The views expressed in this presentation are the views of the author and do not necessarily reflect the

views or policies of the Asian Development Bank Institute (ADBI), the Asian Development Bank (ADB),
its Board of Directors, or the governments they represent. ADBI does not guarantee the accuracy of
the data included in this paper and accepts no responsibility for any consequences of their use.
Terminology used may not necessarily be consistent with ADB official terms.

Increasing the accessibility

to essential medicines
for UHC in Thailand: Roles of the NHSO

Somruethai Supungul
Bureau of Medicine and Medical Supply Management

http://www.nhso.go.th/1
Outline

1. Background of Thailand
2. Medicine Reimbursement system managed by
NHSO

http://www.nhso.go.th/eng 2
Thailand: at a glance (2017)
• Population 69 million
• GNI (2017) $US 6,000
(UMIC)

• Gov. Health Budget 17% Total

Budget

• Total Health Expenditure

• 4.5- 6.0 % GDP [$US 300/cap]
• Out of pocket 12% total heath
expense
4 Thailand: at a glance (2017)
Public Health insurance schemes
in Thailand
Scheme Civil Servant Social Security Universal
Medical Benefit Scheme Coverage Scheme
Scheme
(CSMBS) (SSS) (UC)
Introduced in 1980s 1990s 2002
Beneficiaries Govt. employees & Private sector Rest of population
dependents, retirees employees:
Pop Coverage 4.5 million (3 %) 10 million (17.5 %) 48.8 million (76 %)
Funding Govt. budget Payroll contribution Govt. budget
Tripartite
Payment to •Fee-for-service for OP • Capitation for OP •Capitation for OP
health facilities •DRG for IP • DRG for IP •DRG with global
• on top for high cost budget for IP
drugs (E2) •On top for high cost
and CA protocol drugs (E2)
Instrument and some
Chronic Dis, and CA
protocol
2. Medicine Reimbursement system managed by NHSO

National lists of Essential Medicines (NLEM)

6
Process for selection New Medicines into
Thai National List of Essential Medicines (NLEM)
Data input
1.Medical colleges 2.Hospitals 3.Drug companies 4.Patient’s network 5.Health Scheme Etc.

NLEM Sub-committee

The 23 national expert working groups

(select and propose draft of NLEM)
The Screening working group
(co ordinate result from 23 working groups)
The Health economic working group
(make suggestion to control budget/social impact)
The price negotiation working group
(negotiate to Drug companies)

NLEM Subcommittee Public Health Insurance Schemes

Make final decision Affordability

National Developing Drug system Committee

Announce in Royal Thai Government Gazette 7
NHSO policy toward medicine management

Administer the UC drug system

to ensure universal access of needed
medications with confidence from beneficiaries
and rational prescribing practices

1. Access to medicines
2. Quality, efficacy & safety of medicines
3. Rational use of medicines
4. Keep costs Affordable
National lists of Essential Medicines (NLEM)

Tools for :

 Ensuring the accessibility to essential drugs for health

problem of Thai population.
 Promoting rational use of drugs
 Medicines procurement list for public hospitals
 Medicines reimbursement list for the public Health insurance
system.

9
3. Medicine Reimbursement system managed by
NHSO

Before 2010 Problems of

Routine service
Payment Mechanism
• capitation for OP,PP
• DRG with global budget for IP
Selection /Procurement
Hospital drug formulary
Public Hospital : selection by PTC
Access to medicines
• unavailable medicines in some
hospitals
- Antiretroviral
– high cost medicines ,
- medicines for rare diseases
- Antidote /Orphan drug
- vaccine

Regional hosp.> 700-750 items (ED 70%)

