be excellent. At present, there are over 9,000 community health centres nationwide. Every district has a community hospital, so there are over 700 community hospitals. Tertiary care consists of health facilities which are fully equipped with expensive 10

medical instruments, resources and specialized staff to provide sophisticated medical services and treatment. Recent statistics indicate that community health centres and community hospitals are the most popular source of health care and about four in five patients used the out-patient health services at the government health facilities. Ideally, a heath care system should be focused on health facilities at the primary level because the provision of health services at this level is cost effective and appropriate for the majority of the population who are facing minor illnesses. Due to their proximity to the community, primary health providers understand the socio-cultural backgrounds of the families and communities in which health services are provided. Government hospitals under the administration of the Ministry of Public Health (MOPH) also play a crucial role in providing health services at the provincial and regional levels. The significance of these government hospitals is evident in the Central and Northeastern Regions of the country. Government hospitals account for 62 percent of all hospitals in the Central Region and 85 percent in the Northeast. In contrast, the share of the private hospitals is as high as 67 percent, or around two thirds, of total health facilities in Bangkok. The second largest share of private health facilities is in Central Region, at 30 percent. The regional disparity in health facilities reflects the extent of differences in social and economic conditions in the regions. For example, the ratio of hospital beds to population is 1 to 740 in the Northeast compared to 1 to 223 in Bangkok, a factor of over three between the two regions. One possible explanation of this disparity is that there is a higher concentration of private hospitals in Bangkok than in other regions. About one in four private hospitals are located in Bangkok. Most of the Bangkok hospitals are relatively large hospitals, with over 200 beds. The disparity in health care facilities, and the importance of economic status, is also evident when comparison is made between provinces in the same region. Wealthy provinces are better off in terms of the number of hospitals and the ratio of population to hospital beds than poor provinces. Moreover, teaching hospitals and medical schools are located in a few politically and economically important provinces in each region, which contributes to the unequal distribution of health care services between Provinces. Differences in health care facilities also affect the use of health services. For instance, the number of in-patients is much higher in the provinces with a higher number of hospital-beds than lower hospital-bed provinces. In other word, access to

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health services is better in the former provinces than the latter, indicating to some extent the existence of inequities in access to health care. 3.2 HEALTHCARE DELIVERY SERVICES Health services in Thailand are classified into five levels according to the level of care, indicated as follows 3.2.1 Self-Care Level: Services at this level include the enhancement of people's capacity to provide self-care and make decisions about health. Thai people trend to realize more about their health such as reducing smoking and performing physical activity. However, self-care approach is lessening due to greater utilization of public and private health facilities. 3.2.2 Primary Health Care Level: The primary health care services include those organized by the community in providing services related to health promotion, disease prevention curative care and rehabilitative care. The medical and health technologies applied at this level are generally in response to the community's needs and culture. Service providers are those people in the area, VHVs or other non-governmental volunteers. Clearly, the services provided are close to self care and primary care service provision. 3.2.3 Primary Care Level: This level of care provided by health personnel and general practitioners (GPs). The feature of Thai primary care system, in addition to provided in health centers and community hospitals is not identified exactly responsible areas as well as is not holistic care services for the family level. The Universal Health Insurance Policy of the present government aims to develop holistic primary care services system at the family level. In the near future, the picture of holistic primary care services can have been seen. The components of primary care level units are indicated as follows: 1) Community Health Posts. A community health post is a village level health service unit established specifically in remote areas, covering a population of 500 to 1,000, and staffed by only one community health worker (a MOPH permanent employee). Services provided at this level include health promotion, disease prevention and simple curative care. 2) Health Centers. A health center is a sub-district or village level health service unit first line unit, covering a population of about 1,000-5,000, with health staff including a health worker, a midwife and a technical nurse. The MOPH is now in the process of assigning a dental auxiliary, a professional nurse, and a health technician to each large 12

health center. Services provided at this level also include health promotion, disease prevention, and curative care. Health center staff nurse health programs according to the standard procedures established by the MOPH, under the technical supervision and support of the community hospital. 3) Health Centers of Municipalities, Outpatient Departments of Public and Private Hospitals at All Levels, and Private Clinics. At these facilities, outpatient care is provided by physicians and other health professionals. 4) Drugstores. This is the primary care level that provided by pharmacist or pharmaceutically- trained personnel. 3.2.4 Secondary Care Level: Health care at this level is provided by medical and health personnel with various degrees of specialization. General and specialized facilities include the following: 1) Community Hospitals. A community hospital is located in a district or subdistrict with 10 to 150 inpatient beds, covering a population of 10,000 or more. There are doctors and other health professionals. Generally, services provided are mostly curative care, compared to those at primary care facilities. 2) General or Regional Hospitals and Other Large Public Hospitals. A general hospital in this category is equipped with 200 to 500 beds, while a regional hospital has over 500 beds and medical specialists in all fields. 3) Private Hospitals. Most private hospitals are operated as a business entity with both full-time and part-time staff, and clients are required to pay for services. 3.2.5 Tertiary Care. Health services at this level are provided by medical and health professionals, mostly with specializing expertise. Tertiary Care facilities include: 1) Regional Hospitals 2) General Hospitals 3) University Hospitals and public large hospitals belong to Ministry as Local Administrative Organization. 4) Large Private Hospitals have all fields of medical specialists. Most are over 100- bed private hospitals. The classification of health facilities mentioned above is relatively rough as a matter of fact that the tertiary care facilities also provide primary care services.

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The Thai health care system has been developing in all the dimensions listed above. The provision of health services in particular covers all levels and localities. There is a good referral system that links the different parts of the health care together to increase access to health services. In addition, Thailand has had universal health care coverage since 2001, which has resulted in excellent access to health care including access to preventative and basic medical care. The system has also provided social and financial risk protection for households. Nevertheless, coverage by some parts of the health system has remained low, including screening services such as cervical screening, high blood pressure screening, diabetics, and hyperlipidemia. This has reduced early detection and prompt treatment. Issues requiring continual development include the equal distribution of the health workforce to prevent disparities between rural and urban 3.2.6 THE WORLD HEALTHCARE SYSTEM FRAME WORK System building block ---------------------------Service delivery Healthcare worker Information Medical products Vaccines & technologies QUALITY Financing SAFETY Leadership/ governance
Source: WHO. Everybody Business: Strengthening Health System to Improve Health Outcomes: WHO’s Framework for Action. 2007. Geneva, World Health Organization.

overall goals/outcomes ------------------------------ACCESS COVERAGE improved health (level and equity) responsiveness social and financial risk protection improved efficiency

Areas and between cities where social, economic and political differences exist. Health providers and medical technologies are highly concentrated in big cities rather than small towns and rural communities. The government should take measures to strengthen the motivation and status of health providers working in disadvantaged rural communities. At the same time, the government should conduct cost-benefit analyses of medical technologies, particularly diagnostic and therapeutic, including cost and distribution. The quality and safety of health care, including incidences of medical errors, is an important factor in the survival of patients. Statistics from 14

hospital records reveal that 35 percent of deaths in the hospitals result from medical errors. About half of the errors can be prevented. Emphasis should be placed on improving adherence to hospital-acquired infections standard. National health expenditures have increased significantly, from 147,837 million baht in 1995 to 248,079 million baht in 2005. Curative care accounts for about three quarters of total health expenditures, compared to only 5 percent for prevention and health promotion. The proportion invested in health promotion and disease prevention programs should be increased. Thailand has a relatively good health information system, which leads, to some extent, to evidence-based policy formulation. However, improvement in the Information system is needed, particularly in relation to the coverage and timeliness of data. 4. .HEALTHCARE FINANCING MANAGEMENT IN THAILAND The amount of money spent on health, per capita increased by 1.6 times, increasing from 2,486 baht in 1995 to 3,974 baht in 2005. The majority of the increase has been for hospital care rather than for health promotion. During the previous decade, health expenditure in Thailand increased dramatically, rising from 147,837 million baht in 1995 to 248,079 million baht in 2005, an average annual growth of 6.6 percent which was similar to the annual Gross Domestic Product growth rate of 6.4 percent. As a percentage of Gross Domestic Product, Total Health Expenditure was 3.5 percent in 1995, reaching 4 percent in 1997, the year Thailand faced an economic crisis. After the crisis the ratio decreased to be 3.3 percent in the year 2001. After the Implementation of the Universal Coverage Scheme the ratio increased and reached 3.7 percent in 2002 before stabilizing at 3.5 percent GDP by 2005. Per-capita health expenditure rose from 2,486 baht in 1995 to 3,974 baht in 2005, a 1.6-fold increase during the decade. Thailand has expanded health welfare in order to reduce household spending such as the Free Medical Care Scheme for the Poor, the Low-Income Card, the voluntary Health Card Scheme and the Universal Health Care Coverage Scheme in 2001. After 2002 till 2005, public-financing agencies played the major role at 6364 percent of total health expenditure. Of this, the household expenditure declined from 43 percent in 1995 to 27 percent in 2005 of the. Considering health functions, health expenditure dominantly spent for curative services at three quarters; resulted in only 5 percent of total health expenditure were for preventions and health promotion services in 2005. This implied that government spending on health would be affordable in the long run. One of policy message is that Thailand should invest more, 15

