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Uses of civil registration and vital statistics to guide policy-
making and planning in Thailand
Phusit Prakongsai, MD. Ph.D.International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
Presentation to the CRVS workshop Dusit Thani Hotel, Bangkok, Thailand
25 September 2012
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CRVS and health information system in Thailand
• CRVS is part of the Thai health information system (HIS) which is not a single system, but consists of multiple sub-systems of health information with involvement of many key stakeholders:– Vital registration from Ministry of Interior (MOI);– Facility-based data on births and deaths from several
Departments of MOPH, National Health Security Office (NHSO), CGD;
– Community-based household surveys from National Statistical Office (NSO), MOPH, research institutes;
– Disease surveillance and investigation from Department of Disease Control of MOPH,
• Main financing sources for HIS– Regular government budget,– Sin tax, 2% earmarked tax fund from tobacco and alcohol
consumption through Thai Health Promotion Foundation,– Direct payments from data users, either public or private
organizations.
Monitoring & Evaluation of health systems reform /strengtheningA general framework
Data sources
Indicatordomains
Analysis & synthesis
Communication & use
Administrative sourcesFinancial tracking system; NHA
Databases and records: HR, infrastructure, medicines etc.
Policy data
Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness
Clinical reporting systemsService readiness, quality, coverage, health status
Vital registration
Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems
Targeted and comprehensive reporting; Regular country review processes; Global reporting
Improved health outcomes
& equity
Social and financial risk protection
Responsiveness
Fina
ncin
gInfrastructure
/ ICT
Health workforce
Supply chain
Information
Interventionaccess & services
readiness
Interventionquality, safety and efficiency
Coverage of interventions
Prevalence risk behaviours &
factors
Gov
erna
nce
Inputs & processes Outputs Outcomes Impact
WHO’s framework for monitoring health system strengthening and outcomes
Source: WHO. Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. 2007, Geneva, World Health Organization.
Data availability for M&E system in Thailand (1)Data availability for M&E system in Thailand (1)
Input Output Outcome Impact
HCF HRH
Infra struct
ure
Gover
nance
Med/Health tech
HIS access
quality
safety
efficienc
y
Interven
coverage
Risk factor
s
H outco
me
Responsive
Equity
Finan prote
ction
Civil registration and vital statistics
Biennial SES Biennial HWS Census / SPC NHES MICS Reproductive H survey NHA
Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey, MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes
Data availability for M&E system in Thailand (2)Data availability for M&E system in Thailand (2)
Input Output Outcome Impact
HCF
HRH Infra structu
re
Gover
nance
Med/Health
tech
HIS access
quality
safety
efficiency
Interven coverage
Risk factors
H outco
me
Responsive
Equity Finan protect
ion
Facility-based report H resource survey HIS electronic IP database Dis surveillance Behavioral H survey Sero-sentinelSurvey Specific dis registration Quality assurance (HA)
7
Life Expectancy at Birth (1950-2050)
0
10
20
30
40
50
60
70
80
90
1950
-195
5
1960
-196
5
1970
-197
5
1980
-198
5
1990
-199
5
2000
-200
5
2010
-201
5
2020
-202
5
2030
-203
5
2040
-204
5
male
female
Source: UN (constant fertility)
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Using vital statistics for monitoring and projection of changes in demographic
profiles and population pyramid of Thais from 1990 to 2030
8
19902000
2030
2008
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2000 2005 2010 2015 2020 2025 2030
The increasing rate of Thai population by age groups from 2000 to 2030
Note: The year 2000 is the baseline data of 100
10
Using mortality and disability data for the estimate of DALY loss in pre-elderly and
elder people
Source: Thai BOD study 2004
0 20 40 60 80 100 120
Cancer
