66284 Thailand Country Development Partnership in Health (COP-H) Partnership Agreement Thi s partnership agreement, effective as of February 5, 2007. is between the ROYAL THAI GOVERNMENT and the World Bank. The agreement formally endorses the collaborative efforts to implement the CDP-H program in three areas: HIV/AIDS, health financing and human resources in health. Attached herewith is the concept paper, detailing the program framework, activities and implementation arrangements. t1 euA T~ ----- ... .... ................ .~..... Ian C. Porter Dr. Manit Teeratanitkanont Country Director, Thailand Deputy Permanent Secretary The World Bartle Ministry of Public Health Thailand Country Development Partnership in Health (CDP-H) Concept Paper February 2007 CDP-H 2 Table of Contents Table of Contents.......................................................................................................................................... 2 Introduction................................................................................................................................................... 3 Framework .................................................................................................................................................... 6 CDP-H Program............................................................................................................................................ 7 Component 1: Improving the Effectiveness of Thailand’s HIV Response.................................................. 8 Activities ................................................................................................................................................. 11 Component 2: Improving the Effectiveness of Public Expenditures in the Health Sector........................ 13 Activities ................................................................................................................................................. 15 Component 3: Improving Human Resources in Health............................................................................. 17 Activities ................................................................................................................................................. 18 Summary of Expected Outputs ................................................................................................................... 18 Implementation Arrangements.................................................................................................................... 20 Partners ....................................................................................................................................................... 20 Work plan and Timetable............................................................................................................................ 21 Summary Program Costing......................................................................................................................... 22 Annex 1: Thailand Country Development Partnership in Health Sector Policy Matrix............................. 25 Annex 2: Total Program Costing by Program Component and Main Activity .......................................... 42 CDP-H 3 Introduction 1. Thailand has enjoyed some remarkable successes in improving the overall health status of the population. During 1964 – 2000, life expectancy at birth substantially increased from 55.9 years to 69.4 years for male and 62.0 years to 74.1 years for female. Maternal Mortality Rate (MMR) declined from 374 to 13.7 per 100,000 live births during 1962 – 2003. Infant Mortality Rate (IMR) per 1,000 live births rapidly declined from 84.3 in 1964 to 26.1 in 1996. The rate of low - birth - weight newborns has dropped from 10.2 percent in 1990 to 8.9 percent in 2002. Some previously predominant public health problems are on decline: malnutrition, anemia among pregnant women, iodine deficiency disorders, vaccine-preventable diseases, helminthiases, malaria, encephalitis, leprosy, rabies and sexual transmitted infections. Effective HIV/AIDS policies from the 1990s prevented an estimated 7 million HIV infection from incurring by 2006. 2. However, there are also persisting old and new challenges. Although internationally Thailand has been seen as one of the most successful countries in the world in terms of AIDS prevention and control, projected numbers of HIV-infected persons are still massive and require urgent attention. Chronic non-communicable diseases such as heart disease and cancer have become the major causes of mortality among Thai people as a result of increased life expectancy and behavioral risk factors. While physical health has improved dramatically, a recent trend shows increase of mental disorders and suicide situation. The rate of outpatients attending mental health clinics has increased from 25 contacts per 1,000 population in 1991 to 37 in 2003. There are also emerging new infectious diseases as Severe Acute Respiratory Syndrome (SARS), foot-and-mouth disease, and avian influenza that need serious and timely attention; especially since there was one reported case of probable human to human transmission of H5N1. 3. Thailand’s health service system has evolved from self-reliance and traditional healers to a modern medical and public health service system where several levels of healthcare are being provided. The public sector is the main service provider with involvement of the private for- profit and non-profit sectors in a much smaller but increasing role. However, since the economic boom started in 1989, there has been a rapid expansion of private health facilities in Bangkok and other large cities. The growth of the private sector is a significant pull factor for health professionals to urban centers, due to a large gap of incentives between the two sectors. There are now large regional disparities in health service inputs: most medical doctors are concentrated in Bangkok and provinces in the Central region. In 2002, the doctor to population ratio varied from 1:767 in Bangkok to 1:7,251 in the Northeast (national average 1:2,750). CDP-H 4 Internal brain-drain has become a major human resource challenge for deploying and retaining professional health staff in rural and more remote areas. A similar divergence can be observed in the hospital bed/population ratio; in 2003 the ration in Bangkok was 1:206 compared to 1:759 in the Northeast. Diffusion of high-end medical technology (CT scanners, MRIs) follows the same trend. 4. Total health expenditure in 2001 was 3.2 percent of GDP. This is equivalent to 2,560 Baht per capita, 56 percent of it from public sources. Government funding for the health sector amounted to 7.4 percent of the total national budget allocation in the year 2003. Most of the budget was allocated for curative care at the central level, and to the lesser degree for health promotion and disease prevention. Based on National Health Accounts for 1994 to 2002, it is estimated that the total national health expenditure was around 3.50 percent of GDP in 2004, and would increase to 3.64 and 3.88 percent of GDP in 2010 and 2020, respectively. 1 Achieving almost universal coverage through public mandatory insurance arrangements in 2002 is one of the most significant achievements in the development of Thailand’s health system. It took 27 years from the emergence of the first targeting schemes for the poor to universal health coverage. The 2001 National Health Security Act merged the then existing Free Health Card for the Poor, subsidies for the less poor to join voluntary health insurance and added coverage for the 30 percent previously uninsured population to the pool to create a Universal Coverage scheme characterized by a flat 30 Thai Baht co-payment. The cost of this UC Scheme is born by the national budget. The UC scheme, the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Security Scheme (SSS) now cover an estimated 96 percent of the population, with the UC scheme alone covering 74 percent. Overall, the universal health insurance policy has been very effective in improving access to health services for the poor. Incidence of out of pocket catastrophic health expenditures (defined as more than 10 percent of household expenditures) declined from 5.4 percent in the pre-UC era to 3.3 percent after. The impact of out-of-pocket expenditures for health on increasing the poverty headcount (impoverishment) has declined from 2.1 percent to 0.8 percent. 2 Overall utilization of health centers and district hospital services has doubled after the introduction of the UC scheme. At the same time, the continuous implementation of the scheme is facing its own challenges, including ensuring sustainable funding sources, addressing cost-pressures, harmonization of benefits and management arrangements across the three Schemes (UC Scheme, CSMBS and SSS). 1 Patcharanarumol W, Cichon M, Tangcharoensathien V., Vasvid C., Tisayaticom K. 2006. Research series of Thai healthcare financing: part 1 financial reform options of healthcare coverage in Thailand. Journal of Health Science, 15(1): 17-30. 