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Progress in achieving the Progress in achieving the health-related MDGs:health-related MDGs:Lessons from ThailandLessons from Thailand

Phusit Prakongsai, MD. Ph.D.International Health Policy Program (IHPP)

Ministry of Public Health, Thailand

Health in the Post-2015 Development AgendaThe side event prior to the Prince Mahidol Award conference

Centara Grand & Bangkok Convention Centre, Bangkok, Thailand29 January 2013

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0

20

40

60

80

100

120

140

160

180

200

220

240

260

U5

MR

per

1,0

00

live

bir

ths

5 10 20 50 100 200 400Total health expenditure per capita (USD, logarithm)

Top ten MDG4 performersTop ten MDG4 performers

Source: Analysis of World Health Statistics

Thailand 2000-05

Source: Rohde et al. (Lancet 2008)

Good Health at Low Cost !Good Health at Low Cost !

Where is Thailand standing at?Where is Thailand standing at?MDG4 - Child mortalityMDG4 - Child mortality

* GNI < USD5,000 per capita; Births > 100,000/year

U5MR vs. THE per capitaLow- and middle-income countries

Rank

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Progress in achieving MDG5

3

Improving maternal mortality: MMR 1960-2008

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

450.0

MMR 1960-2008: five sources of references

BPS

BHP

RAMOS

TDRI

Lancet 2010

Per 100,000 live births

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4

MDG6 - Coverage of universal access to ART in Thailand, 2006-2009

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Key contributing factors (1)

•Development of health systems: –First strand: expansion of strong district

health systems both infrastructure and workforces

• More resource allocation to district and provincial levels,

• Government bonding “mandatory public health services” by all health-related graduates.

• The MOPH high level production capacity of nursing and other health-related personnel contributed significantly to the functioning of rural health services.

5

Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand6

Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population

Adequate and appropriately manned rural health facilitieis

Rural community hospital with 2-8 doctors cover 30-80,000 population

Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential.

Source: Health Resource Surveys (various years)

Four decades of infrastructure and workforce developmentFour decades of infrastructure and workforce development

0

100

200

300

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

All District Other public Private

Hospitals

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

120,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctors Nurses

Doctors and nurses

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

Population per bed

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctor Nurse

Population per doctor and nurse

The advent of district hospitals (1977)

Public service mandate of new MDs (1972)

First batch of two-year technical nurses (1982)

Now fully upgraded to RNs

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

88

Promoting the use of primary health Promoting the use of primary health care care From reverse to upright triangle: PHC From reverse to upright triangle: PHC

utilization utilization (OP visits)(OP visits)46.2%

(5.5)

29.4%(3.5)

24.4%(2.9)1977

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals

( ) : Number of OPD visits (millions)( ) : Number of OPD visits (millions)

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals200046.1%(51.8)

35.7%(40.2)

18.2%(20.4)

Source : Rural Health Division, MoPH

27.7%(10.9)

32.8%(12.9)

39.4%(15.5)

1989

Provincial hospitalsProvincial hospitals

Rural health centersRural health centers

Community hospitalsCommunity hospitals

Budget shift

Peace, econ gwt, democracy

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Key contributing factors (2)Key contributing factors (2)

•Development of health systems: –Second strand: the extension of financial

risk protection through piece-meal targeting approach, addressing the poor and vulnerable, and gradually extended to formal and informal sectors until universal health coverage for the entire population was reached in 2002.

9

Strong political commitment to expand financial risk protection

Long march towards universal health coverage in Thailand GNI per capita and health insurance coverage, 1970-2009

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

1111

More government budget to Health

1972

1990

2004National budget

Public health budget

29,000 mil. ฿

986.6 mil. 986.6 mil. ฿฿(3.4%)(3.4%)

16,225.1 mil. 16,225.1 mil. ฿฿(4.8%)(4.8%)

335,000 mil ฿

77,720.7 mil. 77,720.7 mil. ฿฿ (78x) (78x) (8.1%)(8.1%)

1,028,000 mil ฿ (35x))

2010 Public health budget rose to 14% of National budget

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Contributions of non-health sectors• Poverty: sharp drop of poverty incidence

with growth of economy

12

Adult literacy, >15 years, % Youth literacy, 15-24 years, %Both Male Femal

eGender gap

Both Male Female

Gender gap

1980 88.0 92.2 83.9 0.91 96.9 97.6 96.2 0.992000 92.6 94.9 90.5 0.95 98.0 98.1 97.8 1.002005 93.5 95.6 91.5 0.96 98.1 98.2 97.9 1.00