especially significantly increase in investment on health promotion and disease prevention program which should be used for cost-effective interventions. One main challenge of health care financing in Thailand, especially the UC scheme, is the affordability and sustainability of the government subsidy. 4.1 FINANCIAL RESOURCES FOR HEALTH CARE IN THAILAND The government’s financial source has been the biggest funding source of the MOPH, yet during the years 1980 – 1989, the allocated budget decreased from 29.9 percent in 1980 to 19.7 percent in 1989. However, after 1989 the government’s allocated budget for the MOPH started to rise again and reached 37.1 percent in 1997 and 63.4 percent in 2003. It is due to the fact that during the said period, Thai economy started to recover, the economic growth was steady and rapid plus the government’s policy of human-cantered development. Efforts were put into the health insurance to cover all people and promote good health for all. Budget allocation for public health increased from 4.2 percent in 1989 to 7.7 percent in 1998. However, after the Financial Crisis, the government had to lower the budget allocation in order to comply with the IMF agreements. In 2001, the budget allocation was 6.7 percent of the country’s total budget. It is seen that the budget for MOPH were quite high in the past decade. Budget data shows that during 1969-01, the allocation was about 2.7 – 7.7 percent of the total country budget, or about 0.4 to 1.0 percent of the GDP. This is because the foreign debt burden and the budget for security have decreased, until the outbreak of the Financial Crisis in 1997, which has hiked the foreign debt from 5 percent in 1997 to 10.9 percent in 2001. The MOPH, consequently, has been allocated lower budget, in the fiscal year 2001 - 58,692.2 million baths plus another 2,400 million baths from the Health Insurance Funds, totaling 61,097.2 million baths, or about 6.7 percent of the total country budget. In the fiscal year 2003, MOPH received 69,133.94 million baths or 6.915 percent of the total country budget. However, in term of real value of the budget, it is found that the 2001 budget was lower than the 1996 budget. It is noteworthy that during 1997 to 2001, there was a lot of foreign loan. In 1997 the loan was 1,360 million baths, 1998 =1,360 million baths, 1999 = 3,560 million baths, 2000=2,360 million baths, and 2001 = 446 million baths. From the perspective of expenditures, it can be seen that about 31-53 percent of budget was for the salary, 28-50 percent for the operation, while a portion of investment was dependent on the economic situation i.e. about 11-39 percent. The Private Financial Sources: initially, private sector was the largest financial source for 16

the public health financing. Since the coverage of the health insurance has not been 100 percent, 30 percent of the population is without health insurance. This suggests that these people are to pay for their healthcare. Also, Thai people are used to taking care of their own health, like buying one’s own medicine, when sick. This suggests that the household financial source for the healthcares is very important in the MOPH’s determining the provision of public health services. In Thailand, total health expenditure was around 3.5 percent of GDP in 2003. Public health expenditure of total expenditure on health was 63.4 percent in 2003, whereas private health expenditure of total expenditure on health was 36.6 percent during same period. The financial sources from the households in healthcare account for 73.9 percent of the total health care expenditure. In the year 1989, the households’ contribution to the health care increased to 80.1 percent due to the fact that the government had reduced public health budget, resulting in increased financial burden on the households in taking care of their health. After 1989 until the 1997’s Financial Crisis, the household’s financing health has a decreasing trend i.e. 62.9 percent, but it increased to 66.8 percent in 2000.In the future, the economy is expected to be better and thus the government will be able to provide more financial support for the public Health plus the policy of public health reformation, which aims to increase the health insurance to cover every one and improving the quality of the public healthcare establishments and services. More people are expected to use public health services, instead of buying their own medication. This also contributes to the decreasing trend of household’s healthcare spending. The financial aids from abroad: it is found that the foreign health financial aids tend to decrease, from 1.44 percent in 1980 to 0.15 percent in 1990, and the decrease propensity is continuing to be 0.14 in 2000. On the contrary, Thailand is now becoming a financial aids provider rather than a receiver. In the efforts to heighten the public health insurance, the MOPH, as the principal responsible agency, has pushed forwards many programs to respond to the government’s policy. One of them is the program of 30 baths for Every Disease, which started in the April of 2001. It has begun with the participation of the MOPH healthcare establishments by launching a pilot program in 6 provinces covering 1.3 million eligible people. the program was expanded to the 75 provinces and some districts of the BKK Metro with participation of 1,017 government healthcare establishments and 103 private establishments covering 38.8 Million rightful people. In April of 2002, the program of 30 baths for Every Disease has successfully covered 17

all the districts of Thailand with 45 million eligible people under its coverage and participation of healthcare establishments in all the covered districts. As a result, the rightful people now have easier and cheaper healthcare access. Further, the MOPH also encourages people to have their own families’ dedicated healthcare establishments, which are near their homes by allowing people to register their choices of their dedicated healthcare establishments at their nearby Community Health Centres. Regarding payments for the “Health Insurance for All” project, the Office of the Permanent Secretary of MOPH will be responsible for allocating the fund to each Provincial Public Health Office according to its population size. The Provincial Public Health Office will in turn allocate the fund to each of its healthcare establishments, according to its population size. Total health expenditure (2005) Indicator 2002 200,768 The % GDP 3.68 Public financing agencies% 63 Out-of-pocket 28 Other private financing 9
The million baht agencies % The baht per capita

2003 210,368 3.55 63 25 12 3,335

2004 225,652 3.47 64 26 10 3,641

2005 248,078 3.49 64 27 9 3,974

3,197

Source: national health accounts in Thailand – 2005 5. ORGANIZATION OF THE HEALTH SYSTEM IN THAILAND The organizational structure at the central level of the MOPH consists mainly 3 task clusters, described below: 1. The Office of Permanent Secretary of MOPH is responsible for the drafting of

policies, plans, and supervising, monitoring and appraising the outcomes of the operation units of the Ministry. It also administers to ensure that the execution is in line with the law, undertakes legislation of laws regarding the health establishments and other related affairs and is also responsible for the production and development of public health personnel. 2. The Task Cluster for the development of medicines is responsible for the development of medical science, the therapeutics and recovery of potency, development and transfers of medical knowledge and technology for therapy and recovery of health. The cluster is also responsible for establishing healthcare standard, and developing alternative medicines for the provision of quality public 18

health services to the public for the purpose of good mental and physical health of the people. The Task Cluster comprises 3 departments - the Department of Health, the Department of the Development of Thai Medicines and Alternative Medicines and the Department of Mental Health. 3. The Task Cluster for development of Public Health is responsible for the development of public health science for promoting health, controlling and preventing diseases, research and development of knowledge and technology, transfer of knowledge for promoting health and controlling and preventing diseases for the purpose of good mental and physical health of the people. It comprises 2 departments - the Department of Disease Control and the Department of Health. 4. The Task Cluster of Health Service Support is responsible for supporting the public health service providing units, the systems and mechanism facilitating public health service provision and the public health system. They are also responsible for administering the protection of consumers of healthcare services and drug products for the purposes that the general people can take care of their health efficiently and receive standard and quality health services and products. The Cluster consists of 3 departments - the Department of Service Support, the Department of Medical Science and the Food and Drug Administration. The organizational structure of the regional agencies which are under the administration of the Office of Permanent Secretary of MOPH, consist of Provincial Public Health Offices, hospitals, Public Health Offices, the PCUs and the community clinics. The above agencies are the major healthcare service providers who help the people promote health, control and prevent diseases, and provide medical treatment and recover health. They utilize the knowledge and technology that have been developed and transferred from the technical Department and adjust and apply them appropriately according to the specific requirements of their regions. The organizational relationship between the technical Department at the centre and the regional public health operation agencies is basically staff relationship in which the centre provides support to the regional agencies. For healthcare at the primary level, there are the PCUs providing the services within the scope of Tambon and village. They are responsible for arranging a suitable aggregate of health services for the rural people in their responsibility areas which normally have 1,000 – 5,000 people. There 19

