ATC121115: Report of the Portfolio Committee on Health on a study tour to Bangkok, Thailand, dated 12 September 2012

Report of the Portfolio Committee on Health on a study tour to Bangkok , Thailand , dated 12 September 2012

The Portfolio Committee on Health having undertaken a study tour to Thailand from the 23-27 January 2012, reports as follows:

1. Background and Objectives

The National Health Insurance (NHI) is currently high on the health policy agenda. The intention of this financing system is to promote efficiency and the equitable distribution of financial and human resources, improving health outcomes for the majority. The proposed NHI seeks to address health challenges.

The Committee decided on the study tour pre-empting the piloting of the NHI in various areas of South Africa , as well as health care services in general. The NHI will reshape South Africa ’s health care system. The Committee also decided on visiting Thailand as it is a country which is perceived to have one of the good health care systems. The lessons learnt from the Thai government healthcare system would assist Members of Parliament (MPs) in their future oversight activities.

The Committee was interested in the following areas of learning:

· National Health Insurance;

· Recruitment and retention strategies of doctors in the rural areas, which assist in the good functioning of primary health care;

· Integration between Conventional and Traditional medicines; and

· Their Office of Standards of Compliance.

2. Delegation

The following members formed part of the delegation:

Dr MB Goqwana, Committee Chairperson (ANC)

Ms BT Ngcobo (ANC)

Ms MJ Segale-Diswai (ANC)

Ms MC Dube (ANC)

Mr M Waters (DA)

Mr DA Kganare (COPE)

The following Parliamentary officials accompanied the Committee:

Ms Vuyokazi Majalamba: Committee Secretary

Ms Nonceba Mahlanyana: Committee Assistant

Mr Zubair Rahim, Committee Researcher

3. Visit to the National Health Security Office (NHSO)

Delegation at the NHSO

The delegation interacted with the following persons at the NHSO:

Dr Winai Sawasdivon: Secretary General of the NHSO

Dr Yoslip Suchanwanich: Bureau of Information Technology

Ms Netnapis Suchanwanich: Assistant Secretary

Ms Netnapis Suchanwanich briefed the Committee and expanded on the constitutional provisions, the universal coverage reform objectives, the National Health Security Act, Thailand ’s universal coverage, and the structure of the NHSO.

3.1 Constitution of Thailand

Section 51 of Thailand’s Constitution B.E. 2550 (2007) stipulates that everyone has equal right to receive appropriate and standard public health services; and indigents shall have the right to receive free medical treatment. Section 80 stipulates that the State shall carry out the policy directive to:

· Promote, support and develop the heath system that emphasise the health promotion;

· Provide and promote the standardised public health service to people universally and efficiently; and

· Encourage private sector and community to participate in the health development and provision of public health services.

The NHSO is a state agency, officially founded in 2002, under the National Health Security Act. It is responsible for the health security of 47.5 million Thai citizens. Every person born as a Thai should feel secured, irrespective of being sick or not. The mandatory duties of the NHSO are to manage the health security fund and allocate the subsidiary budget to 236 clinics and 963 hospitals to promote and develop a good health care system for all Thai people in order to assure the quality of care provided to Universal Coverage (UC) members. The NHSO has to control and supervise health care units to achieve the required standards of health services for all members.

The vision of the NHSO is to have a health security system that ensures equitable accessibility, public confidence and provider satisfaction. The mission of the NHSO is to:

· Promote and develop a quality health care system with public confidence and provider satisfaction;

· Promote the participation of civil society and local administration organisations in health security development;

· Promote and protect the people’s right to health security as well as reinforce the learning process of the public realizing their rights and duties. Manage the health security funding and the utilisation of the fund in the manner of sufficiency and efficiency; and

· Establish an organisational management system which is of high standard and promote continuous development towards a learning organisation.

3.2 Aspects relating to health sector reform

The presenter provided an overview of the universal coverage reform objectives, the Thailand universal coverage and aspects relevant to the National Health Security Act.

3.3.1 Universal coverage reform objectives

The following objectives underpin the reform process of universal coverage:

· To improve efficiency through:

o Rational use of healthcare by level – beginning with primary care while ensuring proper referral;

o Long-term cost containment through capitation contract model.

· To ensure equity across schemes;

· To ensure a sustainability system; and

· To ensure quality of care through the accreditation system and utilisation reviews.

3.3.2 Thailand Universal Coverage (UC)

There are three public insurance schemes, which cover 96% of the population, though 4% is still uninsured. The three schemes are as follows:

· Civil Servant Medical Benefit Scheme (CSMBS) introduced in the 1960s, which covers government employees, their dependents and retirees. Ten percent of the population is covered in this scheme;

· Social Health Insurance (SHI) which was introduced in the 1990s and covers private sector employees. Twelve percent of the population is covered in this scheme; and

· Universal Coverage (UC) introduced in 2001. Seventy-four percent of the Thai population is covered by this scheme.