Cardiovascular diseases
Unintentional injuries
HIV/AIDS
Mental disorders
Digestive disorders
Genito-urinary diseases
Diabetes
Musculo-skeletal diseases
Infectious diseases
Others
0 20 40 60 80 100 120
Cardiovascular diseases
Cancer
Chronic respiratory diseases
Sense disorders
Diabetes
Infectious diseases
Digestive disorders
Genito-urinary diseases
Unintentional injuries
Neurological disorders
Others
YLLs
YLDs
45-59 yrs 60+ yrs
11
Additional health workforce requirementfor elderly care (based on workload method)
Workforce 2010 2020
Formal care providers
Nurses
(1:200)
23,888 33,880
Physio-Therapists
(1:200)
2,499 3,708
Social workers
1( :5000)
1,528 2,155
Non-formal care providers
Family members (1:1)
499,873 741,766
Care givers
1:7)
71,410
105,967
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Projected total expenditure on personal healthcare by age group,
2009 to 2015 Personal care by age groups
0
100,000200,000
300,000
400,000
500,000600,000
700,000
2008
2009
2010
2011
2012
2013
2014
2015
year
Baht (m
illio
n)
80+
70-79
60-69
45-59
15-44
0-14
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Long-term financial projection, 2006-2026 based on 1994-2005 NHA, by ILO and Thai experts in
2008Expenditure Share in GDP of Financing Agencies - Long-term Trends
0.0
1.0
2.0
3.0
4.0
5.0
6.0
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026
Per
cent
MoPH OthMin LocGovt StateEnterprise CSMBS SocSec UC WCF PrivIns TrafficIns ERBenefits PrivHH NonProfit RoW
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Health financing arrangements and three public Health financing arrangements and three public
health insurance schemes in Thailand after achieving health insurance schemes in Thailand after achieving
UHC in 2002UHC in 2002
Health care finance and service provision of Thailand after achieving universal coverage (UC)
General tax
General tax Standard Benefitpackage
Tripartite contributionsPayroll taxes
Risk relatedcontributions
CapitationCapitation & global
Co-payment budget with DRG for IP
Services
Fee for servicesFee for services - OP
Population Patients
Ministry of Finance - CSMBS(6 million beneficiaries)
National Health Insurance Office The UC scheme (47 millions of pop.)
Social Security Office - SSS(9 millions of formal employees)
Voluntary private insurance
Public & Private Contractor networks
Source: Tangcharoensathien et al. (2010)
Traditional FFS for OPDirect billing FFS(2006+) for OP
FFSuntil 2006, DRG for IP
Capitation for OP
DRG with global budget
Full capitation
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Public health insurance scheme Public health insurance scheme
beneficiaries beneficiaries
by income quintile, by income quintile, 2003 and 20072003 and 2007
UC scheme covers mostly the poor, approx 50% in Q1 & Q2 UC scheme covers mostly the poor, approx 50% in Q1 & Q2
24%
1%9%
26%
1% 3%
24%
4%
6%
24%
7% 6%
18%
34% 21%
16%
38%
23%
11%
48% 55%
12%
35%
57%
0%
20%
40%
60%
80%
100%
UC SS CS UC SS CS
2003 2007
20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest
Distribution of government subsidies for health:
BIA from 2001 to 2007
28%
31%
28%
29%
20%
22%
26%
24%
17%
15%
20%
20%
17%
16%
14%
14%
18%
15%
11%
12%
0% 20% 40% 60% 80% 100%
OP&IP
OP&IP
OP&IP
OP&IP
2544
2546
2549
2550
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
More pro-poor health care system after achieving UC preventing budget cut from the Thai government during the economic crisis
in 2007-2008
24%
1%9%
26%
1% 3%
24%
4%
6%
24%
7% 6%
18%
34% 21%
16%
38%
23%
11%
48% 55%
12%
35%
57%
0%
20%
40%
60%
80%
100%
UC SS CS UC SS CS
2003 2007
20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest
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Financial risk protectionTrend of health impoverishment 1996-2008
1996 2008
Per 100 households
0 – 0.5
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1+
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Inequity in geographical distribution of Health workforce in 2007
Pharmacists
4,600-8,4328,433-12,27412,275-16,11516,116-19,956
Nurses
280 - 652653 - 904905 - 1,1561,157 – 1,408
PharmacistsPharmacists NursesNurses