are fulltime public health personnel stationed at the public health units such as Sanitation Officers, Midwife Nurses and Technical Nurses. In addition, Dental Officers, Technical Nurses and Public Health Officers are also working there. Public Health Offices are responsible for the assistance, supports, supervision, monitoring and appraisal of their accomplishments. 6. PRIMARY HEALTHCARE MANAGEMENT ROLE IN THAILAND Thailand has a long history of primary health care (PHC) development which started before the Declaration of Alma Ata in 1978. The National PHC programme was implemented nation-wide as part of the Fourth National Health Development Plan (1977–1981) focusing on the training of ‘grass-root’ PHC workers consisting of village health communicators and village health volunteers. Since then PHC has evolved through many innovative health activities: community organization, community self-financing and management, the restructuring of the health system and multi-sectoral co-ordination. Many of the essential elements of PHC have been achieved. Improvements in the nutritional status of children under five households accessibility to clean water, immunization coverage, and the availability of essential drugs have been observed. PHC has been successful in Thailand because of community involvement in health, collaboration between government and nongovernment organizations, the integration of the PHC programme, the decentralization of planning and management, intersectors collaboration at operational levels, resource allocation in favor of PHC, the management and continuous supervision of the PHC programme from the national down to the district level, and the horizontal teaining of villagers to villagers. 6.1 Conceptual Model of the Primary Healthcare in Thailand Public policies specific government programs may be formulated analyzed and evaluated without necessarily taking into account the actual organization. Interest group further strengthening of the basic health infrastructure to support PHC. A system of ‘family health facilities’ which will be the ‘facility for each family’ and work with the community and family to improve health related risks and addressing all new diseases. Ups, this analytical framework is based on two conceptual models of the implementation process (voradej chandarasorn 1999) 6.2 Management Model

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The model hypothesizes that success of an implementation depends upon the capacity of responsible implementing organizations the ability to implement policies, therefore, may be hindered by the following factors 1. inappropriate design of organization and work systems 2. inadequate and poorly trained staff 3. the agency’s inability to deploy the personnel to their appropriate place 4. under utilization of resources as well as the utilization of resources in the wrong direction Apart from the aforementioned model and theories, this study also benefits from review of related literature in particular the primary healthcare development for rural villages require a new management approach. The approach stipulated that. 1. Basic healthcare services could be delivered most cost-effectively if integrated 2. The demand for medical care services could be met, to a great extent, by up grading existing healthcare personnel to be clinically competent Para physicians 3. The need for healthcare promotion and disease prevention services could be more broadly and effectively met through community participation. The approach proved to be a successful one. Under its guidance primary healthcare development and personnel development a number of innovations and modifications of the existing healthcare system which constituted. 1. reorganization and strengthening of the primary healthcare services Infrastructure by (I) integrated curative, disease prevention, and healthcare services by coordinating and administration them a single primary healthcare administration. (ii) Establishing a department of community healthcare within the primary healthcare hospital (iii) Improving management and supervisory practices in part by developing a practical management healthcare system. 2. Development of community healthcare from existing healthcare services personnel, to be deployed to every district hospital and sub- district healthcare centre 3. Development of community healthcare volunteers in every village including training of a village healthcare volunteers in every village, 21

4. Stimulating other community and private sector involvement by establishing healthcare committees in every village and at every administrative level, and by eliciting the interest and support of other private sector group. 7. STRATEGIES FOR IMPLEMENTING PRIMARY HEALTH CARE In 1998 twenty years after the conference in alma-ata, WHO sponsored a follow up meeting in ALMATY, Kazakhstan to explore new strategies to achieve health for all in the 21 century. Participants described sustainable healthcare gains resulting from the implementation of primary healthcare in many regions, but inadequate progress in other areas where there had been deterioration in health statues. They concluded that the PHCs approach had resulted in considerable improvements in health outcomes. They recognized inconsistent implementation as a key challenges, and identified the following prerequisites (WHO 2000b) for effective primary healthcare 1. supportive national healthcare policies with long term commitments 2. decentralized responsibility and accountability 3. acceptable conditions for health worker 4. financing to assure access for the poor 5. continuous efforts to improve quality 6. community empowerment and participation 7. sustainable partnerships These elements when combined in a continuous cycle of planning implementation and monitoring. Can be used to steer a health system towards better performance. A variety of additional strategies will enhance the delivery of primary healthcare. They include community oriented primary healthcare and improving collaboration among stakeholders. 7.1 Community Oriented Primary Healthcare Community oriented primary healthcare is a systematic approach to improving primary healthcare services through integrating clinical medicine with public health at the community level (kark 1998, Abramson 1998) this involves sequence of related activities that include 1. defining a community by geographical, demographic or other characteristics 2. determining the health needs of the community in systematic manager 3. identifying and prioritizing healthcare problems; 4. developing programmes to address priorities within the context of primary healthcare 22

5. assessing outcomes 7.2 Uniting Stake holder’s through Partnership Primary healthcare is also enhanced by sector wide approaches that unite key players. Such as development banks, donor organizations and government agencies, around shared goals and collective responsibilities. The assumption underlying this approach ins that better use of available funds is likely to occur when healthcare services delivery policies are developed jointly among involved parties and when those policies are then reflected in consistent resource allocations and institutional framework (cassels 2000). 8. Financing Primary Healthcare Services in Thailand The implementation of government healthcare policies and health initiatives will only succeed when health care systems are rationally funded to achieve priority objectives. Apriority goal of primary healthcare is to provide easy access to essential healthcare services for all with as few financial barriers as possible. A limited number of physician payment options exist in any country or healthcare system. They include fee for services. Salaries, capitation payments, integrated capitation and combination payment systems. While the advantage and disadvantages of each option may vary depending on social and cultural considerations particular to given country. Some generalizations about the main system of payment can be made. In healthcare system financed by free-for service payments, patients are usually not registered with specification primary healthcare. In addition free-for-services payments may be associated with relatively higher payments for diagnostic studies and medical procedures but relatively lower reimbursement for cognitive services such as counseling and education which characterize the practices of family doctors, healthcare system that principally use fee-for- services payment have experienced spiraling costs resulting from the unrestrained incentive to pay for any services provided. 8.1 Strategies to Improve Primary Healthcare Services • • • provide sufficient funding to support a strong primary healthcare infrastructure minimize financial barriers to essential healthcare services provide financial and other incentives to attract family doctors to increases of greatest need

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• •

use a combination of payment methods to support and reward high quality comprehensive, equitable primary healthcare services measure performance and provide incentive for targeted services such as prevention