2 Limwattananon et al 2005 (from a presentation to the International Conference on Social Health Insurance in Developing Countries; December 5-7, 2005, Berlin, Germany. CDP-H 5 5. The Ministry of Public Health (MOPH) is the principal agency responsible for health policy, regulation and oversight. National Economic and Social Development Plans and corresponding sectoral development plans are the main instruments for setting strategic directions for sector development. Thailand’s Eighth National Economic and Social Development Plan (1997 – 2001) put people at the center for development. Economics was identified as a supporting tool for improving quality of life of the Thai citizen. The Ninth Plan (2002 – 2006) continued to focus on human-centered development and embraced the Sufficiency Economy Philosophy as the direction for the country’s development and administration. In this Plan, health is a holistic concept including physical, mental, social and spiritual well-being. To improve an individual’s health status it is, therefore, necessary to develop all four aspects of human, social, economic and environmental development. 6. In accordance with the Ninth Plan, the National Health Development Plan of the same period has identified seven development strategies, which includes (i) development of management systems for health, (ii) development of health security and service quality, (iii) development of basic factors for good health and health promotion, (iv) development of people’s healthy behaviors and potential as well as strength of civic groups for health, (v) development of health knowledge and technology, (vi) management of human resources for health, and (vii) development of Thailand’s competitiveness in health. Through these strategies, Thailand has observed improvements in the quality of life of the Thai citizen with regard to health. 7. The MOPH is still also closely involved in the integrated management of public health services. The health services concept in Thailand comprises of the following: (i) self-care at family level, (ii) primary health care level, (iii) secondary care level, and (iv) tertiary care level. Although the Thai health care system is pluralistic, it is dominated by the public sector, in particular in rural areas where more than 2/3 of the population resides. In 2003, there were 9,765 rural health centers covering all sub-districts; 725 community hospitals with 10-120 beds covering 91 percent of districts; 74 general hospitals; 25 regional hospitals; 57 military hospitals; and 10 medical school hospitals. The management of Government health facilities has historically been very centralized. Centralized MOPH management is now being challenged by a new decentralization policy as well as by the emergence of third party payers. As mentioned above, since the economic boom of the late 1980s, the private sector has been growing; 364 private hospitals provided an additional 34,863 beds and about 15,000 private clinics, mostly in urban areas. CDP-H 6 Framework 8. The CDP instrument. The World Bank’s latest Country Assistant Strategy (CAS) entitled “Partnership for Development� formalizes a new and innovative partnership between Thailand and the World Bank Group, shifting from primarily a borrower-lender relationship toward a true development partnership. Under the new partnership, the Government sets its national agenda, currently comprising four pillars: human and social capital; community development and poverty alleviation; economic restructuring for balanced and sustainable growth; and good governance. The Bank group focuses its intervention on areas where it can play a catalytic role. It also supports sharing Thai lessons with other countries in the Region, such as Thailand’s successes in HIV/AIDS control, universal health insurance coverage and human resources for health. 9. The primary instrument for Bank assistance to Thailand is the Country Development Partnership (CDP), in which the Bank’s support can take the form of analytical and advisory activities, technical assistance, capacity building, donor coordination, and/ or partnership. The CDP also serves as a vehicle for engaging civil society, the private sector, and other partners in the policy (re)design, implementation and monitoring process. To date, CDPs have been initiated in six areas: social protection, education, financial and corporate competitiveness, poverty analysis and monitoring, governance and public sector, and environment. 10. The Royal Thai Government (RTG) and the World Bank have had a very positive experience with previous CDPs. For example, the CDP-Basic Education Reform (CDP-ED) was formalized in February 2004 after a series of consultations with the Ministry of Education (MOE) and other key Ministries and agencies involved. Three priority areas were identified to assist the RTG in the implementation of its ongoing, but rather slow, education reform program. They included (i) basic education finance reform, (ii) decentralized school-based management, and (iii) teacher development in core curriculum skills of mathematics and science. The key counterparts were the Office of the Education Council (OEC) and the Office of the Basic Education Commission (OBEC). 11. Several key factors contributed to the success of the implementation of the CDP-ED. First of all, the CDP-ED was responsive and in line with the Government’s interests and priorities. Secondly, the nature of this CDP-ED was policy-based as well as implementation- focused that moved beyond research studies to pilot testing. Documented positive and negative results create conditions for wider implementation, especially when key stakeholders – from CDP-H 7 policy level administrators to practitioners – have been involved. Finally, a Steering Committee (SC) and three Working Groups (WGs) contributed significantly to the successful implementation of the CDP-ED. The SC was dedicated, committed and highly effective in providing overall oversight and guidance of the implementation and in keeping up implementation momentum. The WGs, comprising of well known scholars and practitioners, provided a clear direction to guide the research work under Phase I and pilot implementation during Phase II. Experience with the CDP-ED and other successful partnerships have guided the preparation process of this program. 13. Based on the successful experience with CDPs in other sectors and in the face of ongoing and newly emerging challenges in the health sector, the RTG has requested for Bank support through a health sector Country Development Partnership (CDP-H). The partnership will also facilitate the sharing of relevant Thai health sector development experience in the East-Asia and Pacific Region and beyond. CDP-H Program 14. Program objectives are to support the development of the Thai health sector’s agenda in three main areas: (i) sustaining HIV/AIDS program financing and revitalizing HIV prevention and impact mitigation, including improving Anti-Retroviral Treatment (ART) program performance,(ii) strengthening public expenditure management capacity in the health sector, particularly for the general tax-funded Universal Coverage (UC) Scheme in order to achieve sustainable financing healthcare for the whole population, improve efficiency and harmonization across three public insurance schemes, in the context of decentralization, and (iii) evaluating and disseminating lessons learned of Thai experiences on addressing health sector human resource challenges for the benefit of countries in the Asia Pacific region. 15. The scope of the partnership was developed through several collaborative meetings between the World Bank and Ministry of Public Health teams. The HIV/AIDS epidemic continues to be an important public health challenge and the proposed collaboration is based on the good track record of the previous collaborative work on the economics of HIV/AIDS treatment, as well as on Voluntary Counseling and Testing. Long-term sustainability of the successful universal health insurance coverage program had been raised by the Thai counterpart as the highest priority issue for the partnership, in particular in view of the perceived comparative advantages and experience of the World Bank in this area. The human resources component was included when it was globally identified as one of the major constraints affecting the capacity of health care systems to deal with health challenges. Thailand has in the recent past CDP-H 8 implemented successful policies on addressing health human resource challenges that should be shared and learned among countries in the region and beyond. 16. There are also several cross-cutting issues across the components of the partnership. The HIV/AIDS epidemic and cost of ARV treatment is closely linked to the sustainability of the Government health insurance schemes. The governance and implementation arrangements of the HIV/AIDS program are linked to the inclusion of HIV/AIDS treatment and some prevention costs into health insurance coverage. Human resource issues are important for both high quality HIV/AIDS prevention and treatment as well as for improved institutional capacity of Government health insurance schemes. These links will be recognized when implementing the partnership. Component 1: Improving the Effectiveness of Thailand’s HIV Response 17. Since the first AIDS case was reported in 1984, Thailand has faced a serious and evolving HIV epidemic. In the first wave of its epidemic in the late 1980s, HIV infections exploded among injecting drug users, reaching 40 percent among those who visited clinics in just one year. A second wave soon followed, with HIV infections developing among sex workers in the Northern Chiang Mai area, reaching 44 percent by 1989. This second wave soon engulfed sex workers in Bangkok and elsewhere, and spread to the male clients of sex workers and thereafter to their sexual partners. By 1991, HIV infections peaked at 143,000 cases. 