ระบบบริการปฐมภูมิ นับว่าเป็นฐานรากที่สำคัญ ของการที่จะให้บรรลุ Universal Health Coverage โดยไม่ทิ้งใครไว้ข้างหลัง เพราะว่าผู้ที่มักจะถูกทิ้งไว้ข้างหลัง มักจะเป็นท่านที่อยู่ในชุมชน ที่ระบบบริการปฐมภูมิ ระบบสุขภาพชุมชน ใกล้ชิดอยู่ ปีนี้เป็นปีครบรอบ 40 ปี คำประกาศ Health for All ในท่ามกลางบริบทโลกที่เปลี่ยนแปลงไปมาก จากเมื่อ 40 ปีที่แล้ว ปฐมภูมิจึงต้องวิวัฒนไป

1. Priorities with Primary Healthcare:
How Thailand address in the UHC
Dr. chuchai Sornchumni,
Deputy Secretary General
National Health Security Office, Thailand
National Health Security Office - Thailand

2. National Health Security Office - Thailand

3. National Health Security Office - Thailand
Dignity , Solidarity , Security
Universal Health Coverage #UHC and Global Health Security are
two sides of the same coin. To make the world safe, solidarity is t
he rule of the game. No one is safe until everyone is safe.
Tedros Adhanom Ghebreyesus DG, WHO, 2018
• The human right to health
guarantees a systemof health
protection forall.
• Everyone has the right to the
health care they need, and to li
ving conditions that enable us
to be healthy, such as adequat
e food, housing, and a healthy
environment.
• Health care must be provided
as a public good forall, financ
ed publicly and equitably.
Countries that invest in UHC make a
sound investment in theirhuman capit
al. WHO 2018

4. National Health Security Office - Thailand
2016 - 2030

5. National Health Security Office - Thailand
3.83.8 Achieve universal health
coverage, including financial
riskprotection, access to
quality essential health-care
services and access to safe,access to safe,
effective, quality andeffective, quality and
affordable essentialaffordable essential
medicines and vaccines formedicines and vaccines for
all.all.
SDG 3: Ensure healthy lives and promote well-being for all atEnsure healthy lives and promote well-being for all at
all agesall ages

6. National Health Security Office - Thailand
The Sustainable Development Goals (SDGs) 2016-2030
SDG 3: Ensure healthy lives and promote well-being for all at allEnsure healthy lives and promote well-being for all at all
agesages
3.13.1 Reduce the global maternal mortality
3.23.2 End preventable deaths of newborns and children
under5 years of age
3.33.3 End the epidemics of AIDS, tuberculosis, malaria
and neglected tropical diseases and combat hepatitis,
water-borne diseases and othercommunicable
diseases.
3.43.4 Reduce by one third premature mortality from
non-communicable diseases through prevention and
treatment and promote mental health and well-being.
3.53.5 Strengthen the prevention and treatment of
substance abuse, including narcotic drug abuse and

7. National Health Security Office - Thailand
3.63.6 By 2020, halve the numberof global deaths and
injuries fromroad traffic accidents.
3.73.7 By 2030, ensure universal access to sexual and
reproductive health-care services, including forfamily
planning, information and education, and the
integration of reproductive health into national
strategies and programmes.
3.93.9 By 2030, substantially reduce the numberof deaths
and illnesses fromhazardous chemicals and air, water
and soil pollution and contamination.
The Sustainable Development Goals (SDGs) 2016-2030
SDG 3: Ensure healthy lives and promote well-being for all at allEnsure healthy lives and promote well-being for all at all
agesages

8. National Health Security Office - Thailand
Health and well-being : Why UHC ?

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Goal and objectives of UHC : Health financing
system
Health financing
arrangements
Revenue
collection
Pooling
Purchasing
Benefits
UHC intermediate
objectives
Equity in
resource
distribution
Efficiency
Transparency
and
accountability
UHC Goal
Utilization Need
(Equity in the
use of health
service)
Quality
Universal
financial protecti
on
Applied form : Diane McIntyre and Joseph Kutzin. Health financing country diagnostics: a foundation for national strategy development, WHO,
2016.