8.2 Supporting Primary Healthcare Research Consistent with breadth of primary healthcare, primary healthcare research encompasses a broad range of topics including producing in isolation (Van weel 7 knotterus.2000) Examples of research that can best be done in primary healthcare settings include 1. epidemiology and natural history of common primary healthcare services problems 2. effectiveness of diagnosis and treatment of healthcare problems in primary healthcare 3. methods to improve the integration of community primary healthcare with secondary and tertiary care 4. the relevance of evidence based medicine and treatment guidelines for primary healthcare patients with multiple problems and in different care settings 5. methods to integrating preventive services with ongoing illness-oriented care 6. reduction in errors and increasing patient safety in primary healthcare 7. determinants of patients physician satisfaction in primary healthcare 9. PRIMARY HEALTHCARE EFFICIENCY The Thai health system is very efficient when compared to other developing countries, particular for primary health care and health insurance. The Thai health care system’s efficiency of resource use can be determined by comparing the reduction in the child-mortality rate (death among those aged under 5 years) compared to total health expenditure per capita. Scaling up primary health care (e.g. universal coverage of immunization and skilled birth attendance) while creating a health system with low inequity are likely to be the main reasons for such efficiency achievements. The primary health care system plays a pivotal role in health achievements and efficiency improvements of the Thai health care system. Contracting the district-level health providers to provide primary care and close-to24

client services for Universal Coverage beneficiaries is an important means of ensuring efficient and rational use of services while ensuring proper referral systems. The transport costs incurred by households using these close-to-client services are also much lower. When the majority of Universal Coverage members who are poor and residing in rural areas can actually exercise their rights in using a comprehensive range of services provided by the primary health care network, it results in equity in health service use and efficient use of public resources. Using fee-for-service reimbursement to pay health care providers of the Civil Servant Medical Benefit Scheme sends a strong signal to healthcare providers who are supreme commanders of health resources to provide more diagnostics, medicines, and probably unnecessary medical treatment. Empirical evidence consistently confirms Civil Servant Medical Benefit Scheme beneficiaries receive more branded and more expensive medicines than beneficiaries in other public health insurance schemes. Moreover, evidence shows that Civil Servant Medical Benefit Scheme beneficiaries have higher hospital admission and greater cesarean section rate than other schemes. It is found that even though Civil Servant Medical Benefit Scheme finances five times higher per capita, clinical outcome is more or less similar to beneficiaries of the Universal Coverage scheme. 1. In the Thai health care system, the problem of over-use of medicine, especially expensive antibiotic drug and new medical technologies is not only found with the Civil Servant Medical Benefit Scheme, but it is also evident in health service provision of private for-profit health care providers. The limited capacity of the government to regulate private for-profit providers facilitates inefficient use of public and private health resources. 2. The 10th National Development Plan of Thailand makes policy recommendations for improving efficiency in public health resource use: 9.1 Primary healthcare equity The investments in health have enabled greater numbers of Thais to receive health care. This is especially the case for poor people who are able to gain hospital care as a result of the Universal Health Insurance scheme. Everyone has clearly seen this improvement. Infant mortality is an indicator of the quality of health care. Among poor families the infant mortality rate has fallen from 40.8 per 1,000 births in 1990 to 23 in 2000. Thailand has made marked improvements in health equity due to the expansion of the health insurance coverage provided by the three major public health 25

insurance schemes. The Civil Servant Medical Benefit Scheme covers around six million government employees and their dependants; the Social Security Scheme protects approximately nine million employees in the formal sector from non-work related health care expenditure; and the Universal Coverage scheme covering approximately 47 million people (75 percent of the entire population) who were not previously beneficiaries of the Civil Servant Medical Benefit Scheme or the Social Security Scheme. During 1992-2006 the poorest of Thai households spent, on average, a higher percentage of their household income than the richest. Nevertheless, inequity in health spending has improved because the proportion of household spending on health to income of the poorest. Significantly decreased from 8.17 percent in 1992 to 2.23 percent in 2004, whilst that of the richest has slightly decreased from 1.27 percent in 1992 to 1.07 percent in 2004. The pattern of health service use also indicates greater equity. For instance, the increase in utilization of primary care and secondary care levels of the lower income quintiles lead to a significant improvement of equity in ambulatory service use. Despite the above mentioned improvements within the Thai health system inequalities still exist between different socio-economic groups. The rich-poor mortality gap in under-five mortality rates (U5MR) still occurs. Furthermore, the survey of self-reported health assessment by the National statistical Office and International Health Policy Program, 10. Changing of health service administrative structure In the past few years, many changes have occurred in the administrative structure of health in Thailand. New autonomous organizations, with separate management board have been set up by the law to take over various important responsibilities from MoPH. Whether the new structure could create more efficiency of the health system needed to be closely followed up. 1. The Office of Health Promotion Fund, established as an autonomous agency under the Prime Minister, manages the 2% earmarked ‘sin tax’ imposed on alcohol and cigarette. The office has since become the major agency in providing funding to various organizations in society for health promotion activities. Practically, the health promotion budget was shifted from the MoPH. 2. Office of National Health Security, established as an autonomous agency under MOPH, with separate management board, manage almost all the health

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service budget which used to be under the MoPH. Whereas the MoPH still maintain the administrative power over the health facility management. 3. The National Heath Commission Office, established as an autonomous agency, under the Prime Minister in 2007. The responsibility of the office is to get broader participation in health policy formation through support of national and local health assemblies. With all these changes, the good system of work is needed to be in place for good coordination among stakeholders. Careful management during the transitional stage will prevent organization conflict and guarantee future collaboration. The present economic situation in Thailand is much different than the health situation when PHC was introduced to the country. Implementation of PHC in the next decade should be derived from lessons learnt and new initiatives to meet the socio-cultural and economic growth. The continuous trend of decentralization and community empowerment are essential factors that should be taken into account in moving forward. The establishment of the sub district administrative authority to be the local body for community development is the major milestone for community self reliance. Community organization, and people themselves will have more potential to undertake the most innovative schemes for social development. Thus PHC management and implementation should be decentralized to the sub district Administrative Organization which is closely linked to existing PHC program. To ensure the continuity, the sustainability and the true spirit of PHC, future activities should be initiated as follows: 1. Strengthening of the sub district administrative authority committee in Health planning and management. 2. Establishment of basic health package, quality standard of health care and facility, practice guidelines and people’s right in health. 3. Establishment of PHC Collaboration Center to coordinate all related organizations to bring about multidisciplinary supports for empowering sub district Administrative Organization in health management. 4. Redefine the roles of VHVs in the context of community self reliance in health. With the vast experience, VHVs could be the important human asset in the community in health planning and management. 5. Further support the movement from ‘VHV’ to every household and every individual’s capacity for health development. This must also be done not only through 27

the actions from the MoPH, but using public media as well as overall community development supported by the Thai Health and the National Health Commission. 6. Further strengthening of the basic health infrastructure to support PHC. A system of ‘family health facilities’ which will be the ‘facility for each Family’ and work with the community and family to improve health related risks and addressing all new diseases. 7. Further strengthening of intersectoral movements on health including Healthy Public Policy/HIA and decentralization of health facilities. 8. Further strengthening of health equity through continuous reform of the Universal Coverage systems. 11. CHALLENGES FOR THE FUTURE OF PRIMARY HEALTH CARE National governments and the international community are renewing their efforts to expand access to PHC and they have committed a lot of financing for this purpose. But there have been many major changes in these last three decades that pose big challenges for the future of PHC. The drafters of the Alma Ata Declaration drew largely on the experiences of those post-revolutionary and post-colonial regimes, which were rapidly overcoming a lack of health facilities, health workers and drugs. Whilst some remote areas still lack health services many settings have both trained and untrained people, providing health care and selling drugs. The boundary between public and private sectors is blurred and government health workers frequently ask for informal payments or see patients privately. Many of these activities occur outside an organised, regulated framework of health care provision. Potential users are much more likely to live near a health facility or some kind of provider than 30 years ago, but now they face major challenges in paying for care and finding competent providers and effective and appropriate drugs. PHC was designed to deal with prevention/health promotion and with infectious diseases associated with poverty, poor sanitation and certain insect vectors. Although these illnesses persist, there is growing pressure on health systems to address other problems. People are also affected by other chronic conditions, associated with ageing and “lifestyle” changes. This raises difficult questions about which treatments are appropriate, who should pay for them and how health systems should be organised to help people manage long-term conditions. Concern is growing about the potential threat of epidemics of new diseases or organisms resistant to the available drugs. Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza 28

pandemic. Government responses rely heavily on convincing people to report suspicious outbreaks and cooperate with public health measures they may perceive to be against their short-term interest. This requires high levels of trust between the population and their health system. More actors are involved in health systems than thirty years ago, including a variety of private providers of health-related goods and services, national and international NGOs, citizen advocacy groups and political parties (where competitive electoral politics have been introduced). Governments are seeking new ways to influence health systems with their powers to allocate money, enact and enforce laws and publish information. This sometimes involves new types of partnership for service delivery and regulation. Finally, there have been dramatic developments of new technologies for diagnosis and treatment of disease, which influence the design of health systems. In addition, the rapid changes in information and communication technologies are having a big impact. Providers and users of health services increasingly have access to the mass media, mobile telephones and the internet. They carry health information produced by governments, professions, citizen advocacy groups and private companies. In contrast to 30 years ago, when health professionals were the major source of expert knowledge, people have a variety of sources from which to find information. The anniversary of the Alma Ata Declaration provides a good opportunity to reaffirm national and international commitments to expand access to PHC. But, it is important to understand the changed context when formulating strategies for achieving this. Many innovations have emerged that involve quite different roles for governments, markets, civil society and individuals than the drafters of the Alma Ata Declaration envisaged. We need to find ways to involve all actors in an intensive process of innovation and learning if the latest statements of good intentions are to be translated into major improvements for poor people. 12. Health System Strengthening using Primary Health Care Approach Thailand has achieved universal coverage of healthcare since 2002 by the Implementation of Universal Healthcare Coverage (UC) Scheme. At present, three main public health financing schemes cover the entire population. The Social Security Scheme (SSS) covers formal sector employees while the Civil Servants’ Medical Benefit Scheme (CSMBS) covers government employees and their dependences. The