18. Thailand initially viewed HIV as a foreign disease limited largely to foreigners, that warranted only a small budget - USD180,000 in 1988. However, in 1991, Thailand under the premiership of Mr. Anand Panyarachun, launched a massive HIV response, in which the RTG: • Moved the AIDS program to the Prime Ministers’ Office; • Increased HIV expenditure over 20-fold, to USD44 million by 1993; • Launched a nationwide HIV awareness campaign under the leadership of cabinet minister Mechai Viravaidya; • And most importantly, initiated the 100 percent condom program. This program made consistent condom use compulsory in all sex establishments, distributing free condoms and enforced compliance, otherwise legal sanctions would be applied to these brothels. 19. The results were dramatic. The program reduced visits to commercial sex workers by half, increased condom use to 90 percent, cut Sexually Transmitted Illnesses (STIs) by 90 percent and greatly reduced Thailand’s overall HIV epidemic, from a peak of 143,000 HIV cases in 1991 to 20,000 in 2005. CDP-H 9 20. Between 1996 and 1999, programs to prevent vertical transmission from HIV-positive mothers expanded from pilot sites to a national scale throughout the country. Universal access to ART took place in 2001; by 2006 Thailand was providing treatment to over 100,000 cumulative number of People Living with AIDS (PLWA) who are members of the three public insurance schemes, including those treated in the private sector. Thailand has now almost achieved universal treatment coverage for public funded free ART services. However, there are concerns about program performance, particularly physician preparedness, early recruitment and ensuring treatment adherence. These concerns have grown after a recent joint study with the World Bank underscored the importance of improving program performance to preserve first-line antiretroviral regimens. 21. Notwithstanding these notable successes, major challenges remain in an evolving HIV epidemic. The Asian Economic Crisis led to a reduced government investment in nearly all areas, including AIDS prevention. While expenditure has recovered, it is now orientated largely to treatment and care, and HIV prevention spending has declined in its proportion of total expenditure on HIV/AIDS. 3 HIV is still by far the largest cause of mortality among Thais aged 15-44. Residual transmission in commercial sex remains unacceptably high. The largest source of HIV infection in Thailand today is among discordant couples, largely men already infected through commercial sex, to their spouses. HIV infection among injecting drug users has never been successfully addressed, with HIV prevalence rates from 35-50 percent and remains a major amplifier of HIV in Thailand. HIV prevalence among men-having-sex-with-men in Bangkok has grown from 17.3 percent in 2003 to 28.3 percent in 2005. The scope and coverage of interventions for men-having-sex-with-men is currently limited. 22. The recent public sector reform in 2001 spearheaded by the Civil Service Commission has ruined the institutional capacity on HIV control in the existing STI clinics under the Provincial Health Office (PHO), on the grounds that PHO has no role in service provision. STI clinics provided weekly health checks; information, education and communication activities; advocacy of condoms for Commercial Sex Workers (CSW) and played a major role in successful HIV control in the past years. This role was transferred to the Provincial Hospital, who had no skill-mix in community outreach or work with CSW. Most importantly, CSW are reluctant to use services in provincial hospitals, due to stigmatization. Another major problem is the recent decentralization policy in which the MOPH allocated HIV prevention budgets to provincial governors, but they are not responsive to requests to support HIV prevention services. 3 Teokul W, Patcharanarumol W, Vasavid C, Kittireangcharn N, Khananurak B, Cheewacheun P and Tangcharoensathien V, 2005 Thailand National AIDS account. Nonthaburi, Ministry of Public Health, IHPP. CDP-H 10 23. In summary, HIV prevention requires revitalization in the context of an evolving HIV epidemic and an emphasis on treatment. As we turn to AIDS treatment, we must remind ourselves that AIDS treatment is only feasible in a context of effective HIV prevention and Voluntary Counseling and Testing (VCT). No country has yet successfully achieved universal coverage of AIDS treatment in the face of sustained high HIV transmission. Effective HIV prevention is an absolute prerequisite for sustainable AIDS treatment. Alongside, the recognition that AIDS treatment has received greater emphasis on HIV prevention in recent years is a recognition that AIDS impact mitigation – ameliorating the impact of AIDS among orphans and vulnerable children and the elderly – has also been neglected and requires concerted analysis and attention. 24. Thailand also recognizes that it faces major challenges in AIDS treatment. The quality and performance of the AIDS treatment program is open to question and requires a rigorous review and reinforcement. This is critical to ensure that existing affordable front-line HIV treatment regimens are protected and preserved for as long as possible, to minimize costly recourse to second line treatment. To date, there have been relatively few cases of treatment failure in Thailand, and there is still every opportunity to maximize the lifespan of first-line treatment. At present, there are several obstacles to optimal treatment performance, but these obstacles have not been systematically analyzed, in order to develop a training and support program to enhance treatment performance. Major obstacles include limited and uneven physician preparedness, inadequate client management and follow-up and incomplete treatment adherence. A rigorous AIDS treatment program review would identify several opportunities to strengthen the performance of the treatment program and propose concrete measures to rapidly enhance treatment performance, based on strengthened ART systems, guidelines, training, supervision and support. 25. The proposed HIV analysis has significant benefits not only for Thailand, but for the wider Asian region. The prevention challenges faced by Thailand – revitalizing prevention in the context of an evolving epidemic and behavioral reversal in light of complacency and treatment availability – are challenges which other countries in Asia with mature and successful responses – including Cambodia in East Asia and India in South Asia – also confront. Similarly, Thailand, with the most extensive and advanced HIV treatment program in developing countries in Asia, faces the challenges of improving and protecting first line treatment and optimally introducing second line treatment before other Asian countries. This analysis of Thailand’s prevention and treatment challenges, as well as response options thus constitutes a major public good for the wider Asian context, and has significant global benefits which extend beyond Asia. CDP-H 11 Activities 26. Sub-component 1.1: Revitalizing HIV prevention and impact mitigation. The overarching aim of this sub-component is to increase coverage of, and revitalize prevention programs among vulnerable groups. Specifically, this sub-component aims to: (i) convince AIDS policy makers that HIV prevention must be revitalized to reduce future HIV infections and ensure the sustainability of AIDS treatment; (ii) revitalize HIV prevention investments and interventions, and provide clear policy guidance on effective prevention options and prioritization of emerging target populations; (iii) establish a clear policy and good intervention practices on impact mitigation, in relation to orphans and vulnerable children and the elderly who are affected by AIDS; and, (iv) ensure adequate program financing and political commitment for a reinvigorated HIV prevention agenda. The major emphasis will be on revitalizing prevention, with a secondary focus on impact mitigation. Treatment itself has major mitigation effects, both for the patient and his/her relatives and there are social safety nets in Thailand. 27. The activities comprise of: (i) analyzing the changing patterns of HIV transmission in Thailand’s evolving epidemic, which has changed its character and composition greatly over nearly three decades; (ii) assessing the adequacy of existing HIV prevention interventions, in relation to the sources of HIV transmission identified above, and in the light of anecdotal evidence of complacency and behavioral reversals following early prevention successes and current treatment availability; (iii) identifying an optimal mix of intervention priorities to address both the established and evolving patterns of transmission in Thailand (for example, while sex work programs remains a significant source of transmission, recent evidence suggests a greater proportion of infections may be occurring among discordant couples, men-having-sex-with-men and injecting drug users); (iv) conducting a cost-effectiveness analysis to identify the most cost- effective intervention priorities and delivery mechanisms in Thailand; (v) based on evidence generated above, producing a revised national HIV prevention strategy and the implementation plan; (vi) convening a major policy dialogue forum among key stakeholders and general public to reaffirm the primacy of prevention and build consensus on an effective HIV prevention agenda. 