This presentation was given at the International Health Economics Association (iHEA) World Congress in Milan, in July 2015. It includes results and policy implications from the RESYST Purchasing Study conducted in Thailand

1. 1
Strategic purchasing: a comparative assessment of
Civil Servant Medical Benefit Scheme and
Universal Coverage Scheme in Thailand
Walaiporn Patcharanarumol
International Health Policy Program (IHPP)
iHEA, Milan; Wednesday 15 July, 2015

2. 2
Thai Universal Health Coverage
Act 2002 Royal Decree 1980 Act 1990
Comptroller General
Dept, MOF
Social Security Office,
MOL
National Health Security
Office
Public (75%) & private (25%) health facilities
47 mln pop
(reside in rural areas; Q1-2;
children, elderly, informal wk)
10 mln pop
(urban; Q4-5;
children, elderly,
public sector wk)
10 mln pop
(city; Q4-5; only adult
workers in private
sector)
Tax funded Tax funded Tripartite cont
UC Scheme Civil Servant
Scheme
Social Health
Insurance
67 million Thai populations

3. 3
Thai Universal Health Coverage
Act 2002 Royal Decree 1980 Act 1990
Comptroller General
Dept, MOF
Social Security Office,
MOL
National Health Security
Office
Public (75%) & private (25%) health facilities
47 mln pop
(reside in rural areas; Q1-2;
children, elderly, informal wk)
10 mln pop
(urban; Q4-5;
children, elderly,
public sector wk)
10 mln pop
(city; Q4-5; only adult
workers in private
sector)
Tax funded Tax funded Tripartite cont
UC Scheme Civil Servant
Scheme
Social Health
Insurance
67 million Thai populations

4. 4
Key actors – UC Scheme
“Clear mission of a purchaser”
Purchaser:
National Health
Security Office
Government: Cabinet,
Executive Board &
Quality Board
75% of total pop:
Rural areas, Q1-2,
informal workers
Providers:
Network of health center &
district hospital
•Contract agreement
•Payment
•Medical Audit
•Data
submission
•Direction e.g.
BP sub-committee
•Financial audit
•Regular meetings
•UCS close ended-budget
•Annual report
•Members
Registration
•Provide
services
Member of the Board
Member of the Board
•Hotline 1330

5. 5
Key actors – Civil Servant Scheme
"Mission: money transaction for providers”
Purchaser:
Comptroller General Dept,
MOF
Government:
Ministry of Finance &
Director of CGD
10 mln pop:
Urban areas, Q4-5,
Govt staff, pensioners
Providers:
Mainly public hospitals
•Payment
•Medical Audit
•Data submission - DRG
•Claim reimbursement - FFS
•Financial audit
•Regular meetings
•Open-ended budget •Annual report •Members declaration
•Provide services

6. 6
Key findings 1 Purchaser-Government
UC Scheme Civil Servant Scheme
1. PG: policy
framework
The 2002 Act - clear expectation
and mandate of an effective and
efficient purchaser by NHSO
No role of purchaser (by
law and perception) –
only money transaction
for providers by CGD
2. PG:
accountability
Independent government body
with the Boards of multi-
stakeholders
Dept of MOF,
bureaucratic system
3. PG: resources of
government
budget
Close ended-budget with
“negotiation”, however,
approved < proposed budget,
pressure btw PP
Open ended-budget with
a sense of “entitlement”
4. PG: promoting
equity
• Budget for under-served areas
• Special mech e.g. mobile
cataract surgery team to rural
areas, contracting private
hospitals for open heart surgery
No

7. 7
Key findings 2 Purchaser-Providers
UC Scheme Civil Servant Scheme
5. PP: which
providers
(quality, equity)
Geographic limitation of health
centers and district hospitals
Hospital Accreditation which
happened before UC era
Any public hospitals
according to the
convenience of the
members
6. PP: improve
health systems
efficiency
• Close ended payment
• Primary health care
• Health technology assessment
• National Essential Drug List
• National Essential Drug
List but still under Fee-
For-Service
reimbursement for out-
patient service
7. PP: provider
performance
(quality imp)
• Special payment e.g. asthma patient
- corticosteroid inhalation / no
readmission
• No
8. PP: mutual
accountability
and transparency
• In-house and networking for
medical, coding & billing audit (DRG)
-> hospitals return money back if
fraud or get more payment if
• Audit by outsourcing

8. 8
Key findings 3 Purchaser-Citizens
UC Scheme Civil Servant Scheme
9. PC: engage with
citizens to
determine their
health needs and
protecting financial
catastrophe
• Citizen Representatives are
member of the Boards (5/31)
• Expansion of benefit package
based on evidence of HTA and
sub-committee of Benefit
Package process
• No process, subject to
providers’ and members’
requests
10. PC: citizens’
awareness of their
entitlements,
obligations and
access to services
• Capitation - incentive of
providers to register members
• Political campaign,
advertisement
• Attractive slogan “30 baht cures
all diseases”
• Government process,
official letter circulation
11. PC: views of
citizens
• Annual public hearing,
satisfaction survey (providers and
citizens)
• Hotline 1330, 24 hrs / 7 days
• Telephone of the MOF –
not effective, official
working hours, together
with other tasks of CGD

9. 9
Factors
Contributing factors Undermining factors
A. Legal
framework
• Clear policy, expectation and
mandate of “a purchaser” for
benefit of people and health
system
• Clear policy of not to be “a
purchaser”, just only for money
transaction
• Too many other important tasks
e.g. advice on fin mgt, public
procurement in the organization
B. Governing
body,
organization
and
accountability
framework
• An independent organization
• Governing body of multi-
stakeholders – citizens’
engagement
• Adequate number and
competency of staff (useful of
health background)
• Government structure with rigid
mandate using command and
control
• Inadequate and no health
background staff
C. Resources • Too tight budget – pressure
and conflict btw purchaser and
providers
• Too easy budget – soft budget ->
inefficiency of the system

10. 10
Factors
Contributing factors Undermining factors
D. Information • Information management
• Using appropriate ICT
• Pool of information
• Fragmented data requirement of
different schemes creates trouble
to providers – information rather
than service orientation
E. Communi-
cation
• Two way communication
• Proactive communication –
NHSO staff visited providers
• Official process of bureaucratic
channels - ineffective
F. Audit • Neutral auditing mechanism
• Team work of audit
• An opportunity for
improvement
- Knowledge and skill of
the audit team and
providers
- Data quality of providers
• Penalty and incentives
• Bad attitude, perception and
practice of investigators and
being investigated persons

11. 11
Conclusion – some improvements
• Strategic for more impacts
 UCS – adequate budget and more equity in resource
allocation among health facilities
 Civil servant scheme – more efficiency of the scheme and
more equity across the schemes
• In case of multi-purchasing mechanisms in a country (e.g.
Thailand),
 Strategic purchasing function of one purchasing mechanism
alone is not adequate
 Limited outcomes and impacts within one purchasing
mechanism – smaller population coverage, smaller impact
 Urgent needs of strategic purchasing across purchasing
mechanisms -> harmonization is needed

12. 12
www.wpro.who.int/asia_pacific_observatory
http://resyst.lshtm.ac.uk
@RESYSTresearch
The research is a collaboration between RESYST and
the Asia Pacific Observatory on Health Systems and Policies (APO)
RESYST is funded by UK aid from the UK Department
for International Development (DFID). However, the
views expressed do not necessarily reflect the
Department’s official policies.
More information: http://resyst.lshtm.ac.uk/research-projects/
multi-country-purchasing-study