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rest of population is covered by the UC Scheme. The main objectives for universal coverage are as follows:

1. Equity: An equal sharing of health care expenditure and equity of access to the
same quality of health services.

2. Efficiency: Efficient use of resources by good administrative and management
practices.

3. Choice: People have the right to choose their health services in order to reduce the
problem of an imperfectly competitive market.

4. Good health for all: Universal healthcare coverage aims not only to provide
curative care but also to provide disease prevention and health promotion where appropriate.
Thailand’s health financing system: Summary through PHCs CSMBS SSS Population groups covered Government employees, Private employees public sector workers and dependents Estimated population coverage in 2004 (as a % of total population of 65.1 millions) Financing Source of financing Financing agent provide payment method health expenditure per capita General tax Ministry of Finance (MOF) Fee for services and DRG 3,800 baht 4.5% Social Security Office Capitation 1,830 baht general tax and co-payment national health security office (NSHO), MOPH 10.0 % 11.2 % 30 BHAT SCEME Self-employed and the rest of the population not covered by CSMBS and SSS 78.8 %

Capitation. of 1414 bhat Notes: * Health and Welfare Survey (HWS) 2004, National Statistical Office (NSO) ** From 2004 on, the contribution rate has been adjusted from 3% with 1% each of the employee, employer and government *** Estimated by Simins, health expenditure per capita of the 30 Baht Scheme in 2004 is 1,614 baht

The Thailand Ministry of Public Health has been examining the possibility of this idea for several years. Based on research, discussions and brainstorming sessions, the ideal universal coverage health system should have the following characteristics:  Easy access and simplicity in order to benefit from this programme.  People should be the part of the ownership, overseeing, access and cost sharing of health services.

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 The universal healthcare coverage should reduce the problem of overlap and inequity of healthcare schemes.

 It should be a transparent system. The providers, consumers and third parties/
payers/ purchasers must be able to check easily the effectiveness, and the administrative power should be balanced among the three partners.  There should be efficiency and equity of budgeting, planning, and development of the health services based on evidence and information.  It should have appropriate methods of co-payment  It should institute a reasonable role for insurers in order to pool the risks.  Lastly, it should be a accountable, reliable and accepted scheme. From the above, the Universal Coverage Committee has suggested the three possible alternatives toward universal health care coverage, as follows: 1. Expansion of existing systems Now a days, there are several health insurance/welfare schemes in Thailand, for example, Voluntary Healthcare Card Scheme, Civil Servants Medical Benefit/Welfare Scheme (CSMBS), Social Security Scheme (SSS; compulsory scheme for formal sector) and Health Welfare for the low income group, the elderly, children under 12 and other underprivileged groups. Although these schemes have covered various population groups, they have not yet covered 100% of the total 60 million Thai populations. Besides, there are still some weaknesses in terms of efficiency and equity.. If we expanded the previous schemes to become universal health coverage, the study would need to:  Set the universal standard regulation for health for all.  Change their philosophy to offer health schemes of greater similarity.  Readjust the legislation related to health insurance, especially private health insurance.  Adapt a registration information system.  Organize the payment mechanism and reimbursement standard to operate in the same direction.  Set a more appropriate accreditation system and consumer protective system. The expansion of the previous health schemes would be cost saving from the adaptation in the initial stage and would not greatly affect the structure of government services. Furthermore, another strong point is the comparability between health 31

schemes. However, these advantages cannot be used for adaptation because of their existing limitations, for instance, the basis of their capitation and their philosophy. There are several weaknesses of the expansion concept. Firstly, there is inequity in health care access and financing systems between the differing health schemes. Secondly, there are differences in health cover efficiency because each scheme is an individual independent system administered by different Ministries. Some schemes are mandatory, other are not. Still many people are not eligible for insurance. Yet, some people may belong to more than one health scheme to provide necessary gap coverage because of practical difficulties on both consumer and provider sides. Lastly, some commercial groups may oppose and try to block the legislation to make possible the necessary changes seen as blocking their benefits. 2. Single-payer system The philosophy of this system is a national health insurance, which is managed by government. This system is suitable for starting when there are no existing health insurance schemes. In this system, the government can organize health legislation so all people can access the same basic health services, with pooling of risks for providers and vertical equity of health financing. The difficulty in a country which already has health insurance schemes is in the transition stage and the question of how to integrate all existing health insurance schemes together, since each scheme has their own funding, concept, package and payment methods. The strength and weakness of the single-payer system should be analyzed in three parts, namely equity, efficiency and choice/quality of system. The strong point lies with equity, in that all people can access in the same basic of health services. With respect to efficiency, such a system can reduce the adverse selection problem, reduce the overlap/gaps between previous health schemes and introduce a standard to administration and to information systems. Lastly, with respect to choice and quality of care, it offers a way to stimulate the providers to compete with each other in order to increase the quality of services. A weakness is that, if the administration of the legislation is not adequate, it will lead to equitably poor care. This system would possibly fail if the administration were not appropriate since it is based on a centralized funding system. Moreover, there is no competitive pressure to help maintain adequate quality or contain the budget.

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3. Dual health insurance system for formal and informal sectors In this system, there is a parallel between the formal sector, (e.g. civil servant and state enterprise officers health insurance) and the informal sector (e.g. farmers, selfemployed, elderly, monks children health insurance). For the formal–sector health insurance, the methodology is the same as previously, but it should expand to include spouses and children less than 18 years in the Social Security Scheme. The system of Civil Servant and State Enterprise Medical Benefit Scheme should change to the same direction as the Social Security Scheme with respect to part contribution to funding. The informal-sector health insurance should be managed under the universal health fund with support of government, locality organization and resident co-payment. Poor groups may need to be exempted from co-payment. A strong point of this system is that, by reducing the weakness of the single payer system, for example, it can be compared with each existing health schemes and adjusted accordingly to save costs and to improve the system. However, even though this system seems to be appropriate, it still has some weaknesses. Thus, it might encompass some of the inequity and inequality in benefits and budget present in the existing health schemes. Secondly, the lack of administrative experience in the informal sector funding may lead in the initial stages to overlap of benefits to the families of formal sector health insurance recipients. Lastly, it is very difficult in the political and administrative sense to bring each system of funding together. In summary, the study has suggested that the appropriate way to move towards universal health care coverage is to start from the dual health insurance system for formal and informal sectors before leading to the single-payer or national health insurance in the future. The government launched the 30 Baht health policy. The first phase was established in six pilot provinces - Nakhonsawan, Phayao, Patum Thanee, Samut Sakhon, Yasothron and Yala in 2001. The insured are all of the people who were not in any health scheme and whose names are in the house registrations in those provinces. These people would receive the universal health card or the gold card. This card must show consistency with the individual’s identification card every time they access the health services, which are the government health services or the private sector health services registered with this project. The accessing health service has to follow the referral system from the primary health center or the nearby hospital, which are registered under the project. For emergencies and accidents, the insured can access 33

any government health services. To access needy health services, the insured must contribute a co-pay of 30 Baht per episode. Under this 30 Baht Universal Coverage Policy, the insured will receive the same quality health services as offered by other health schemes. At present, the service package includes most health services except cosmetic care, obstetric delivery beyond two pregnancies, drug addiction treatment, hem dialysis, organ transplantation, infertility treatment, and other high cost interventions. However, with more resources and disease priorities, the inclusion can expand further over time. From the government side, the funding of the system is paid by capitation. The total payment per capita paid from tax revenue is 1404 Baht per year, parts of which are paid to the health care facilities, according to the number of local residents who are registered with them, hence to be served. This capitation includes the costs for the curative, preventive, promotional care as well as the administration. It can be divided into  574 Baht for out-patient care  303 Baht for in-patient care  175 Baht for prevention and control of diseases.  32 Baht for high cost care. This amount of money will accumulate in the central office of budget. In the case of high cost care, such as neurosurgery, cardiac surgery, chemotherapy, radiotherapy, etc, the reimbursement can be done by following the price schedule.  25 Baht for emergency and accident care. The system is the same as for high cost care.  88 Baht for structural investment. This money will accumulate at the central level and will be distributed to the healthcare facilities in the appropriate way.  10% of the total package for central and regional administration, developing the information system and quality assurance.