3.3.3 National Health Security Act

The National Health Security Act ensures entitlement for health services according to the constitution, which applies to all Thai citizens. The National Health Committee is responsible to announce cost sharing of patients. However the poor have to be protected from financial burden.

3.3.3.1 Services covered under the National Health Security Act

The services covered under the National Health Security Act incorporate promotive and preventative care, diagnosis, antenatal care, curative care, medicine, medical supplies, organ substitutes and medical equipments, delivery, boarding expense within health care unit, newborn and child care, ambulance or transportation for patients, transportation for disability persons, physical and mental rehabilitation; and other expenses necessary as prescribed by the Committee.

3.3.3.2 The National Health Security Act B.E 2545 (2002)

In expanding on the National Health Security Act, the presenter provided an outline of the plan, current status, enabling factors for Thai universal coverage, future challenges and coping mechanisms.

In relation to the plan and current status, financial sustainability was ensured by using multiple sources of funds. Currently, the general tax was the only source of fund. There was an attempt to propose a sin tax as an alternative source and there were forecasts that the total health expenditure as a percentage of GDP was still feasible in the next ten years.

In relation to the enabling factors for Thai universal coverage, there was political commitment with a policy agenda setting comprising evidence based policy formulation. The existing functioning of primary healthcare services was close to clients and easily accessible by rural populations.

There was government effectiveness in scaling up and sustaining the universal coverage scheme. There was a high capacity on information systems, which enabled monitoring, evaluation and continued systems for fine tuning.

Future challenges and coping mechanisms comprised the following:

· Rapid demographic and epidemiological transition;

· Little investment in primary preventions of risk and social mobilisation;

· Unsettled debates on moving dependants (spouse and children) of SHI members currently covered by tax funded UC to contributory SHI;

· Strong push by super-tertiary care (teaching hospitals) to extend high cost medical technologies; and

· Slow progress in harmonising across three insurance schemes.

Having completed the presentations, the Committee was taken on a tour to a call centre where all complaints and benefits were being administered. The call centre was a 24-hour service with 60 lines. They received approximately 1000 calls a day. Information at the call centre was kept for 6 months and then archived for 10 years.

3.3.4 Data Centre

The data centre was a centralised centre where all the data of people on the NHSO was administered. Applications were also managed at the centre. The centre was also responsible for checking and fixing problems from other branches.

4. Site visits to hospitals, clinics, and briefing by the Ministry of Public Health

The delegation visited and received briefings from officials at the Samitivej Private Hospital , Rajavithi Hospital , Bang Sie Thong District Ka (primary healthcare) and a briefing by the Ministry of Public Health.

4.1 Samitivej Private Hospital

Delegation at the hospital

Ms Pat Phatraporn Donavanik

Miss Rungnapa Attanung

Ms Pat Phatapraporn Donavanik, Head of International Affairs informed the Committee that Samitivej was a private hospital, and not part of the hospitals that were offering universal coverage.

4.2 Rajavithi Hospital

Delegation at the Hospital

Dr Prakarn Thomyangkoon: Medical Technology Training

Mrs Niyom Somprasong: Human Resources Management

Ms Khunying Duenpen Puengprakieat: Health Insurance

Dr Sukit Paripimanmas: Deputy Director of the Academy Group

Dr Warunee Jinarat: Assistant Director of Finance

Ms Benjawan Khumparat: Deputy Director

Mr Sompson Savarat: Interpreter

4.2.1 Presentation by Dr Prakarn Thomyangkoon

The Committee was shown a video of Rajavithi Hospital and services that were being provided. Dr Prakarn Thomyangkoon informed the Committee that the hospital was initially a hospital for women and was converted to Rajavithi Hospital in 1976. Some of the services offered at the Hospital since 1995 were lung, heart, kidney and liver transplants.

Dr Thomyangkoon informed the Committee that Rajavithi Hospital was the leading International Medical Centre, and its mission was to be the leader of academic international medical centres, by providing professional tertiary medical services, health promotion and having effective transferring systems.

The core values of the hospital comprises enhancing the research and academic mind, creating joyfulness, alliance networking, victor, integrity, teamwork, humanising health care and innovation.

The original Hospital was established in 1951. With 1 154 beds, it is the largest hospital under the Ministry of Public Health. In April 2011, the hospital celebrated its 60 ^th anniversary. The hospital is divided into different directing clusters consisting of the following departments - Departments of General Administration, Finance and Accountancy, Procurement, Planning and Evaluation, Customer Relations and Human Resources.

