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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
7
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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
11
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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
12
Inte
rna
tio
na
l H
ea
lth
Po
lic
y P
rog
ram
-T
ha
ila
nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
nd
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.
13
Inte
rna
tio
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ea
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Po
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-T
ha
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nd
Inte
rnati
onal H
ealt
h P
olic
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m -
Thaila
nd
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.
14
Inte
rna
tio
na
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ea
lth
Po
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-T
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Inte
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onal H
ealt
h P
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y P
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m -
Thaila
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.
15
Inte
rna
tio
na
l H
ea
lth
Po
lic
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-T
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nd
Inte
rnati
onal H
ealt
h P
olic
y P
rogra
m -
Thaila
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.