 10% of the out-patient and in-patient services budget for contingency funds. There
are some criticisms from experts, which can be summarized as:  Loss and bankruptcy of services. In the next 5 years, some hospitals would face the bankruptcy problem and will have to shut down. This problem may occur due to inadequate hospital management of the budget. Moreover, this problem may occur from adverse patient distribution, for example, some hospitals have a high percentage of chronic patients, which is costly. 34

 Quality of services. Quality of care is still a questionable problem for many experts. As in the past, there are still some criticisms of the health care quality in some health schemes, such as the low-income card or Social Security Scheme. At this point, the government is attempting to compel all hospitals to participate in the Hospital Accreditation Programme to provide assurance of the quality of care. Presently, a Clinical Practice Guideline is now being developed to assure the same quality of services.  Lastly, this system is criticized in regard to the role of the locality in administrative decision-making. In this context the government still has not set up tangible methodology. 13. Financing Policies to Achieve Universal Health Care The national objective for health care during the period 2006 to 2010, as set by the WHO is: “To renovate and improve quality of people’s health protection and care to meet the requirement in the human development strategy”. The document also specified tasks related to health financing, emphasizing increases in Government budgets for the grass-roots-level health-care system and preventive health care as well as support for access to health services by social policy beneficiaries, the poor and low-income groups. In parallel, with revision of the user-fee policy in the principle of identifying full costs of health care, the Government would support user fees for the poor and social policy beneficiaries, 13.1 Public Health Care and Protection Strategy in the 2001-2010 In order to achieve the objective of universal health-care provision, the following resolution on health financing was introduced in the Strategy for the People's Health care Protection. 1. State investment for the health-care service shall take the lead in revenues for the health sector. Efforts will be made to allow higher regular expenditures for health service from the total State budget. Priority shall be given to poor, mountainous and remote areas, focusing on preventive services, traditional health services, maternal and child health care and primary health care in local medical units, providing health services to the poor and priority targets. 2. Hospital fees shall be adapted in accordance with costs incurred, level of investment and affordability of the public.

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13.2 Universal Health Care Coverage Policy (30-baht Policy) The fragmented funding and provision of health care made it difficult to provide equitable services, and contributed to inefficiencies and variable levels of quality of care. The implications of reform of the Thai health care system were taken into consideration by the government in 2001, with regard to financing, delivery of services, and consumer rights. The main objectives and characteristics of the Universal Health Care Policy are: universal coverage, single standard, and sustainable system. To ensure the effectiveness of the system, strong emphasis has been placed on both resource and technology efficiencies, underpinned by adequate and stable budget allocation to secure the system’s financial affordability. Legislation was initiated so as to ensure policy sustainability. The government drafted a pertinent law, the National Health Security Act, which was duly enacted in November 2002, to ensure sustainability in terms of policy, financing, and institutional support. 13.3 Implementation of the Universal Health Care Policy In its start-up phase, beginning in April 2001, the “30-baht Universal Health Care Policy” covered six provinces. Coverage was expanded to include 21 provinces, as of June 2001, followed by its expansion, in October 2001, to all but one province. Finally, the province with the capital city of Bangkok was included, in January 2002. As of December, 2005, a total of 47 million people were covered by this scheme. The remainders comprise eight million people who include civil servants and their dependents (spouses, parents, and children) and eight million workers covered under the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Health Insurance Scheme (SSS), respectively. The above three schemes differ with regard to eligible population segment, services provided, and financing as well as payment systems. As funding mechanism, a capitation grant was chosen to finance the UC scheme. A capitation grant based on a rate of 1,202 baht per registered capita per year was prepaid to the health care facility to cover the benefit package during the first two years. The budget under the Universal Coverage Policy was allocated to provinces according to the registered population. The payment mechanism was applied to both public-sector and private-sector facilities. Highest priority was given to channeling allocations to the primary care units based on the registered population. Secondary and tertiary hospitals were funded from the budget of and through primary care units for inpatient care, commensurate with their services as determined by the number and type of referred cases. The capitation grant rate was increased to 1,396.30 baht for the 36

fiscal year 2004/2005, owing to study findings that showed a capitation grant rate of 1,510 baht as adequate. After the third year of implementation, household surveys revealed that the “30 baht Universal Health Care Policy” was strongly supported by the beneficiaries, regardless of their socio-economic status. 13.4 Challenges for 30-baht Policy Thailand might be one of only few countries whose governments have made headway towards accomplishing any universal coverage of health care policy during the economic slowdown period. Attempts to achieve universal coverage have had a long history. It has been advanced during the past five years by adopting the current UC policy and its implementation, in terms of area coverage and package comprehensiveness. Nationwide coverage was achieved within one year and the policy is heading in a sound direction given the accumulated experience and knowledge. However, rapid policy implementation has threatened the sustainability of the policy, to some extent, as the existing health-care infrastructure, including healthcare personnel, have had limited capabilities/resources to perform their new roles and functions. Moreover, there still have been problems of under funded and less-thanideal quality of medical services. The challenge has remained how to keep the system sustainable and to meet people’s expectations of health-care services. Thailand’s Universal Health Care Policy is an example of how a middle-income country manages to pursue equity in health-care with remarkable achievements. It is obvious that this policy is welcomed by the public and is fully supported by politicians, thus ensuring a “governmental commitment”. Both successes and future challenges have been identified. The Thai experience may be shared with other countries facing similar challenges. The lessons learned might be useful to other developing as well as developed countries in paving the way to increase investment in health-care and treating public health as a core concern of development.

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Health care finance and service provision of Thailand after achieving universal coverage (UC)

General tax

Ministry of Finance - CSMBS (6 million beneficiaries) Standard package

General tax National Health Insurance Office The UC scheme (47 millions of pop.) Benefit Social Security Office - SSS Tripartite contributions (9 millions of formal employees) Payroll taxes Risk related Voluntary private insurance contributions Capitation & global Co-payment Public & Private Contractor networks Services Fee for services Fee for services - OP

Capitation budget with

Population Patients DRG for IP

13.5 Achievements of the UC Scheme 13.5.1 Beneficiaries of the UC Scheme The UC Scheme, by its historical development, is the extension of the previous Medical Welfare Scheme to cover the rest of population. The Medical Welfare Scheme was the public health financing scheme for the poor, the disabled, the elderly, children under 12, veterans and the monks. Therefore, the UC Scheme has relatively higher proportion of the poor more than the other two schemes. Beneficiaries in income quintile 1 and 2 in the UC Scheme are more than half while in the SSS and the CSMBS account for 6.9% and 16.1% respectively. Success of the UC Scheme and harmonization of the UC Scheme with the others would strongly affect equity improvement for the poor. 13.5.2 Improving access to healthcare From 2002-2007, utilization rate of ambulatory service increased 4.2% annually, while hospital admission rate increased 2.2% annually. Health service utilization has changed to focus more on primary care since the Fourth National Economic and Social Development Plan (1977-1982) when rural healthcare infrastructures were extensively developed. Share of health service utilization at district hospital increased Substantially after the implementation of the UC Scheme but slightly declined in 2004. Share of health service utilization at health centre haven’t changed significantly 38