The academic cluster consists of the following – Centre of Medical Speciality in Otolaryngology Head and Neck Surgery, Departments of Emergency Medical Services, Obstetrics and Gynaecology, Surgery, Medicine, Physical Medicine and Rehabilitation, Orthopaedic, Psychiatry, Anaesthesiology, Ophthalmology, Pathology and Laboratory, Medicine, Radiology, Dentistry, Pharmacy, Nutrition and Dietetics Academic Support Information, Technology, Family Medicine, and Radiation Oncology (Radiotherapy).

The nursing cluster consists of the following – Departments of Out-Patient Nursing, In-Patient Nursing, and Nursing Academy .

Centres of excellence include ear, nose and throat, retina, organ transplantation, laparoscopic and endoscopic surgery, trauma, cardio-vascular and cancer, head and neck.unit

The hospital also offers three to five year residency training programmes in 13 specialities as follows – general surgery, neurology, Thoracic Surgery, Orthopaedic Surgery, Obstetric – Gynaecology, Internal Medicine, Ophthalmology, Ear, Nose and Throat, Anaesthesiology, Emergency Medicine, Radiotherapy and Oncology.

Fellowship training courses in 19 subspecialties include – cardiology, nephrology, Gastro-Enterology, Endocrinology, Rheumatology Gynaecologic Oncology, Spine Surgery, Hand Surgery and Microsurgery, Gynaecological Laparoscopy, Glaucoma, Retina and Vitreous, Maternal Foetal Medicine, Arthroplasty, Infectious disease, Head and Neck surgery, Minimally invasive Surgery, Hepatopancreatobiliary Surgery, Pulmonary Disease and Pulmonary critical care.

Short Courses Training include – laparoscopic cholecystectomy , Gynaecological Laparoscopic Surgery, Dialysis Course,

Gastrascopic Technique, Head and Neck Surgery Oncology Course, Temporal Bone Surgery Training Course and Postgraduate Cardiovascular Perfusion.

Mrs Niyom Simprasong, Human Resources Manager, presented the Human Resource Management plan of Rajavithi Hospital . The human resource agenda included staff engagement and the staff environment.

Having concluded the presentations, the Committee was taken on a tour of the Out Patients Department where all patients that were in the Universal Coverage were being administered.

4.3 Primary healthcare of Bang Sie Thong District ka

Delegation at the Hospital

Ms Yupha Tarwonsarn

Mrs Sabul Thongplere

Ms Vipapoan Kernnak

Ms Yupha Tarwonsarn briefed the Committee and informed the delegation that the clinic provided services to patients around the area. There were about 9000 people living in the area. The area was called area number 4. One of their responsibilities was to assist people to take care of themselves by advising them on healthy diets to follow. Patients were also encouraged to exercise. She informed the Committee that the clinic was taking care of patients under universal coverage. The funds for the clinic were centralised and each patient was allocated 2000 BHT per year. They treated all patients even those who did not have money/funds, as all people have the same rights.

The clinic on average attended to 20 patients or less per day. The clinic operated from Monday-Friday, from 08:30-16:30. A doctor visited the clinic twice a month but the facility was run by nurses who were also provided accommodation at the clinic. The clinic did not have an ambulance. Deliveries were not performed at the centre and those in labour were referred to a hospital, which was 5 kilometres from the clinic.

From questions asked by the Committee about how the universal coverage operates, the nurse informed the Committee that they did not properly understand universal coverage.

4.4 Ministry of Public Health

On arrival at the offices of the Ministry of Public Health, the Committee met the following officials:

Dr Somchai Pinyopornpanich: Minister of Public Health

Dr Suvaj Siasiriwattana: Acting Director General

Dr Damrongsak Bulyalert

Dr Tara Chirakarn

Dr Taries Krassaniarawiwong

Mrs Saewapa Jongkitipong

Mrs Jonokolnee Tiensong

Mrs Sirina Ratipichakul

Dr Damrongsak Bulyalert briefed the Committee and informed the delegation that the population of Thailand was around 66 million. It comprised of 76 provinces, 878 districts, 7,255 sub-districts and 74,955 villages. He informed the Committee that other public hospitals were managed by the:

• Ministry of Defence;
• Ministry of Finance;
• Bangkok Metropolitan Administration; and
• Ministry of Education (medical school hospitals).

Thailand has four major healthcare schemes which include the universal coverage programme (used by the general population), social security programme (used by corporate employees), civil servant medical benefit scheme (CSMBS) (used by government employees and state-enterprise employees), and out of pocket, including private health plans.