10. National Health Security Office - Thailand

11. National Health Security Office - Thailand
Conceptual Framework: ThreeConceptual Framework: Three
dimensions of UHCdimensions of UHC
Pooled funds
• to extend coverage
to those individuals
who previously were
not covered,
• to services that
previously were not
covered
• to reduce the direct
payments needed for
each service.
Source World Health Report : 2008 & 2010

12. National Health Security Office - Thailand
Social Health and Well-being Protection forAll
Why political willingness ?
http://journals.plos.org/plosmedicine/article?id=10.1371/
journal.pmed.1001693
Widen to
Social
Protection &
Base on
political will

13. National Health Security Office - Thailand
BENEFIT PACKAGE
• Benefit package in a desirable universal health
coverage should include health services from
health promotion, disease prevention, curation
, and rehabilitation.
• However, extending these health service
coverage will affect coverage of the other dime
nsions.
• It is difficult to cover 100% of these
dimensions.
• Therefore, some services may not cover or
require co-payment.
• In order to balance the coverage of these
dimensions, four related dimension of
effectiveness outcomes may be considered.

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UNIVERSAL HEALTH COVERAGE
• Towards UHC implementations are not only using financial mechanisms to
extend coverage but also promoting new relationship of key stakeholders in UHC.
• Roles of purchasers include to reimburse health care cost to service providers
according to service agreements, to prepare optimal benefit packages to be able
to promote effective outcomes and remove financial risks from the beneficiaries,
to ensure appropriate distribution of services between regions.
• Consumer right protections and stakeholder participations are also important to
promote good relationship with stakeholders.

15. National Health Security Office - Thailand
Utilization Need
(Equity in the use of health
service)
Goal and objectives of UHC : Health Financing
System

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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
48 M. pop
(reside in rural areas; Q1-2;
children, elderly, informal wk)
8 M. pop
(urban; Q4-5; children,
elderly, public sector
wk)
10 M. 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

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Thai UC – three dimensions of UC cube
• X axis:
– 99% pop overage by 3 schemes
[UCS 75%, SHI 15%, CSMBS 10%]
• Y axis:
– Free at point of services, very
minimum out-of-pocket
– Low incidence of catastrophic
health expenditure and medical
impoverishment
• Z axis:
– Extensive and comprehensive
benefit package, exclusion list for
some non-life threatening
services
– High cost services are covered
e.g. dialysis, chemotherapy

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Health care financing strategies of the UC policy
• Promote primary care Promote the use of primary care by
contracting a primary care unit (PCU) as the main contractor and
gatekeeper
• Benefit package of the UC scheme is quite comprehensive
comprising OP, hospitalization, health promotion and disease pre
vention, most of the high cost care, dental care, medicines and o
perations
• Decentralization  purchaser provider split, Promote Local
Government in Community Hea
• Cost containment  Changing provider payment from historical
allocations to close-ended payments;
18

19. National Health Security Office - Thailand
Primary Healthcare in Thailand
19

20. National Health Security Office - Thailand
Milestones of primary health care development in Thailand
present
Primary
care
services
1942
Health
centers
1968
Community
hospitals
1975
Adoption of
PHC/HFA
concept
1978
Decade of Health Center
Development (1992-2001
)
1992
Universal coverage schemeUniversal coverage scheme
UC policy:
promoting
primary care
2002
Traditional
herbal
medicine
20071996
Thai Health Care
Reform
Initiative
VHVs
1963
Sarapee
Banphai
Proj
1966
Watbot
Experiment
1974
Lampang
Project
Samerng,
Nonthai
Thai Health
promotion Fu
nd
2001
Civic movement
1981
1950
Vertical
Disease
Control
Programs
Financial
Crisis
1997
1999
Decentralization
started
HSRI
2014
2010
On top
payment for
Primary care
2013
Pay for QOF
(Primary Care
Level)
Strengthening of primary
care service system
Primary Care
Cluster