28. Sub-component 1.2: Improving AIDS treatment program performance. This subcomponent aims to improve the performance of the AIDS treatment program by systematically examining and addressing early recruitment, physician preparedness, client management, community participation and support, treatment adherence, minimization of resistance, prolonging of first-line treatment, behavioral dis-inhibition and risk compensation and CDP-H 12 HIV prevention among discordant couples. The objectives of this assignment are: (i) to strengthen primary HIV prevention among discordant couples; (ii) to enhance treatment program performance to ensure that first-line treatment is preserved for as long as possible; and (iii) to improve planning and delivery of second-line treatment. 29. The activities include: (i) assessing the current program performance in order to identify strengths and weakness for improvement; (ii) proposing concrete actions to improve program performance, based on the above analyses; and (iii) convening a major policy dialogue forum among key stakeholders and the general public to affirm the importance of improving the quality, and performance of the AIDS treatment program. 30. Sub-component 1.3: Adequate and sustainable AIDS program financing. This sub- component aims to ensure adequate and sustainable financing of the national AIDS program, through better use and wider mobilization and better harmonization of different sources of finance. 31. The activities for this sub-component include: (i) continuing the ongoing resource tracking exercise; (ii) estimating and projecting resource needs in the future based on existing data where possible and the modeled trend of HIV epidemic under a range of assumptions; and (iii) comparing total AIDS expenditure projections to total health expenditure projections in order to assess the proportionality of projected AIDS expenditure. 32. Sub-component 1.4: HIV/AIDS program governance. This component aims to develop and implement a clear and coherent institutional structure for optimal AIDS program management in the face of the need to revitalize prevention to achieve universal treatment coverage, and integrate the contributions of numerous stakeholders which include NHSO, BATS, SSO, MOF and local administrations. Several commentators have noted that episodic independent institutional reviews are an underemphasized element of a sustained AIDS response. 33. This sub-component comprises of the following activities: (i) a detailed institutional analysis, which assesses the strengths and weaknesses of the current program’s governance and institutional arrangements, in the face of program integration into the health system and decentralization; (ii) an assessment of institutional experiences and lessons in other countries that may be relevant for Thailand; and (iii) the achievement of a consensus among key stakeholders on an optimum governance and institutional management structure for Thailand’s AIDS program. CDP-H 13 Component 2: Improving the Effectiveness of Public Expenditures in the Health Sector 34. Since October 2001, Thailand has introduced sweeping reforms of public finance in the health sector. From general revenues, the Government now provides health insurance to about 47 million people (74 percent of the population) through the UC Scheme. This is in addition to the two other public health insurance schemes that existed before – SSS and CSMBS. The overall goal is to ensure that the entire Thai population benefits from universal health insurance coverage. Introduction of the policy was a remarkable success and is being closely monitored by other countries in the region that are struggling with ensuring access to health services for their populations. In October 2006, the new Government announced plans to abolish the co-payment of 30 Baht, increasing worries about rising cost-pressures on public expenditures, moral hazard and increased utilization rates. The new Government has set up working groups to review options and advise Government on the medium term health sector development agenda. 35. The introduction of the universal health insurance policy also meant that most of public expenditures in the health sector are now channeled through public health insurance schemes. In 2002, the three Schemes accounted for 74 percent of total Government expenditure in the health sector of 114 Billion Baht. The tax-funded UC Scheme alone accounted for 47 percent of total Government health sector expenditure. The MOPH is moving away from an integrated model of service provision and the government set up the National Health Security Office (NHSO) as a purchaser of health care from MOPH as well as private facilities for its members when the contract model was adopted. This poses significant institutional challenges for public expenditure management in the health sector. The schemes are facing rapid escalation of cost driven by increased utilization of services by the insured population, new technologies and incentives inducing supply-induced demand, especially for CSMBS where fee for service reimbursement is the major payment method for providers. 36. The UC Scheme experienced 30 and 37 percent annual increases in utilization of outpatient services between 2001-2003 and 2003-2004 respectively, and for inpatient services the respective rates were 9 and 14 percent. Such trends, without close monitoring and evaluation, pose risks for the sustainability of health coverage that is largely supported by public expenditures. For instance, a recent successful World Bank-Thailand joint study "The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand�, notes that the Government’s proposal to include ART for AIDS patients raises concerns about the sustainability of the overall health care financing system and the expansion of coverage in particular for second-line Anti-Retroviral (ARV) drugs would require careful analysis. CDP-H 14 37. Renal Replacement Therapy (RRT) was excluded from the benefit package of the UC scheme since its beginning in 2001, due to high cost and significant long term financial implications. However, the two other Schemes (CSBMS and SSS) fully include RRT in their benefit package. International Health Policy Program (IHPP) has generated several models of forecast demand, financial implications of RRT, cost effectiveness and supply side assessments. The cost per life year saved 4 for peritoneal dialysis was USD 10,170 and hemodialysis, USD 10,490. This was four times of GNI per capita (USD 2,540 per capita, World Development Report 2004). However, the cost per life year saved for ART 5 was USD 590. According to Musgrove (2000), RRT is neither a public good nor produces a positive externality. The catastrophic nature to households seems to be the only justification for public spending on RRT. The current policy agenda under discussion is whether the UC scheme should provide RRT for its members and if so, how the overall costs could be managed. If RRT is included, it would put serious long-term financial stress on the scheme. 38. To cope with these challenges, new capacities need to be acquired and institutionalized, including actuarial analysis to appropriately predict the expenditure needs and impact of including new benefits into the Government financed insurance scheme; moving from input- to output-based financing arrangements and using contracts as the main instrument for expenditure controls; appropriately costing the outputs; and monitoring and accountability for effectiveness and appropriate use of public funds. 39. There are also challenges arising from historical fragmentation in the management of the three public schemes: the UC Scheme is being managed by the National Health Security Office (NHSO), MOPH; the CSMBS is managed by the Department of Comptroller General (DCG), Ministry of Finance (MOF); and the SSS by the Social Security Office (SSO) and Ministry of Labor (MOL). Formal accountability arrangements differ with NHSO being governed by a board with wide stakeholder representation and the CSMBS being integrated into MOF structures. Fragmentation of the schemes is also expressed in differences in benefit packages that pose a challenge to the policy objective of universal insurance coverage. Although legislation has been passed assigning overall coordination responsibility of public health insurance schemes to the NHSO, an action plan for the harmonization of management arrangements and benefits is yet to be agreed upon and implemented. 4 Tangcharoensathien et a.l 2005. Universal Access to Renal Replacement Therapy in Thailand: A Policy Analysis. IHPP, 5 Lertiendumrong J, Yenjitr C, Tangcharoensathien V. 2005. Cost and consequence of ART policy in Thailand. Background paper: Economic evaluation of Anti-retroviral policy. Nonthaburi: Ministry of Public Health, International Health Policy Program. CDP-H 15 40. In 2002, the Government also launched a decentralization reform in public finance management. This reform aims to decentralize 35 percent of public revenues and expenditures to local governments. The implication of this decentralization policy on public financing of the health sector and the modality for its implementation still needs to be developed. An early proposal of introducing Area Boards to manage the UC Scheme has not been implemented because of capacity constraints. 