Some of for-profit hospitals are Bumrungrad International Hospital and Bangkok Hospital , and not-for-profit hospitals are hospitals like Mission , McCormick and Overbook Hospitals .

Dr Bulyalert informed the Committee that there was a Thailand Medical Hub Project and its vision was to:

· Promote Healthcare Services, Health Promotion Services, Health Products and Thai Herb Products, Traditional Thai Medicine and Alternative Medicine; and

· Generate revenue while avoiding negative impacts on primary system of healthcare services through a monitoring mechanism.

The mission of the project is to:

· Establish a central body to effectively implement various strategies;

· Develop the country’s competitiveness in healthcare industry;

· Generate revenue in healthcare services;

· Promote healthcare service providers and educational institutions, both public and private, in all sectors to achieve international standards of services;

· Create healthcare innovations with added values;

· Develop a consumer protection system through the processes of quality assurance and consumer safety monitoring; and

· Promote identities and wisdoms of Thailand .

The objective of the project is to strengthen Thailand ’s competitiveness in the healthcare industry through developing a healthcare service system of international standards in both public and private sectors.

Thailand was also taking care of medical tourists and Dr Bulyalert in his presentation described medical tourists as people who:

· Need care but lack adequate out-of-pocket (OOP) funds to afford a procedure in their home country;

· Seek lower price for cost savings;

· Seek better medical services; and

· Avoid long waiting times.

Treatments undertaken by United States tourists include dental care, cosmetic, orthopaedic and cardiovascular surgery. The Committee was informed about a comparison of the price of care for selected procedures in the US , India , Thailand and Singapore . The American Medical Association (AMA) guidelines for patients travelling overseas for medical care were as follows:

· Medical care outside the US should be voluntary;

· Financial incentives to go outside the US for care should not inappropriately limit diagnostic and therapeutic alternatives, or restrict treatment or referral options;

· Financial incentives should be used only for care at institutions accredited by recognised international accrediting bodies;

· Local follow-up care should be coordinated and financing arranged to ensure continuity of care;

· Coverage for travel outside the US for care must include the costs of follow-up care upon return;

· Patients should be informed of rights and legal recourse before travelling outside the US for care;

· Patients should have access to physician licensing and outcomes data, as well as facility accreditation and outcomes data;

· Transfer of patient medical records should be consistent with Health Insurance Portability and Accountability Act (HIPPA) guidelines; and

· Patients should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.

Issues

· Public hospitals have to fulfil their primary missions in providing services to the people of Thailand ;

· Some hospitals such as university hospitals and regional hospitals show potential to provide services to medical tourists; and

· Monitoring mechanisms are needed to determine if they could provide additional services without negatively affecting their primary missions.

Performance Indicators for Service Monitoring

• Prevention quality indicator
• Patient safety indicator
• Paediatric quality indicators
• US centres for Medicare and Medical Services
• Drug related problems
• Laboratory Services
• Waiting time
• Healthcare personnel indicators
• Customer indicators

4.6 Bumrungrad International Hospital

Mr Kenneth Mays welcomed the delegation and informed the Committee that Bumrungrad International Hospital was a private hospital, which operated in a business framework. He stated that government did not force private hospitals to join universal coverage. He indicated that the hospital was opened by doctors who wanted to start a private hospital. The main hospital was opened in 1997. It was the largest private hospital in Southeast Asia . Mr Mays informed the Committee that there were 100 private hospitals and about 30 public hospitals in Bangkok .

Mr Mays indicated that the hospital was a 22-storey building with 450 operational beds. The hospital treated over 1 million patients a year (outpatients and inpatients). Over 420,000 were international patients from over 190 different countries. The hospital was managed by an American-led international team and had over 1,200 physicians and dentists, many with international training/certification.

The Committee was informed that the Bumrungrad Hospital also contributes to social responsibility. There was a Bumrungrad Hospital Foundation, which was established in 1990, which was dedicated to providing healthcare to underprivileged Thais. The foundation had provided over 100, 000 Thais with free services ranging from check-up programmes to life-saving surgery for children with defective hearts.

5. Findings by the Committee

· Most hospitals in Thailand were private and were not part of the universal coverage.

· Most officials in public health facilities that were visited did not know or fully understand universal coverage;

· Half a million of the Thai people do not have insurance;

· One seventh percent of Thai people were not employed which made it difficult to compare with South Africa as this country has a high unemployment rate; and

· Thai traditional medicines were not covered in the universal coverage.

6. Conclusion

Having concluded the study tour, the Committee agreed that there was a need to visit other countries to compare and to study their universal coverage.

The Committee would like to thank Ambassador Douglas Gibson and his office for their support and guidance in preparation for and during the trip.