1988 1996 2007

Poverty incidence (based on national poverty line)

42% 15% 8%

• Education– Better in youth literacy than adult literacy in

term of level of average literacy and gender gap

Source: UNESCO website

Source: Thai National Economic and Social Development, profile of poverty

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Key challenges in moving towards health system development and

sustainable development in Thailand

13

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14

Life expectancyLife expectancy• Life expectancy gain was significant during 1975-2005 but stagnated in men in 1990s

due to adult mortality from HIV/AIDS, road traffic injuries and increasing NCDs

Life expectancy at birth, 1975 to 2005

58.0 58.0

69.967.9

69.963.8 63.8

74.9 75.077.6

50.0

60.0

70.0

80.0

1975 1985 1995 2000 2005

Male Female

Source: Synthesis from NSO survey of population changes for 1975, 1985, 1995 and 2005, and

MOPH-DOH-THP 2003 for 2000

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Future challenges: adult health

15

Top five of all-age mortality, by gender in 2004

Source: Analyzed by Thai Working Group on Burden of Diseases

Male cause of mortality Female cause of mortality

1. HIV/AIDS 1. Cerebro-vascular diseases

2. Cerebro-vascular diseases 2. HIV/AIDS

3. Accidents /injuries 3. Diabetes mellitus

4. Liver cancer 4. Coronary heart diseases

5. Chronic Obstructive Pulmonary Diseases

5. Liver cancer

Can the current health systems cope with increasing proportion of BOD attributable from injuries, use of alcohol, unsafe driving, NCD and HIV/AIDS?

There is a need for a major policy review how Thailand controls risk factors contributing to adult mortality.

Mismatch between increasing burden of disease from NCD and low investment in HP and disease

preventionDALY lost from Risk factors, Thailand 1999 and 2004

943

838

595

594

440

410

238

169

144

132

91

54

53

29

25

1,310

550

490

490

400

370

220

140

370

120

120

60

70

30

40

0 200 400 600 800 1000 1200 1400

Unsafe Sex

Alcohol

Blood pressure

Tobacco

Non-Helmet

BMI

Cholesterol

Low intake of fruit and vegetable

Illicit Drugs

P hysical Inactivity

Air P ollution

WSH

Malnutrition-Inter

Malnutrition-Thai

Non-Seatbelt

DALYs('000)

19992004 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%

0

50

100

150

200

250

300

350

400

450

500

Q1 Q2 Q3 Q4 Q5

Thou

sand

s

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol0

50100150200250300350400450500

Q1 Q2 Q3 Q4 Q5

Thou

sand

s

inactivity

low intake fruit

cholesterol

BMI

Blood pressure

smoking

Alcohol

DALYs attributable to risk factors

17

Majority of health care finance is still for curative care universal access to ARV

(Source: UNGASS Reports 2008 & 2010)

200

7

200

8

200

9

Total Expenditure:Total AIDS expenditure, million Baht

6728,6928

720

8

Total Health Expenditure, million Baht2488,52

3 6 3 ,771

383,051

Total AIDS expenditure, as

per capita population, Baht 105 110 114

per capita PLWHA, Baht 1160,0

142,75

144,17

% GDP008

008 008

% THE27. % 19. % 19. %

Sources of Fund:         Domestic, % of Total AIDS Expenditure 83 85 93         International, % Total AIDS Expenditure

17 15 7

Types of Expenditure:         Treatment, % Total AIDS Expenditure 71.8 65.8 76.1         Prevention, % Total AIDS Expenditure 14.1 21.7 13.7

Inequity in geographical distribution of health workforce in Thailand

Physicians

800-3,3053,306-6,2746,245-9,2729,243-12,300

Dentists

5,500-15,14315,144-25,76725,768-36,39036,391-47,011

Nurses

280 - 652653 - 904905 - 1,1561,157 – 1,408

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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The principle of“Triangle that moves the mountain”

Knowledge generation & management

Social and civic movement

Political commitment/

Policylinkages

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Lessons learned

• Public health policies: pro-poor, pro-rural ideology

• Strong commitment by the government– Explicit five year National Health Plans (1960-2010): consistent

development of district health system in line with rural development

• Long-term investment and continuous development of district health system and PHC,

• Increasing participatory process of civil society through several mechanisms,

• Strong implementation capacity and a pragmatic and learning approach to policy implementation

– Participatory of MOPH and others e.g. education, agriculture, economic and employment, transport as well as private sector, civil society and communities

21

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Thank you for your attention