General hosp. > 500-550 items (ED 80%)
District hosp. > 350-375 items (ED 90%)
10
 Compulsory license on
 2 antiretroviral medicines ( effevirenz , Lopinavir/ritonavir)
 A medicine for heart disease (Clopidogrel)
 Anti-breast cancer (Letrozole)
 Anti-breast cancer and anti-lung cancer (docetaxel)
 Anti- CML (imatinib)

http://www.nhso.go.th/eng 11
The development system for increasing
the accessibility to special medicines
 NHSO act as a facilitator
 To encourage many counterparts to be the member of
the committee especially patients network, hospitals, +/-
NGO
 Responsible for set up the management system under the
limited budget
 Reduce the limited factors and find out the other supported
factors
 Develop the infrastructure of the system, the registry program
 Team
 Voluntary staffs in the communities etc.
 Plan for budget negociation
e.g. AIDs and HIV committee,
Renal Replacement Therapy committee,
Orphan drugs andhttp://www.nhso.go.th/eng
Drugs Shortage Steering committee12
The development system for increasing
the accessibility to special medicines
National List of Essential Medicines

General essential medicines Special Items

- high cost medicines

- Antiretroviral(+Antituberculosis)
- Dialysate solution
- Antidote

Regional procurement Central Procurement

Hospital procurement
http://www.nhso.go.th/eng 13
 National Procurement Process

Procurement Committee
DDC, DMSc Pharmacopoeia,
Thai FDA
specification WHO recommended

Population-based Utilization -based

forecast Demand Forecasting forecast

Compare with Price Negotiation* Companies

PAHO price by GPO Competition

Purchase order

VMI stock
a) High cost medicines, ARV, TB

Tools for increasing access to high cost medicine ?

1. Central procurement /Central bargaining

2. Compulsory licensing (CL) : effavirenz,
Letrozole, Tenofovir
3. Managed Entry Agreement
 PAP : imatinib
 Price-volume agreement : IVIG, AZT,
Tenofovir+Emtricitabine+Effavirenz
 Cost capitation agreement : imigluderase
 Voluntary licensing (VL) : Sofosbuvir
 Pay-for- performance agreement : in process
 Smart vendor managed inventory (VMI)

request for Initial stock

E2 project

Prescription
NHSO
Vaccine Project
TB project

ARV Project

Dispensing Antidote project

Data Application
(OP+IP) for medical Reimbursement CAPD project

DMS

delivery

VMI stock
5 days/ 1 month
PD First Policy in Thailand
 CAPD: Logistic management

Patient House
Hospital
นํ ้ายาล้ างไตหนึง่ ถุงหนัก (kg) 2
หนึง่ เดือนใช้ (ถุง) 120

หนึง่ เดือนผู้ป่วยต้ องใช้ นํ ้ายาหนัก (kg) 240

เท่ากับข้ าวสาร (ถุง) 48

18
 Service Unit/Hospital Patient
Home
Key-in data everyday

Delivery of CAPD
package
NHSO

GPO Delivery
completion
information

Requesting order

Thailand Post Distribution

Storage and
Inventory control
At Patient’s house
• Appointment by phone 1-2 days before send CAPD Fluid
• Check and count CAPD Fluid at Patient’s house and send
to Android system

20
Management In Flooding
The Accessibility to antidotes and anti-venoms
Antidote Management system in Thailand
 Before 2010
 Low accessibility to antidotes and other orphan
drugs in Thailand
 Inefficient stock system and inefficient delivery
system at any health care level
 Lack of skill and experience for diagnosing and
treatment due to rare cases context

http://www.nhso.go.th/eng 23
 Orphan drugs and drug shortages
steering committee
1. The Clinical Toxicology (Thailand )
2. The Poison Center : Siriraj Hospital
3. The Poison Center : Ramathibodi Hospital
4. The Center of Occupational Health
5. The Poison Information Center, the Department of
Medical Sciences
6. The Government Pharmaceutical Organisation
7. The Military Pharmaceutical Organisation
8. The Thai Red Cross Society
9. The Food and Drug Administration
10. The Ministry of Public Health
11. The National Health Security Office
 Orphan and drug shortages
steering committee
This committee responsible for
o Drug selection
o set up stock and distribution
o consultation for treatment
o Health care worker Training
o Monitoring and evaluation
o Purchasing plan
o production or Imported + drug registration
o Guarantee the minimum order
o Inventory management and Drug delivery
system
Antidote and Orphan drugs