After the UC Scheme implementation. It was found that the poor benefited from this improved access to healthcare more than the rich especially at public health facilities. (1) However, this improved access to healthcare increased workload of health personnel at public health facilities substantially and it became one of the major causes of internal brain drain during this period. 13.5.3 Prevention of medical impoverishment The UC Scheme could reduce household expenditure on health including catastrophic healthcare expenditure. It was fond that incidence of catastrophic expenditure (health expenditure more than 10% of household expenditure) reduced from 5.4% in 2000 to 3.3-2.8% in 2002-2004. As a result of this, it was estimated that the poverty headcounts due to out of pocket payments dropped from 2.1% in 2000 to 0.8-0.5% in 2002-2004. 13.5.4 Promoting equity in health Many features of the UC Scheme promote equity in health. For its source of healthcare finance, it was found that Concentration Index (CI) of general tax revenue in 2002 was 0.6996. Which indicated the rich contributed a larger share than the poor. Recent study on benefit incidence analysis. Found that for ambulatory services, the government subsidy was pro-poor at district health system. The CI was - 0.3326 and - 0.2921 for health centre and district hospital respectively. It was slightly less progressive at general and regional hospital ambulatory services, as the CI was 0.1496. For inpatient care, it was more progressive in favor of the poor at district hospital, the CI was -0.3130 in 2001 and -0.2666 in 2004. It was less progressive in favor of the poor at general and regional hospital, the CI was -0.1104 in 2001 and -0.1221 in 2004. 14 Challenges and strategies Universal coverage for health care 14.1 Aligning pluralistic public health protection system Although there was consensus among every steak holders that Thailand should have Universal coverage for health care. But in detail each group had some different opinion. There were hot debates from existed public health purchasers during the reading of the National Health Security bill, is aimed to harmonize all the existing public health security schemes. it was expected that beneficiaries of SSS and CSMBS would utilize health services, according to benefit packages specified by their own schemes, under the system managed and supervised by the NHSO. However, the labor union leaders were worried that the transfer of health service part of the SSS and 39

the WCS to the NHSO could affect their benefits. Civil Servants also worried that management under the National Health Security Bill would affect their benefits, too. Finally, the National Health Security was shaped to compromised every stack holder. CGD, NHSO and SSS. A memorandum of understanding (MOU) among the NHSO, the SSO and the CGD was signed 2004 to set up a committee and subcommittees to collaborate and coordinate the development of each health care financing scheme. The developments of management information system, standard of health services and health facilities, 14.2 Appropriate payment mechanism Experience in Thailand shows clearly that public health care providers are also response to different payment mechanism in similar way with private ones. It should be noted that public hospital in Thailand have been allowed to keep their revenue for purchasing goods and services include salary for temporary staffs, and they still get salary for permanent staffs from government. Currently, public health protection schemes face different problems according to their payment mechanism. The CSMBS still face the problem of moral hazard. Currently, hospitals use their own services fee schedules for reimbursement to CSMBS. There are quit different prices for the same treatment between hospitals. The standard fee schedule and systematic medical auditing system are needed to solve these problems for outpatient services. The WBS still has positive balance for its fund. Nevertheless, there were complains from members and private hospitals that the ceiling for reimbursement was too low and Process was very slow. The WCS is going to increase reimbursement from the fund up to 45,000 Baht. This measure will create more cost pressure to the Workmen Compensation Fund and might need to increase contribution. The UCS and SSS have adopted capitation as a main provider payment mechanism. The capitation contract model is an effective long-term cost containment strategy. But the flat rate capitation payment is an incentive for providers to give limited services to those needing expensive care services, like senior citizens, and patients with chronic conditions. Age and other risk factors should be taken into account in calculating the capitation rate, to prevent selecting low risk beneficiaries for hospital registration, and their bias in service provision. Also, some selected high-cost, low-volume medical services and equipment should be paid by other payment mechanism which more performancebased approach than capitation. In addition, keeping and close monitoring of their quality of care must be diligently enforced. 40

14.3 Long-term financial sustainability The UCS now depends on general revenue financing through annual budgeting process, and remains vulnerable to receive budgets below actual cost of services from budgetary competition among Ministries. Researches were conducted to establish new sources of finance for UC scheme such as increasing co-payment, direct premium collection or earmarking general tax. Although the SSS does not have financial problem now, Expansion of coverage of Social Security Scheme to non-working spouses and dependants (estimated at 6 million beneficiaries who have been currently covered by UC scheme) without raising the contribution rate, by 2005, the UC Fund will save the budget at least 9 billion baht. 14.4 Improve equity, quality and efficiency Thailand still retains a fragmented health insurance system and single fund management is not politically feasible at the moment. Fragmented social health protection schemes are very likely to be inequitable and not likely to work in the interests of the poor. For example, government subsidies for different schemes were quite different. Regarding quality of services, quality of care provision at health centers and district hospitals in rural areas are still different from urban areas where there was greater use of higher-level hospitals. Capitation payment in the SSS and the UCS has been associated with giving fewer medicines for chronic conditions. And moral hazard was found in the CSMBS which use the fee-for-service system. Primary care and appropriate referral system is a key strategy for overall systems efficiency and better quality. Unfortunately, implementation is much more difficult. There is no real primary care system in Thailand before the universal coverage era. Thai people were familiar with freedom of choices to visit any health facilities and contact directly to specialist. Therefore one of the main strategies is to strengthen near home primary care services. 14.5 Recent Changes in the Thailand Health Care System The health care system underwent several reforms. In 1952, the area of responsibility was extended by adding the health-care infrastructure and the development of human resources in order to provide health-care services throughout the country. Various health policies were on the agenda of national development plans, beginning with the implementation period of the First National Economic Development Plan (19611966), and notably the implementation of successive National Economic and Social 41

Development Plans since. Health care is organized and provided by the public and private sectors. The MOPH is the principal agency responsible for promoting, supporting, controlling, and coordinating all health service activities. In addition, there are several other agencies playing significant roles in medical and health development programmes such as the Education, Interior, and Defence ministries, the Bangkok Metropolitan Administration, state enterprises, and private-sector Enterprises. They operate health facilities including hospitals that provide primary, secondary and tertiary medical services. During the last ten years, the numbers of private hospitals and clinics increased exponentially in Bangkok and primate cities. Public-sector and private-sector health care facilities were categorized as follows: • In Bangkok, there were five medical-school hospitals, 29 general hospitals, 19 specialized hospitals and institutions, as well as 61 health centres and 82 health centre branches. • Throughout the country, beyond the city of Bangkok, public health facilities included four regional-level medical-school hospitals, 25 regionallevel hospitals, 40 specialized hospitals, 70 provincial-level general hospitals under the auspices of the MOPH, and 56 hospitals operated by the Ministry of Thailand in the 2000’s • These medical facilities were underpinned by 725 community hospitals at district level as well as 214 municipal health centres. At the sub-district or tambon9 level, there were 9,765 health centres as well as 66,223 rural and 2,470 urban primary health care centres. The latter two types of health facilities were managed by village health volunteers (close to 800,000 in 2004) under the supervision of health workers at sub-district health centres. • The private sector also played a significant role in providing curative care. In 2003, there were one private medical school in Bangkok, 346 private hospitals (100 in Bangkok and 246 in other provinces), 11,853 clinics, 12,878 pharmacies (1st and 2nd class) and 2,106 traditional medicine drugstores. • In 2002, the overall ratio of hospital beds to population was 1:206 in Bangkok, compared to the ratio of 1:462 in all other provinces. The ratio of physician to population was 1:3,295 for the whole country, ranging from 1:767 for Bangkok to 1:7,251 for the North-eastern Region.