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Primary Care Development : UC Policy
– Strongly implement primary care service Policy , First
strategy – equity in accessibility + efficient health services +
increase health promotion and disease control
– Promote family medicine/family practice in PC unit
(Community Medical Unit)
– 2 main types of providers managed by NHSO to effect PC –
CUP, private clinics in cities (BMA)

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Service management: PHC orientation
• District health system is a typical contractor provider network
– Gate keeping role for OP and IP
– Patient bypassing contractor provider network without referral are
liable for full payment
– Rationale use of service by level: lower unit cost
– Better access: lower transport cost shouldered by patients
– Better outcome: continuity of NCD control, DM, HT
• Excellent centres were strengthened at regional level
– Referral centre for specialised care within the region e.g. heart,
cancer, trauma, premature babies
22

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Integrated
Healthcare
System
Medical Treatment/
Traditional Medical
Community Based
Home Healthcare
Health Volunteer Health Promotion
Prevention
Rehabilitation
Primary care Secondary Care Tertiary Care
• People/patient
network
Palliative CareRefer-send back
Local authority & community participation

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Community Hospital under UHC
• Medical care provider at district level, 120-150 beds
• CUP – contracting unit for primary care
– Main contractor = purchaser (but also be provider) – one
PCU
– Provide medical care services to the beneficiary : diagnosis,
treatment both inside/outside the hospital, and also integrat
ed health services: PP and rehabilitation, and mobile clinic
– Technical center and supervisor, supporting system for PCU
in the network: personnel, medicine, medical devices/ Com
munication system / monitoring-evaluation system / technic
al support and quality control

25. National Health Security Office - Thailand
Health Center under UHC
Strengthening primary care service
• PCU – catchment 10,000 pop, working 56 hrs/week, easy access
• Personnel: one physician, 2 registered nurse, 3 health sciences
officers, etc.
• Roles:
– PP services, continuity of care
– Curative care: diagnosis/curative – acute / chronic care,
primary care, EMS – 24 hrs. / coordinating care
– Dental care
– Home visit
• Support Primary Health Care and Community Development

26. National Health Security Office - Thailand
Community Health
Promotion Fund
Fund Management
Committee
Health promotion
Health prevent.
Youth
group
Aging
gr.
Diable
gr.
Chronic dis.
patient
NHSO co-finance 45
baht/cap. Muni.&TAO
co- finance 30,40,60 %
Community Health Plan with people participation
Primary Care
Wome
n gr.
- Sign contract with
TAOs & municipalities
- Train & build
capacity of Fund
Committee.
- Fund performance
monitor. &
evaluation
- Promote Innovation
and learning centers.
Rehabilitation
15% of total fund to support

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Community Health Fund: Community-based health care
2.
Considerate
Society
3.
Treatment
of common
diseases
4.
Care for
Chronic Diseases
5.
Care for
Elderly
7.
Health
Promotion
1.
Sufficiency
Economy
Better
Community
health
Strong
Community
6.
Diseases
control

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Primary Healthcare in Thailand
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30. National Health Security Office - Thailand
Collaborations Focusing on Active Aging and Long - term Care
LOCAL
GOVERNMENTS
LOCAL
GOVERNMENTS
NHSO
THAI HEALTH
PROMOTION
FOUNDATION
MINISTRY OF
HEALTH
MINISTRY OF
SOCIAL
DEVELOPMENT &
HUMAN SECURITY
1. LOCAL HEALTH
PROMOTION FUND
3.Long-term
care
Department of
Health
ACTIVE AGING ACTIVE AGING & LTC
Healthy
subdistricts
Elderly’s
centers for
quality of
life(ECQL)
2.Provincial
rehabilitation
fund

31. National Health Security Office - Thailand
201
6
2017
2018
LTCLTC BUDGETBUDGET 2016-20182016-2018
600 m
100,000
person
900 m
150,000
(growth
50%)
193,200
person
(growth
28.8%)
1,159m

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Purchaser
s
PeopleProviders
Policy
maker
Context based
learning &
Action
ConclusionConclusion

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Q & A and Discussion

34. National Health Security Office - Thailand
chuchai.s@nhso.go.th