41. The purpose of the component is to strengthen public expenditure management in the health sector through (i) better capability to forecast expenditure needs; (ii) harmonization of benefits and management arrangements among the three public health insurance schemes and in the context of Thailand’s decentralization policy; (iii) strengthening expenditure management, monitoring and accountability arrangements of the public health insurance schemes; and (iv) ensuring efficiency of public expenditures through appropriate incentives to providers and patients. Activities 42. Sub-component 2.1: Developing a model for sustainable health financing path. This sub-component will build actuarial and modeling capacity in the NHSO for estimating public expenditure needs for the UC Scheme, CSMBS and SSS, and identifying sources for covering these needs in the framework of the overall public financing development context in Thailand. It will analyze cost-pressures on the UC Scheme stemming from demographic and a changing disease profile in the society, modernization of medical technologies, mainstreaming new benefits (e.g. universal coverage of ART for AIDS patients) and prevailing incentives in the current health services financing modalities. It will attempt to model both, expected changes in demand as well as supply side response. MOPH has set up in October 2006 ten task forces to scrutinize how the UC scheme could be further strengthened. Long term financing is a major concern. This sub-component would work in synergy with the task force on UC Scheme chaired by Professor Ammar Siamwala. 43. Sub-component 2.2: Developing policy options for harmonization of the three public health insurance schemes. This sub-component will support a set of activities which will aim to reach consensus on realistic steps towards harmonizing (i) fund management arrangements; (ii) benefit packages; (iii) contracts and financing modalities for healthcare providers; and (iv) financial accountability arrangements to ensure effective use of resources in the three schemes. The activities will take into account ongoing discussions on harmonizing drug benefits, medical audits and information management systems. CDP-H 16 44. Activities will comprise of an analysis of the strengths and weaknesses of current arrangements, costs of the core benefit package common for the three Schemes, development options for synergies in the management of the schemes at the national and local levels, and consensus building activities for the harmonization agenda. 45. Sub-component 2.3: Improving public expenditure management in the health sector. This sub-component will review evidence of incentive-driven inefficiency in public expenditure in the three public health insurance schemes. It will review evidence of moral hazard among the population from essentially free healthcare. It will also review evidence of supply-induced demand and cost escalation. In particular, the CSMBS is experiencing double-digit annual rates of cost increase. Public per capita subsidy to CSMBS in 2006 is 3.6 times higher than per UC beneficiary. It will assess institutional capacity of the three public schemes to engage in the design and enforcement of performance contracting to monitor utilization of health services and expenditure. The scope of work will also include relevant issues about health care providers, such as continued supply side subsidies to public health care providers for staff salaries that may dilute incentives from insurance payments and create an uneven playing field for the private sector; as well as the ability of health care providers to respond to incentives such as decision rights about staffing or residual claimant. 46. The component will propose policy instruments to improve the efficiency of expenditures and options for institutional capacity strengthening to effectively implement the proposed instruments. 47. Sub-component 2.4: Developing a model and institutional strengthening plan for appropriate level decentralization of public health insurance schemes and expenditure management. This sub-component will review the implication of the RTG’s 2002 decentralization policy on public finance, and the public service provision roles of Local Administration Units on the public health financing and expenditure management arrangements in the health sector. It will also recommend and facilitate consensus building on the appropriate level of decentralization needed for public financing to avoid fragmentation of insurance risk pools and to ensure delivery of public health goods, and will also recommend options for decentralized institutional and accountability arrangements. It will also develop an action plan for institutional strengthening of the decentralized level of public health expenditure management. CDP-H 17 Component 3: Improving Human Resources in Health 48. The delivery of health services is staff intensive and the number, skill levels, and motivation of the health workforce is among the main determinants of the performance of the health system. Inadequate attention to health workforce issues has limited the effectiveness of the implementation of health programs. Health workforce challenges in the public sector include: a lack of qualified professionals, difficulties in deploying health workers to rural and remote areas, skill mix, low morale and poor performance. These contribute to low quality care and inequality in access. At the same time, the private sector is becoming a major contributor to service delivery and its role is not adequately recognized or integrated in health sector dialogue and policies. 49. The central importance of the health workforce in achieving better health outcomes and meeting the Millennium Development Goals (MDGs) has been recognized by several East Asian and Pacific countries, all of whom have highlighted it as a high priority item in their development agenda. Thailand in particular has in the past implemented successful human resource policies that enabled to recruit, deploy and maintain professional health staff in rural areas. In 1967, the Thai Government enforced a three-year mandatory public service for new medical graduates (and later extended to nurses, pharmacists and dentists) where more than two- thirds of them were deployed in rural areas. Since 1975, the government started incentives for rural doctors, including hardship allowances, no-private practice allowances, over-time payments and non-official hours special service allowances. In addition to financial incentives, the Government also used non-financial incentives such as higher career status of rural doctors,6 social recognition and preferential entry to residency training programs for candidates having completed rural health services. 50. However, rapid development of a medical services export industry in Thailand and growing domestic demand from the Thai middle class have contributed to the growth of the private sector, and a strong pull for health professionals from rural areas to urban areas and into the private sector. Although, the Government has further increased incentives for deployment of health professionals to rural areas, the income differentials up to 11 times are hard to resist. The RTG is currently devising strategies for ensuring increased supply of health professionals to rural areas. 6 Cha-aim Pachanee, Suwit Wibulpolprasert. Dual Track Health Policies: Incoherence between the Policies on Universal Coverage of Health Insurance and Promotion of International Trade in Health Services in Thailand. Pre- publication copy from authors. CDP-H 18 51. Thailand’s past successes and current challenges are an interesting example for other countries in the region that face serious human resource issues in the health sector. This is the case for example in Cambodia, Indonesia, Timor Leste and Vietnam. Thailand has been leading an Asia Pacific Action Alliance on Human Resources for Health (AAAH) to work on human resource issues that are of interest regionally and globally. In the true nature of partnership, the proposed CDP-H will support systematizing experiences on Thailand human resource policies and regional dissemination of lessons learned. 52. This component will be implemented in the framework of the East Asia regional study on human resources in the health sector supported by the Bank Netherlands Partnership Program. This program includes Thailand as a case study of successful human resource policies in the past as well as the analysis of policy responses to the current challenge of internal brain drain from the public to the private sector that is also relevant to low income countries in the region. Activities 53. Sub-component 3.1: Health workforce challenges in Thailand. This sub-component will undertake an in-depth review of health workforce challenges in the past and at present in Thailand and an evaluation of strategies for workforce management in order to identify effective and ineffective practices. 