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15. CONCLUSION 1. PHC has been successful in Thailand because of community involvement in health, collaboration between government and non-government organizations, the integration of the PHC programme, the decentralization of planning and management, intersectors collaboration at operational levels, resource allocation in favour of PHC, the management and continuous supervision of the PHC programme from the national down to the district level, and the horizontal training of villagers to villagers. 2. To strengthen and sustain community self-reliance, village health revolving funds were set up. Selected community leaders were trained in planning and management and assigned to manage the so-called “Self-managed PHC Villages” and their skill and knowledge were transferred to other villages 3. Improvement in quality of health services. Followed the coverage expansion; effective referral system in regional basis was also developed. Health centers, staffed by paramedics, are now gradually upgraded to be primary care units and staffed by medical personnel. 4. The need for healthcare promotion and disease prevention services could be more broadly and effectively met through community participation. The approach proved to be a successful one. Under its guidance primary healthcare development and personnel development a number of innovations and modifications of the existing healthcare system 5. The effectiveness and equity of healthcare system correlated with their orientation towards primary healthcare. This correlation was demonstrated in a study that measured the healthcare out comes of the industrialized nation in relation to the characteristics of their healthcare system policies and practices that reflect primary healthcare. 6. Conventional medical resources were not available in rural areas - doctors and nurses were unwilling to work outside better-equipped urban health facilities and their numbers were insufficient. It was essential to train members of rural communities to deliver basic health care to their own people (community or village health workers) 7. The main methods of financing for health care include the national health insurance system, general revenue, private insurance, community-based 43

insurance and out-of-pocket payments. The choice of method will impact on who bears the financial burden, the amount of resources available and who manages the allocation of resources. 8. The budget under the Universal Coverage Policy was allocated to provinces according to the registered population. The payment mechanism was applied to both public-sector and private-sector facilities. Highest priority was given to channeling allocations to the primary care units based on the registered population. Secondary and tertiary hospitals were funded from the budget of and through primary care units for inpatient care, 9. Thailand has implemented the UC Scheme for six years with some successes especially in improving access to healthcare for the poor and financial protection for catastrophic illness. These successes happen as a result of welldesigned systems based on knowledge learnt from health system development in the past. 10. Health service provision based on primary care and district health system, and a tax based financing system. Universal approach and a tax based financing system share a common characteristic of administrative simplicity and, therefore, can be easily implemented in developing countries where administrative capacity is limited. 11. It should be noted that vertical equity of a tax based financing system depends on a country specific tax structure and higher share of income tax would result in more vertical equity. Health service provision based on primary care would ensure access to healthcare for the poor and improvement of system efficiency. 12. They use fee-for-service method for specific services or equipments i.e. prosthetic heart value, which they would like to promote more usage. On the other hand, they use case mixed method i.e. to control inpatient cost. Quality improvement program and measurements to improve equity are the next step after achievement of the universal coverage. 1. PHCs are the well designed organizational structure and management system. The establishment of a coordinating mechanism for primary healthcare evaluation. at district level the strength is the structure of the district coordinating committee

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2. Health objectives will be more or less independent of national budget constraints. Affordability needs to be assessed also in relation to the contributory capacity of individuals, employers and other entities paying taxes to the state and other public programmes, 3. The implementation of government healthcare policies and health initiatives will only succeed when health care systems are rationally funded to achieve priority objectives. Apriority goal of primary healthcare is to provide easy access to essential healthcare services for all with as few financial barriers as possible. 4. Further strengthening of the basic health infrastructure to support PHC. A system of ‘family health facilities’ which will be the ‘facility for each family’ and work with the community and family to improve health related risks and addressing all new diseases. Reference 1. Anuwat Supachutikul and Jirut Sriratanabal. (2000). Health System Quality. Health System Research Institute. Thailand 2. Public healthcare report (2000): revitalizing primary health care country experience: Thailand and Public healthcare report(2000) health strategy and policy Thailand 3. Araya Tavornwanchai, Preeda Tae-Aruk, and Sunee Wonfkongkathep. (1998). Health of the Thai Children during the Economic Crisis. Health Status from the Impact of Economic Crisis Monitoring Unit 4. Bureau of Health Policy and Plan, Ministry of Public Health. (2001). Inpatient Record, 2000. Bureau of Health Policy and Plan, Ministry of Public Health. (2001).Bureau of Health Policy and Plan, Ministry of Public Health. (2002). Report of Health Resources, 2000. Bangkok. 5. Kannika Damrongplasit,(2009) Thailand's Universal Coverage System and reliminary Evaluation of its Success, UCLA and RAND, Thailand 6. watana vinitwatanakhun(1999)factors affecting organizational effectiveness of nursing institutes in thailand school of nursing science, assumption university bangkok, Thailand 7. Iwana, Reisuke, and Mitsubishi (2009) health security in thailand – can the uc scheme,introduced in the aftermath of the 1997 asian financial crisis be sustained in the current global economic crisis?and Sustainable Development in Asia and the Pacific", 28-30 Sept 2009, Hanoi 8. Mettanando Bhikkhu(2007) A Buddhist Model for primary Health Care Reform J Med Assoc Thai 2007; 90 (10): 2213-21 Full text. e-Journal: http://www.medassocthai.org/journal 9. Worawan chandoevwit(2005)financing universal health-care coverage the faculty of management science, khon kaen university. “extra funding for universal healthcare coverage” funded by the health systems research institute. tdri quarterly review vol. 20 no. 3 45

10. E.M obimbo(2003): primary health care, selective or comprehensive, which way to go, e.m. obimbo, mbchb, mmed, lecturer, department of paediatrics and child health, college of health sciences, university of nairobi, p.o. box 19676, nairobi, kenya, east african medical journal vol. 80 no. 1 january 2003 11. Chutima suraratdecha, albert a. okunad(2007): measuring operational efficiency in a health care system: a case study from thailand, international health policy program, health systems research institute, ministry of public health, tiwanon road, thailand b department of economics, rm. 450bb, university of memphis, memphis, tn 38152, usa c program for appropriate technology (path), seattle, wa 98107-5136, usa 12. Dayl Donaldson, Supasit Pannarunothai, and viroj Angcharoensathien,(1999) health financing in thailand: technical report health management and financing study project adb no. 2997 tha management sciences for health 165 allandale road boston, ma 02130-3400 usa, copyright © 2000 management sciences for health, inc. all rights reserved. 13. Voradeja chandrasorn(1999) implementation of primary healthcare policies in thailand, analaysis of weakness and strengthens of primary healthcare , thai journal of administration development VOL. 30 NO 3 14. Narong Kasitipradith(2001)The Ministry of Public Health telemedicine network of Thailand, International Journal of Medical Informatics 61 (2001) 113–116, Ministry of Public Health, Nonthaburi 11000, Thailand 15. Chutima Suraratdecha∗, Somying Saithanu, Viroj Tangcharoensathien(2005) Is universal coverage a solution for disparities in health care? Findings from three low-income provinces of Thailand International Health Policy Program, Ministry of Public Health, Tiwanon Rd., Nonthaburi, Thailand, Health Policy 73 (2005) 272–284 16. Bureau of Health Policy and Planning, Ministry of Public Health. (2001). Report on Provincial Health Survey, 2001. Bureau of Health Policy and Planning, Ministry of Public Health. 17. Bureau of Policy and Strategy, Ministry of Public Health. (2003). Report on utpatients Care, 2003. Bureau of Policy and Strategy, Ministry of Public Health. 18. Wibulpolprasert, (2008). Healthcare delivery managemenet in thailand , Ministry of Public Health, Tiwanon Rd., Nonthaburi, Thailand, 19. WHO REPORT (2000) strategies for implementing primary health care? Thailand 20. WHO reports (2008) Health System Strengthening using Primary Health Care Approach and healthcare financing Regional Conference on “Revitalizing Primary Health Care” Jakarta, Indonesia, 6-8 August 2008 SEA/RPHC/2008/12 21. Sara Bennett Lucy Gilson(2001) Health financing: designing and implementing pro-poor policies; Copyright: ฉ 2001 by HSRC Image credits: Cover photo: People walking into rural clinic. (C) enjamin Lozare, JHU/CCP M/MC Photoshare, www.jhuccp.org/mmc Designed by: Adkins Design Printed by: Fretwells ABBREVIATIONS APO = Autonomous Public Organization CSMBS=Civil Servants Medical Benefit Scheme, 46

MOPH = ministry of public health MOB= Management by Objectives Tampon = sub-district CMU= Community Medical Unit VHV= village healthcare voluntary GPs= general practitioners UHCS= Universal Health Care Coverage Scheme UC= Universal Coverage PCU= Primary care unit SSS= Social Security Scheme PHCs= primary healthcare centres

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SECONDARY HEALTHCARE HOSPITAL, COLLECTING PUBLIC HEALTHCARE INFORMATION , MAHASARKHAM UNIVERSITY, THAILAND

PRIMARY HEALTHCARE CENTRE , AFTER COLLECTED PRIMARYCARE INFORMATION, MAHASARKHAM UNIVERSITY, THAILAND

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