Current status, problems, and challenges in public health in Thailand Dr. Phusit Prakongsai, MD. Ph.D. International Health Policy Program – IHPP Ministry.

Current status, problems, and challenges in public health in

Thailand

Dr. Phusit Prakongsai, MD. Ph.D.International Health Policy Program – IHPP

Ministry of Public Health, Thailand

Presentation to Asian Consultation Workshop on Education for Global Health Leadership

Melia Hotel, Hanoi, VietnamNovember 4-5, 2008

Mortality profiles by income groups, 2005

Sources: WHO projection baseline scenario *Thai working group, BOD 2004

*

0 200 400 600 800 1000 1200

World

High Income

Lower Middle Income

Low Income

Thailand

Deaths per 100,000

HIV/AIDS

Maternal, perinatal,and nutritionalCancers

Cardiovasculardiseases and DMOther infectiousdiseasesOther non-communicableUnintentionalinjuries Intentional injuries

*

% of Total national deaths 63.9 56.0% of Total national deaths 63.9 56.0% of Total national deaths 63.9 56.0% of Total national deaths 63.9 56.0

Top ten mortality in 2004 Source: Thai Working Group on BOD

% of Total 52.6 42.8

Rank DiseaseDALY('000)

% %DALY('000)

Disease

1 HIV/AIDS 645 11.3 7.4 313 Stroke2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS3 Stroke 332 5.8 6.4 271 Diabetes4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease6 COPD 187 3.3 3.0 125 Traffic accidents7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer8 Diabetes 175 3.1 2.8 118 Osteoarthritis9 Cirrhosis 144 2.5 2.7 115 COPD

10 Depression 137 2.4 2.6 111 Cataracts

Male Female

DALY

Top ten DALY loss in 2004(total 9.9 DALY loss)

Profile of DALY loss by age groups Thailand 2004

DALYs Lost by age and sex and disase categories, Thailand 2004

0

200

400

600

800

1,000

1,200

1,400

1,600

0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+ 0-4 5-14 15-29 30-44 45-59 60-69 70-79 80+

Males Females

Dis

ab

ility

Ad

just

ed

life

Ye

ar

Lo

st (

'00

0s)

Group III Injuries

Group II Non-communicable diseases

Group I Infections, maternal, perinatal and nutritional cond

Risk Burden in 2004Male

0% 2% 4% 6% 8% 10% 12% 14%

Malnutrition - Thai standard

Not w earing seatbelt

Water & sanitation

Malnutrition - int standard

Physical inactivity

Air pollution

Fruit & vegies

Cholesterol

Obesity

Illicit drugs

Blood pressure

Not w earing helmet

Alcohol

Tobacco

Unsafe sex

% of total burden

Female

0% 2% 4% 6% 8% 10% 12% 14%

Malnutrition - Thai standard

Not w earing seatbelt

Water & sanitation

Malnutrition - int standard

Physical inactivity

Air pollution

Fruit & vegies

Cholesterol

Obesity

Illicit drugs

Blood pressure

Not w earing helmet

Alcohol

Tobacco

Unsafe sex

% of total burden

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Health expenditure in Thailand by function in 2001 and 2005

Health administration and health insurance

8.5%

Medical goods4.3%

Ancillary services 0.4%

Prevention and public health services

4.8%

Services of curative & rehabilitative care

78.1%

Gross capital formation

3.9%

Household consumption: tobacco, alcohol and health

Median household expenditure (Baht per month) Sources: Analyses from 2006 SES

52 65

152

303

433

303

390433

650

867

47 6093

120

205

0

500

1000

Q1 Q2 Q3 Q4 Q5

Income quintiles

Ba

ht

pe

r c

ap

ita Tobacco

Alcohol

Health

1945

2000

2001

Informal exemption

1980

1970

User fees

1-3rd NHP1962-76Provincial hospitals

Health Infrastructure

Thailand: historical development of achieving universal coverage

1975LIC

1990

Establishment of prepayment schemes

Expansion of prepayment schemes

1980CSMBS

1983CHF

1990SSS

4th -5th NHP (1977-86) District hospitalsHealth centers

Universal Coverage

CSMBS

CSMBS

SSS

2001

Universal Coverage

SSS

LIC MWS 1994PVHI

Health care finance and service provision of Thailand

after achieving universal coverage (UC)

General tax

General tax Standard Benefit

package

Tripartite contributions Payroll taxes

Risk related contributions

Capitation

Capitation & global Co-payment budget with

DRG for IP

Services

Fee for services Fee 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

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Share of public and private financing sources from total health expenditure in

Thailand,1994 - 2005

64%64%63%63%56%55%55%54%

47%47%45%56%

37%37%

36%

36%

44%44%45%45%

46%53%

53%55%

0

50,000

100,000

150,000

200,000

250,000

300,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Mill

ion

Ba

ht

Public financing sources Private financing sources

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Number of public health workers and health centre

for primary care in Thailand, 1979 - 2006

05,000

10,00015,00020,00025,00030,00035,000

1979 1987 1997 1999 2001 2003 2006

0

500

1,000

1,500

2,000

2,500

3,000

No. of public health workers No. of health centre pop/public h workers

• More than 70% of health centres have the public health workers below the national standard (1 public health worker: 1,250 population) More than 17% of health centres are responsible to more than 10,000 population.

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Public health education in Thailand

• The Ministry of Public Health (MOPH) produces most of the certificate level HRH for its own facilities; whereas University Faculty of Medicine, Nursing, etc. produces graduates with Bachelor degrees,

• The Faculty of Public Health at Mahidol University and others are functioning as Public Health administrators mostly serving medical doctors with or without Public Health education,

• There is no standard for the design of the public health curriculum in Thailand, only a common feature with core and elective courses for two-year programme,

• There is an increasing trend in cooperation between university based department and MOPH in designing and implementing a module-based graduate Public Health programmes.

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ndConclusion (1)

• Thailand is facing epidemiological transition from CD to NCD, and disease burden (in term of DALY loss) from NCD is increasing,

• There is an urgent need to prepare public health competency of health personnel to address disease and illness from life styles and risk behavior,

• There is an increase in public investment in health, and share of household out-of-pocket payments is decreasing,

• However, a very small amount of health resources were spent on health promotion and disease prevention, and mostly on conventional clinical based prevention and health promotion services.

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ndConclusion (2)

• Households in Thailand spent more on harmful products to health (tobacco and alcohol), compared to household health spending,

• Achieving universal coverage (UC) in 2001 with the comprehensive benefit package including disease prevention and health promotion, and using primary care unit as a gatekeeper, is an advantage for primary health care reform in Thailand,

• There is an urgent need to address the issue of inequitable distribution of health facilities and human resources for health among regions, and between urban and rural areas in Thailand.