54. Sub-component 3.2: Regional learning on health workforce management. This sub- component will support regional learning and dissemination activities on effective health sector human resource policies. Thai experts in HR can play an important catalytic role to develop local capacity for addressing national policy and strategies towards HRH in other developing nations. The work in this sub-component would be in the context of ongoing activities sponsored under AAAH. Summary of Expected Outputs 55. Component 1: Improving the Effectiveness of Thailand’s HIV Response. The impact of this component would improve capacity among Thai counterparts in the governance of the HIV/AIDS program, and harmonize the ART program across the three public insurance schemes through consensus building among major stakeholders. The work will also contribute to the Bank’s regional knowledge generation on effective HIV/AIDS programs and policies, and complement the Bank supported HIV/AIDS work in China, Vietnam and Indonesia. Other quantifiable outputs include: CDP-H 19 A research-based policy paper on revitalizing prevention in the face of UC, ART and decentralization, including detailed descriptions for effective HIV prevention and a detailed implementation plan for a revitalized HIV prevention strategy; An institutional assessment report on the strengths and weaknesses of the current HIV/AIDS program, in the face of program integration into the health system in the context of decentralization and action steps to improve AIDS treatment program performance; A policy and analytic paper on AIDS financing which presents projections, identifies funding sources and gaps, and proposes strategies for adequate and sustainable financing based on better use, wider mobilization and greater harmonization of AIDS financing; An institutional appraisal report assessing strengths and weaknesses of the current HIV/AIDS program governance and institutional arrangements, in the face of program integration into the health system and decentralization; and A series of consultation and dissemination workshops to ensure that the reports will contribute to the national policy making and implementation in the HIV/AIDS area. 56. Component 2: Improving the Effectiveness of Public Expenditures in the Health Sector. The impact of this component would be improved capacity among Thai partners in the modeling of long term financial sustainability, management of the UC scheme in order to improve its efficiency, harmonization of the three public insurance schemes, especially in the context of decentralization. This component is also expected to contribute to the regional and global knowledge of scaling up health insurance coverage in low and middle income countries. Other quantifiable outputs include: An analysis of cost-pressures on the UC Scheme, a sustainable health financing path model for the NHSO and the MOF for estimating public expenditure needs for the UC Scheme, CSMBS and SSS, identifying sources for covering these needs; An analysis of strengths and weaknesses of current health expenditure arrangements, the costs of a core benefit package common to the three schemes and options for synergies in the management of the schemes at the national and local levels within a consensus building process on options to improve harmonization; A review of incentive-driven inefficiency in public expenditure (including moral hazard of the population, supply-induced demand and cost escalation) and institutional capacity of the three public health insurance Schemes including policy options for institutional capacity strengthening; A review on the implications of the RTG’s decentralization policy on public finance and public service provision, including recommendations on the appropriate level of CDP-H 20 decentralization of public health insurance schemes and an action plan for institutional strengthening of decentralized public health expenditure management; and A series of consultation and dissemination workshops to ensure that the reports will contribute to the national health financing policy making and implementation as well as into international learning of Thai experience. 57. Component 3: Improving Human Resources in Health. The impact of this component would be improved capacity among Thai partners on research and development in HRH issues. Other quantifiable outputs include: An in-depth review of the health workforce in Thailand and an evaluation of innovative and effective strategies for workforce management; and Regional learning and dissemination on effective health sector human resource policies in the context of ongoing activities under AAAH. Implementation Arrangements 58. A Project Steering Committee (SC) is proposed. It will be Chaired by Dr. Suwit Wibulpolprasert. Other SC members will include the Deputy Director General of SSO, NHSO, Comptroller Generals Department (CGD) of MOF, National Economic and Social Development Board (NESDB), Disease Control Department (DCD) and Bureau of AIDS, Tuberculosis and Sexually Transmitted Infections (BATS) of MOPH, Local Government Support Department of Ministry of Interior (MOI), NGO representatives, the World Bank, and Professor Ammar Siamwala. IHPP will serve as the secretary of the SC, this includes Dr. Viroj Tangcharoensathien as secretary, Dr. Supon Limwattananon as deputy secretary and Ms. Suriwan Thaiprayoon as assistant secretary. 59. IHPP is designated to be the focal point for the implementation of partnership activities, assisting on coordination and communication with the World Bank. IHPP will also be the implementing agency for the IDF grant to finance activities under Component 2. Dr. Supon Limwattananon would be the main focal point on technical coordination and Ms. Chawewan Yenjitr on administrative coordination. Partners 60. Thailand Team: IHPP, BATS, DCD, NHSO, Ministry of Labor’s SSO, MOF’s CGD, MOI’s Local Government Support Department (LGSD), NESDB, and other relevant NGOs. CDP-H 21 61. World Bank Team: Toomas Palu (Senior Health Specialist; Task Team Leader), David Wilson (HIV/AIDS Specialist), George Schieber (Principal Health Financing Specialist), Luis Benveniste (Human Development Sector Coordinator), Achariya Kohtbantau (Human Development Program Specialist), and other staff and consultants as required. Work plan and Timetable 1st ½ 2nd ½ 1st ½ 2nd ½ 1st ½ 2nd ½ Lead agency 2007 2007 2008 2008 2009 2009 HIV/AIDS component 1.1 prevention * BATS/IHPP 1.2 ART pg performance BATS 1.3 Sustainable ART IHPP/BATS program financing 1.4 HIV program BATS governance Healthcare financing component 2.1 Sustainable financing IHPP of healthcare 2.2 Harmonization of Consortium*** insurance schemes 2.3 Public expenditure Consortium management 2.4 Decentralization and ** Consortium financing Steering Committee IHPP meeting**** Note * ready to feed into annual budget processes for FY2009 ** By then the political dimension of the decentralization policy would be clearer *** the existing consortium of harmonization across 3 public insurance schemes, organized by NHSO **** the SC meeting would take place on January and July each year, altogether six meetings CDP-H 22 Summary Program Costing 62. The Table below summarizes the estimated costs and funding sources for the CDP-H. Unit: USD Source of Fund Gap Remarks Estimated % Component cost % WB % Govt % Other WB support 1 576,867 100 282,000 49 14,100 2 0 0 280,767 from Global Fund; Govt 1.1 204,300 194,200 10,100 support is approximately 1.2 176,556 0 0 176,556 2% of the total estimated cost 1.3 114,956 0 0 114,956 or 5% of the 2 prioritized HIV/AIDS sup- programs 1.1 1.4 81,055 77,055 4,000 and 1.4. WB support 2 804,261 100 395,000 49 376,700 47 0 0 32,561 from IDF grant. * from EU grant 2.1 93,711 65,311 28,400 on health sector reform phase II 2.2 114,161 85,761 28,400 (2005 – 2009), managed by 2.3 460,622 168,922 291,700* NHSO for capacity building for staff in and 2.4 135,767 75,006 28,200 32,561 outside NHSO WB support 3 70,000 100 70,000 100 0 0 0 0 0 from BNPP regional TF; 3.1 35,000 35,000 0 Government support in kind 3.2 35,000 35,000 0 from AAAH. Project mgmt 140,833 100 0 0 140,833 100 0 0 Grand total 1,591,961 100 747,000 47 531,633 40 0 0 327,428 Note: Program costing, original in Thai Baht, uses the exchange rate of Baht 36/ USD Due to budget constraints, the MOPH has prioritized the 2 sub-components in the HIV/AIDS program to be financed under the CDP-H, namely 1.1 revitalizing HIV prevention and 1.4 HIV/AIDS program governance. The other two sub-components are subject to further funding availability. The funding gap appearing in Component 2 originated from different exchange rates used at the time of the original budget costing for the IDF proposal and finalization of this concept note. Rearrangement within the component may be required when the component is implemented. CDP-H 23 63. In addition the program is supported by about USD 300,000 over three years from the World Bank WPA budget. This covers the costs of the World Bank team and short term technical assistance needs as required over the course of the implementation of the partnership. CDP-H 24 References Phoolcharoen, Wiput. 2002. Health System Reform in Thailand: the Role of the Health Systems Research Institute. http://www.alliance-hpsr.org (accessed 12 October 2006). Towse, Adrian, Anne Mills and Viroj Tangcharoensathien. 2003. Learning from Thailand’s Health Reforms. http://bmj.bmjjournals.com (accessed 12 October 2006). Wibulpolprasert, Suwit. 2005. Thailand Health Profile 2001 – 2004. Bangkok, Ministry of Public Health CDP-H Annex 1 25 Annex 1: Thailand Country Development Partnership in Health Sector Policy Matrix Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] I. HIV/AIDS Program 1. Revitalizing 1. To assess 1. Research Based on To convene major A research based BATS and IHPP HIV Prevention major sources and assessment and policy dialogue policy paper on and Impact of HIV development analysis, to among general revitalizing Mitigation transmission in of curriculum produce a public and key prevention in the Thailand and on advanced revised national stakeholders to face of UC, ART Policy goals adequacy of training HIV prevention reaffirm the and existing HIV course to strategy and primacy of decentralization. 