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Good Health at Low Cost in Thailand
19
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0
20
40
60
80
100
120
140
160
180
200
220
240
260
U5M
R p
er 1
,000
live
birt
hs
5 10 20 50 100 200 400Total health expenditure per capita (USD, logarithm)
Thailand 2000-05
Rank
Top ten MDG4 performersTop ten MDG4 performersU5MR vs. THE per capita
Low- and middle-income countries
* GNI < USD5,000 per capita; Births > 100,000/year
Source: Rohde et al. (Lancet 2008)Source: Analysis of World Health Statistics
20
U5MR and health systems development:
1970-2010
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Good Health in Thailand
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Good Maternal Health: MMR 1960-2008
Per 100,000 live births
Different figures on MMR in Thailandfrom different data sources and RAMOS
technique199
0199
5199
7200
0200
4200
52006 2008
BPS – MOPH 25.0 10.7 9.7 13.2 13.3 12.2 11.7 11.5
TDRI 44.5 37.4 41.6
RAMOS* & verbal autopsy
44.3 36.5
WHO & UNICEF
50.0 52.0 63.0 51.0 48.0
Lancet (IHME) 44.0 43.0 47.0
Source: Bureau of Health Promotion 2006 & WHONote: BPS = Bureau of Policy and StrategyMOPH = Ministry of Public HealthTDRI = Thailand Development Research Institute* The reproductive age mortality studies (RAMOS) technique identifies and investigates all deaths of women of reproductive age (15-49 years) using multiple data sources. This method includes interviewing household members and health care providers.
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Lessons learnt from CRVS development in Thailand
• Long-term development of CRVS with some degree of political support and commitment high coverage of birth and death registration,
• CRVS is the backbone for HSPA, monitoring progress of health system development, and the impact of health policies in Thailand,
• Analysis of CRVS with other data sources will help facilitate HSPA and monitoring of progress of health system development,
• Challenges of CRVS:– under-reporting of maternal mortality, – lack of SE parameters for analysis of health equity, – limited capacity in policy advocacy, and translation of
evidence and research 23
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Key challenges in strengthening and institutionalizing HIS in Thailand
• Many HIS institutes/organizations are responsible for different components of M&E duplication, inefficiency, and difficulties in networking and standardization,
• Gaps in data quality and availability, particularly data of the private sector,
• Despite adequate financing, more investment in HIS – both human and financial resources are needed,
• Variations in level of technical capacity in data generation, compilation, data processing, data analysis & synthesis, and communication, in responsible institutes,
• Problems in standardization of data generation, collection, and analyses,
• Low utilization of evidence by some policymakers and program managers,
• Need long term capacity building and champions in HIS for M&E
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Structure of Health Information System Development and Networking in Thailand
MOPH
Thai Health Promotion Foundation
Health System Research Institute (HSRI)
Health Information System DevelopmentPlan and Networking
NHSO NESDB
Civil societies
NGOs
Professionals
NSO
Academics
Data owners
Steering committee
Management office
Network and coordinationbetween data producers and users
Reviews for HIS Demands and indicators
Data analysis and synthesis for report
production and publication
Utilization mechanismAccountability, M&E
Research and developmentfor improving health information system
Data qualityassessment
Reviews for health information systems
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Acknowledgement
27
• Ministry of Public Health (MOPH) of Thailand• National Statistical Office of Thailand (NSO)• Health Systems Research Institute (HSRI) • Health Information System Development Office (HISO)• Thai Health Promotion Foundation (THPF) • National Health Security Office (NHSO)• WHO long-term fellowship program of WHO-SEA region• Department of Health Statistics and Informatics, WHO-HQ