26
 Central Procurement
and Collaboration among other organizations
Imported by GPO Manufactured by Thai Red cross

Dimercaprol injection Sodium nitrite injection

Glucagon injection Sodium thiosulfate injection

Succimer Methylene blue injection

 Antidotes distribution
( based on urgency and their availability)

Cyanide antidotes Cyanide antidotes

Cyanide antidotes
Methylene blue Methylene blue
Methylene blue Antivenum
Antivenum
Antivenum CaNa2 EDTA, Dimercaprol CaNa2 EDTA, Dimercaprol
DAT , BAT
General hospitals Regional hospitals
Community hospitals University hospitals Ramathibodi hospitals
 Web based application

 Geographic Information System (GIS)

 On-line Stock

29
 Number of Patient Access to Antidote
Number of Patient per year
รายการยา
Item 2011 2012 2013 2014 2015 2016 2017
Botulinum antitoxin Injection 1 3 5 2 0 0
Calcium Disodium edetate 2 7 15 18 9 18 19
Digoxin specific antibody fragment 1 4 5 1 4
Dimercaprol 2 2 3 13 5 4 2
Diphenhydramine inj. 30 33
Diphtheria antitoxin 18 240 264 59 94 82
Esmolol Hydrochloride 100mg/10 ml 18 22 32 42 6
Glucagon 1 4 5
Methylene blue 17 30 48 55 39 69 89
Sodium nitrite 11 22 30 35 19 17 12
Sodium thiosulfate 17 23 34 40 22 33 25
Succimer 1 3 4 3 6 1
total 49 106 402 466 191 317 236
30
Patient Access to Antivenom

Number of Patient
Items
2013 2014 2015 2016 2017
antivenom for Rattlesnake 337 2,038 2,313 2,501 2,687
Antivenom for green pit viper 356 1,623 2,123 2,233 1,383
Antivenom for Krait 9 34 21 13 20
Antivenom for Viper 13 172 205 170 208
Polyvalent antivenom for
Neurotoxin 31 109 181 208 178
Polyvalent antivenom for
Hematoxin 92 480 765 1,026 1,001
Antivenom for Cobra 126 510 626 673 716
total 964 4,966 6,234 6,824 6,193
31
 International collaboration

CASE (1) LEAD ENCEPHALOPATHY

AUNG HTET THAW (7 MONTHS OLD BOY)
• DAY 3
CONDITION ON ADMISSION

• DAY 5 • DISCHARGE
 CASE (2) LEAD ENCEPHALOPATHY
HEIN THWE ( 11 MONTHS OLD BOY )

CONDITION ON ADMISSION DAY 3

DAY 4 DAY 5 DISCHARGE

CONDITION ON FOLLOW UP
 METHYLENE BLUE
for Taiwan

DIPHTHERIA ANTITOXIN
for LOA PDR and Myanmar
 Cost saving
due to central procurement
From 2010- 2016
Using Purchasing price in 2009 as basic price Saving Unit : USD

year ARV-NonCL ARV_CL ED Cat E(2) EPO/CAPD Total Saving

2010
8,907,677 24,750,922 3,037,543 15,258,756 51,954,898
2011
17,871,763 49,509,529 49,670,753 23,111,379 140,163,424
2012
29,500,819 66,257,010 33,501,682 28,237,894 157,497,405
2013
43,745,449 67,915,751 40,828,581 42,295,357 194,785,139
2014
52,219,778 82,000,880 64,246,998 55,159,629 253,627,285
2015
44,649,801 107,097,868 20,091,332 48,943,980 220,782,981
2016 48,006,380 75,873,013 78,358,114 55,544,497 257,782,004

total 244,901,666 473,404,974 289,735,003 268,551,493 1,276,593,137

Our challenges
 Aging population
 Missing groups
 Person with differently abled
 Prisoners
 Illegal Migrant workers
 Monks
 marginalization

http://www.nhso.go.th/eng 37
Thank you
somruethai.s@nhso.go.th
38
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