1. To revitalize prevention counselors on implementation prevention and to the primary interventions in disclosure of plan build consensus Curriculum importance of relation to the HIV status on an effective preventions and sources of HIV among To consult with HIV prevention Consultation, provide policy transmission discordance partners and key agenda dissemination and guidance on identified couples stakeholders on utilization of effective the results and revised national prevention 2. To analyze 2. Model formulate strategies on cost- development national policy prevention 2. To establish a effectiveness to of advanced clear policy and identify the counseling The National good practices on optimum mix technique, AIDS impact of intervention generate Committee to mitigations to in Thailand, lessons and endorse the orphans and based on good practice, revised national vulnerable epidemiological and scaling up prevention children and context and to strategies for CDP-H Annex 1 26 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] elderly affected identify the best program by HIV/AIDS implementation implementations. options for the 3. To ensure proposed adequate intervention prevention mix. program financing and political commitment for a reinvigorated HIV prevention agenda Resource needs International International National experts: National expert: Publication and for activities experts: experts: 10 pd 30 pd 10 pd disseminations of 30 person-days hard copies: 300 (pd) National 3 workshop 2 sessions of copies experts: 40 pd sessions of 30 workshop participants (preliminary and Several web-base National Qualitative final report to dissemination at experts: research work reach consensus) no cost 60 pd on disclosure of 50 participants, issues: lump sum 2 million THB 2. Improving 1. To assess the To harmonize To propose To convene NAC A research based BATS CDP-H Annex 1 27 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] AIDS current AIDS M&E of ART concrete actions and multi- policy paper on Treatment treatment across three to improve stakeholders to improvement of Program program public program AIDS treatment Performance performance in insurance performance and - discuss program program order to schemes future needs for performance performance Policy goals identify laboratory including strengths and Model testing facilities to laboratories for Consultation, To improve the weaknesses for and scale up monitor drug resistance, dissemination and performance of improvement good practice resistance utilization of the AIDS including first- in the early finding in order to treatment line treatment recruitment of improve AIDS program by and estimated ART treatment examining and needs for enrollees program addressing early second-line performances. recruitment, treatment physician preparedness, client management, community participation and support, treatment adherence, minimization of resistance, prolonging of first-line CDP-H Annex 1 28 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] treatment, behavioral dis- inhibition and risk compensation and HIV prevention among discordant couples * Need further fund raising Resource needs International International Two Two Publication and for activities experts: 30pd experts: 10 pd consultation dissemination dissemination of for review workshops on workshops, guidelines and National M&E and laboratories among NAC and results of program experts: 60pd harmonization improvement: stakeholders 50 performance across 3 30 participants participants assessment, and public recommendations: insurance Two 300 copies schemes consultation workshops on National program experts: performance - 20pd for assessment and harmonization consensus on M&E strategic - 30pd for direction CDP-H Annex 1 29 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] reviews and towards program design model efficiencies: 30 of early participants recruitment of ART enrollees - field operation expenditure for model testing, lump sum 1 million THB 3. Adequate and 1. To continue To build To endorse a A document on IHPP and BATS Sustainable the ongoing common national policy on financing AIDS AIDS Program resource understanding sustainable program and Financing tracking among financing of potential resource exercise. stakeholders on AIDS program, capacity and Policy goals the resource and strategies to identification of 2. To estimate available in the mobilization the gaps. To ensure and forecast past years, resources to meet adequate and resource needs projection of future needs sustainable in the future potential financing of based on available national AIDS existing data resource and program, through where possible resource need better and the trend of for the next 10 CDP-H Annex 1 30 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] mobilization and HIV epidemic years, potential harmonization of resources gap different sources 3. To compare and strategies to of finance total AIDS minimize the * Need further expenditure to gap, in order to fund raising the total health reach consensus expenditure on resource projections in mobilization order to assess strategies the proportionality of projected AIDS expenditure Resource needs International National experts: One session of Several web-base for activities experts synthesis and workshop with dissemination (resource needs propose NAC and other modeling): strategies, 20 pd. stakeholders: 15pd 50 participants 2 sessions of National workshop among experts: 30pd stakeholders: for update 20 participants National AIDS Expenditure Assessment for 2005 and 2006 CDP-H Annex 1 31 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] and resource needs estimates Data collection, lump sum payment for National AIDS Spending Assessment (NASA): 1 million THB Data collection for parameters in the resource needs modeling: lump sum 1 million THB 4. HIV/AIDS 1. Based on To conduct a Communication An institutional BATS Program detail series of policy with stakeholders, assessment report Governance institutional dialogues of on an optimum analysis, to inclusive governance and A summary report Policy goals assess strengths partners to reach institutional on policy and weakness consensus on the structure for dialogue and To develop and of the current optimum HIV/AIDS stakeholder implement a HIV/AIDS governance and program in communication CDP-H Annex 1 32 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] clear and program institutional Thailand on the governance coherent governance and structure for of HIV Program institutional institutional Thailand’s structure for arrangement in HIV/AIDS optimal AIDS the face of program program program management in integration into the need of health system prevention and revitalization so decentralization as to achieve universal 2. To assess treatment institutional coverage and experience and integrate the lessons in other contributions of countries that stakeholders may be relevant for Thailand Resource needs International National experts: One session of Publication and for activities experts: 15pd 30pd workshop: dissemination: 50 participants 300 copies National 5 rounds of experts: 30pd taskforce Several web-base meetings: dissemination 20 persons CDP-H Annex 1 33 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] II. Financing Healthcare Program 1. Sustainable 1. To build To develop a To convene To convene A report on IHPP Health actuarial and model for partners to reach National Health options for Financing modeling Thailand consensus on Security Board sustainable health capacity in expenditure policy options (who are funding for Policy goals NHSO for projection towards a mandated to universal health estimating based on sustainable oversee the 3 insurance To achieve a public population financing public insurance sustainable expenditure dynamic, healthcare for schemes) and financing needs for the macro- the whole other key healthcare for the UC Scheme, economic population partners, e.g. whole CSMBS and context, NESDB, Ministry population. SSS and to supply-side of Finance, other identify sources changes development for covering partners to these needs in acknowledge the the framework resource needs of overall and gaps, and public reach consensus financing on broad policy development directions context in towards long term Thailand financial 2. To analyze sustainability of cost-pressures health sector on the UC Scheme stemming from CDP-H Annex 1 34 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] demographic and changing disease profile, modernization of medical technologies, mainstreaming new benefits (e.g. universal coverage of ART for AIDS patients) and prevailing incentives in the current health service financing modalities Resource needs International Model Two One national Publication and for activities experts: development, consultation workshop: dissemination of 20 pd data workshops 50 participants the model and collection for among results of National all parameters stakeholders: projections: 300 experts: 40 pd in the model, 30 participants copies model testing and peer review of CDP-H Annex 1 35 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] model: lump sum 1 million THB 2. 