1. Progress in achieving the health-related MDGs: Lessons from Thailand
Phusit Prakongsai, MD. Ph.D.
International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
Health in the Post-2015 Development Agenda
The side event prior to the Prince Mahidol Award conference
Centara Grand & Bangkok Convention Centre,
Bangkok, Thailand
29 January 2013
Good morning, first of all I would like to thank the People’s Health Movements for inviting me to share the Thai experiences in achieving the health-related MDGs: Lessons from Thailand.

2. Where is Thailand standing at? Low- and middle-income countries
MDG4 - Child mortality
Top ten MDG4 performers
Good Health at Low Cost !
U5MR vs. THE per capita
Low- and middle-income countries
Rank
International comparison among low- and middle-income countries found Thailand stands at the top league on the fastest reduction in U5MR during Keeping health spending at a relatively low cost (~USD per capita), Thailand is one of the ‘Good Health at Low Cost’ country.
Thailand
* GNI < USD5,000 per capita; Births > 100,000/year
Source: Rohde et al. (Lancet 2008)
Source: Analysis of World Health Statistics

3. Progress in achieving MDG5
Improving maternal mortality: MMR
Per 100,000 live births

4. MDG6 - Coverage of universal access to ART in Thailand,

5. 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

6. Adequate and appropriately manned rural health facilitieis
Rural health centers with 3-6 nurses n CHWs cover 2,000-5,000 population
Extensive production of appropriate cadres and motivated health personnel with mandatory public works and adequate support are essential.
Rural community hospital with 2-8 doctors cover 30-80,000 population
Suwit Wibulpolprasert, MD., Ministry of Public Health, Thailand

7. Four decades of infrastructure and workforce development
The advent of
district hospitals (1977)
First batch of two-year
technical nurses (1982)
Now fully upgraded
to RNs
Public service mandate
of new MDs (1972)
Source: Health Resource Surveys (various years)

8. Source: Rural Health Division, MoPH
Promoting the use of primary health care From reverse to upright triangle: PHC utilization
(OP visits)
46.2%
(5.5)
29.4%
(3.5)
24.4%
(2.9)
1977
Provincial hospitals
Rural health centers
Community hospitals
Budget shift
27.7%
(10.9)
32.8%
(12.9)
39.4%
(15.5)
1989
Provincial hospitals
Rural health centers
Community hospitals
Peace, econ gwt, democracy
Provincial hospitals
Rural health centers
Community hospitals
2000
46.1%
(51.8)
35.7%
(40.2)
18.2%
(20.4)
With good and well manned rural health facilities, more and more people used the rural health facilities and the structure of the out patient visits changed from that of a reverse triangle in late 1970s to that of an upright one, with broader and broader bases.
( ) : Number of OPD visits (millions)
Source: Rural Health Division, MoPH 8
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand 8 8

9. 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

10. Strong political commitment to expand financial risk protection Long march towards universal health coverage in Thailand GNI per capita and health insurance coverage,

11. More government budget to Health
986.6 mil. ฿
(3.4%)
16,225.1 mil. ฿
(4.8%)
77,720.7 mil. ฿ (78x)
(8.1%)
2010 Public health budget rose to 14% of National budget
29,000 mil. ฿
1972
335,000 mil ฿
1,028,000 mil ฿ (35x))
1990
National budget
2004
Public health budget 11
Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand 11 11

12. Contributions of non-health sectors
Poverty: sharp drop of poverty incidence with growth of economy
1988
1996
2007
Poverty incidence
(based on national poverty line)
42%
15% 8%
Source: Thai National Economic and Social Development, profile of poverty
Education
Better in youth literacy than adult literacy in term of level of average literacy and gender gap
Adult literacy, >15 years, %
Youth literacy, years, %
Both
Male
Female
Gender gap
1980
88.0
92.2
83.9
0.91
96.9
97.6
96.2
0.99
2000
92.6
94.9
90.5
0.95
98.0
98.1
97.8
1.00
2005
93.5
95.6
91.5
0.96
98.2
97.9
Source: UNESCO website

13. Key challenges in moving towards health system development and sustainable development in Thailand

14. Life expectancy
Life expectancy gain was significant during but stagnated in men in 1990s due to adult mortality from HIV/AIDS, road traffic injuries and increasing NCDs
Source: Synthesis from NSO survey of population changes for 1975, 1985, 1995 and 2005, and MOPH-DOH-THP 2003 for 2000 14

15. Future challenges: adult health
Top five of all-age mortality, by gender in 2004
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
Source: Analyzed by Thai Working Group on Burden of Diseases
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. 15

16. Mismatch between increasing burden of disease from NCD and low investment in HP and disease prevention
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)
2007
2008
2009
Total Expenditure:
Total AIDS expenditure, million Baht
6,728
6,928
7,208
Total Health Expenditure, million Baht
248,852
363,771
383,051
Total AIDS expenditure, as
per capita population, Baht
105
110
114
per capita PLWHA, Baht
11,600
14,275
14,417
% GDP
0.08%
% THE
2.7%
1.9%
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 17

18. Inequity in geographical distribution of health workforce in Thailand
Nurses
,156
1,157 – 1,408
Physicians
800-3,305
3,306-6,274
6,245-9,272
9,243-12,300
Dentists
5,500-15,143
15,144-25,767
25,768-36,390
36,391-47,011

19. Different figures on MMR in Thailand from different data sources and RAMOS technique
1990
1995
1997
2000
2004
2005
2006
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 & WHO
Note:
BPS = Bureau of Policy and Strategy
MOPH = Ministry of Public Health
TDRI = 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.

20. The principle of “Triangle that moves the mountain”
Knowledge generation & management
Social and civic movement
Political commitment/ Policy linkages

21. Lessons learned Public health policies: pro-poor, pro-rural ideology
Strong commitment by the government
Explicit five year National Health Plans ( ): 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

22. Thank you for your attention