1. To analyze To carry out A policy options Consortium of Harmonization strengths and series of six and strategies Harmonization of three public weaknesses of monthly towards organized by health the current dialogues among harmonization of NHSO insurance arrangement members of the the three public schemes and costing of consortium of insurance core benefit harmonization schemes. Policy goals package organized by common for the NHSO, to reach To reach three Schemes general consensus on agreement on realistic steps 2. To develop broad directions towards options for towards harmonizing synergies in the harmonization of fund management of the three public management the three insurance arrangement, Schemes at the Schemes core benefit national and packages, local levels financing modalities for healthcare providers, and financial accountability CDP-H Annex 1 36 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] arrangements to ensure effective use of resources in the three public health insurance Schemes Resource needs International Consultation Publication and for activities experts: workshop twice dissemination of 30 pd a year, total 5 the harmonization National sessions in three direction: 300 experts: 50 pd years timeline: copies 30 participants Synthesis, further analysis of national dataset: lump sum 1 million THB 3. Improving 1.1 To review To build To convene key A report on Consortium of public any evidence of capacity of partners to reach current situation Harmonization expenditure incentive- fund consensus on of scheme organized by management in driven managers allocation of efficiency, and NHSO health sector inefficiency in resources, and policy options for public broad direction institutional Policy goals expenditure in towards capacity the three public efficiency strengthening CDP-H Annex 1 37 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] To ensure health improvement maximum insurance across the three efficiency Schemes Schemes. through proper incentives to 1.2 To review providers and evidence of patients towards moral hazard efficiency while among the ensure proper population quality of from essentially healthcare free healthcare services 1.3 To review evidence of incentive- driven supply- induced demand and cost escalation 2. To assess institutional capacity of the three public health insurance Schemes to engage in the CDP-H Annex 1 38 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] design and enforcement of performance contracting to monitor utilization of health services and expenditure Resource needs International Long term Four sessions of Publication and for activities experts: Master course consultative dissemination of 30 pd and short workshop: 30 efficiency and courses participants efficiency National training for improvement experts: 60 pd fund across the three managers on public insurance Field work for insurance scheme: 300 assessment and management copies quantification with special of moral attention on hazards across efficiency and three public performance. insurance scheme on the 5 Master demand and courses: unit supply side: cost 1.5 lump sum 2 million THB, million THB fully funded CDP-H Annex 1 39 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] by each Field work on insurance the assessment scheme. of institutional capacity and 10 Short current course, unit practices of the cost 0.3 3 scheme, lump million THB, sum 1.0 million fully funded THB by each insurance scheme 4. 1. To review To recommend To convene A policy Consortium of Decentralization the implications and facilitate public debates on document on best Harmonization of public health of consensus the pro and con possible and organized by insurance decentralization building on and what are the appropriate role NHSO schemes and policy on appropriate level best interest for of Local expenditure public finance of the people in the Administrative management and public decentralization context of Units in financing service of the public decentralization and provision of Policy goals provision roles health insurance healthcare of Local schemes and To ensure Administration develop an effective national Units on public action plan for healthcare health institutional financing financing and strengthening of arrangement in expenditure the decentralized CDP-H Annex 1 40 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] the context of the management level of public government architecture health decentralization expenditure policy. management * will be adjusted if any changes in overall government decentralization policy Resource needs International Series of Series of public Publication and for activities experts: consultative debates, twice a dissemination of 20 pd workshop, 2 year, total 5 the potential role times a years x 3 sessions: of local National years, total 6 50 participants government unit experts: 40 pd sessions: in financing and 30 participants health services provision: 300 copies III. Improving Human Resources in Health 1. Health 1. To review in- A review of workforce depth health health workforce challenges in workforce in Thailand Thailand challenges in the past and present CDP-H Annex 1 41 Main activities Lead agencies A. Researches, B. Capacity C. Policy D. E. Publication reviews or building development Communications synthesis of model [Policy analysis, to main evidences development convening stakeholders and partners and general public consensus forum] in Thailand 2. To evaluate innovative and effective strategies for the workforce, aiming at identifying effective and ineffective strategies and opportunities for policy changes Resource needs USD 35,000 for activities 2. Regional 1. To support leaning on regional learning health and dissemination workforce activities on effective health sector human resources policies (in the context of the ongoing major activities under AAAH) Resource needs USD 35,000 for activities CDP-H Annex 2 42 Annex 2: Total Program Costing by Program Component and Main Activity A. B. Capacity C. Policy D. E. Grand total Researches building development Communication Publication (Baht) (USD) I. HIV/AIDS 1. Revitalizing HIV International 706,800 235,600 - - Prevention National 1,185,600 790,400 592,800 197,600 Others - 2,000,000 540,000 600,000 150,000 Travel (Intl) 140,000 - - Travel(dmstc) 36,000 54,000 126,000 Sub total 2,068,400 3,026,000 1,186,800 923,600 150,000 7,354,800 204,300 2. Improving AIDS International 706,800 235,600 - - - treatment program National 1,185,600 988,000 - - - Others - 1,000,000 1,080,000 600,000 150,000 Travel (Intl) 140,000 - - Travel(dmstc) 36,000 108,000 126,000 Sub total 2,068,400 2,223,600 1,188,000 726,000 150,000 6,356,000 176,556 3. Sustainable financing International 353,400 - - - National 592,800 - 395,200 - Others 2,000,000 - 240,000 300,000 - Travel (Intl) - - CDP-H Annex 2 43 A. B. Capacity C. Policy D. E. Grand total Researches building development Communication Publication (Baht) (USD) 140,000 Travel(dmstc) - 54,000 63,000 Sub total 3,086,200 - 689,200 363,000 - 4,138,400 114,956 4. Program International 353,400 - - - governance National 592,800 - 592,800 - Others - - 600,000 300,000 150,000 Travel (Intl) 140,000 - Travel(dmstc) - 126,000 63,000 Sub total 1,086,200 - 1,318,800 363,000 150,000 2,918,000 81,056 GRAND TOTAL HIV 8,309,200 5,249,600 4,382,800 2,375,600 450,000 20,767,200 576,867 II. Health Financing 1. Sustainable health International 471,200 - - - financing National 790,400 - - - Others - 1,000,000 360,000 300,000 150,000 Travel (Intl) 140,000 Travel(dmstc) - 90,000 72,000 Sub total 1,401,600 1,000,000 450,000 372,000 150,000 3,373,600 93,711 2. Harmonization International 706,800 - - - National 988,000 - - - CDP-H Annex 2 44 A. B. Capacity C. Policy D. E. Grand total Researches building development Communication Publication (Baht) (USD) Others 1,000,000 - 900,000 - 150,000 Travel (Intl) 140,000 Travel (domestic) - 225,000 Sub total 2,834,800 - 1,125,000 - 150,000 4,109,800 114,161 3. Improving public International 706,800 - - - expenditure mgmt National 1,185,600 - - - in health sector Others 3,000,000 10,500,000 720,000 - 150,000 Travel (Intl) 140,000 Travel (domestic) - 180,000 Sub total 5,032,400 10,500,000 900,000 - 150,000 16,582,400 460,622 4. Decentralization International 471,200 - - - - National 790,400 - - - - Others - - 1,080,000 1,500,000 150,000 Travel (Intl) 140,000 Travel (domestic) 36,000 360,000 360,000 Sub total 1,437,600 - 1,440,000 1,860,000 150,000 4,887,600 135,767 GRAND TOTAL 10,706,400 11,500,000 3,915,000 2,232,000 600,000 28,953,400 CDP-H Annex 2 45 A. B. Capacity C. Policy D. E. Grand total Researches building development Communication Publication (Baht) (USD) Financing 804,261 III. Improving Human Resources in Health 1. Health workforce International 235,600 - challenges in Thailand National 592,800 - Others 129,616 Travel (Intl) 140,000 - Travel(dmstc) 162,000 - Sub total - - 1,130,400 - 129,616 1,260,016 35,000 2. Regional Learning on International 235,600 Health Workforce National 197,600 Others 481,800 Travel (regnl) 228,000 Travel(dmstc) 117,000 Sub total - - - 1,260,000 - 1,260,000 35,000 GRAND TOTAL HWF - - 1,130,400 1,260,000 129,616 2,520,016 70,000 Project Management 5,070,000 140,833 Total Program Costing 19,015,600 16,749,600 9,428,200 5,867,600 1,179,616 57,310,616 1,591,961