Dr. Suwit Wibulpolprasert Senior Advisor on Disease Control Ministry of Public Health, Thailand IAC, Mexico City, August 4 th 2008 Fast Tracking and Sustaining the Building of Health Care Systems: from Pro-poor to Sustainable Universal Coverage – The Thai Experience

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand2 Population 63 millions; Literacy rate: 95 % GDP/cap/yr.: $US 3,100 or 6,400 (ppp.) - LMI Life expectancy (yrs.): Male = 70, Female = 75 IMR: 18 per 1000 Live Births MMR: 30 per 100,000 Live Births Dr:pop ~ 1:2,000, Nurse:pop ~ 1: 600 Bed:pop ~ 1:450 Basic Information in 2007

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand3 Health Facilities 9,762 rural health centres, 730 community hospitals, 150 big public hospital 344 private hospitals, 35,806 beds (20.2 %) 16,800 private clinics, 14,000 drug stores Health Worker ~ 4.2 health workers/1000 pop 30,000 MDs, 120,000 nurses, 10,000 dentists, 15,000 pharmacists, 40,000 CHWs, mainly produced by public institutes National Health Expenditure From 3.82% GDP in 1980 to 6.1 % in 2005 Health Care System : 2007

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand4 Active roles in prevention % condom among CSWs, VCTs, Blood screening, MMT for IVDUs and Universal Precaution > 1,000 health facilities are providing ARTs to 180,000 patients as well as PMTCT plus based mainly on government budget, no grant/loan Community strengthening to support long term and continuous care Less than 300 (0.1%) health workers affected and require less than 1% of health workers for ARTs Health Care Systems and AIDs

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand5 Budget for Universal Access to ARV (million ฿ ) YearGov BudgetGlobal FundTotal , , , , , , , ,662

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand6 Health expense: ~ 200 $US/capita per year, or ~ 6% of the GDP Public sector shares ~ 45-55% Universal coverage of health insurance, including PHC, since October 2001, covering from the 1 st to the last $ Universal access to ARTs in 2003, both first and second line Renal Replacement Therapy and Seasonal Flu Vaccines in Health Financing and Insurance in Thailand 2007

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand – Civil servants medical benefits scheme 1975 – Free medical care for the poor – Fast tracking building rural health facilities Voluntary public HI (Health card for the near poor) Compulsory Social Security HI (formal employees) Free med care for children, 1995 – for elderly Total health insurance coverage = 71 % Universal HI - $US.75/visit co-pay for the non poor Universal Access to ARVs Free care for all – no co-payment 2008 – RRT, Flu vaccine, additional high cost drugs covered “30 years evolution starting from pro-poor towards UC” From pro-poor to universal coverage

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand8 Reallocation of health resources for fast tracking expansion of rural PHC facilities in early 1980s 1985 – 1996: Peace and sustain economic growth expanded government budget and reduced security and debt payment by 30% of national budget - allocate to infrastructures, and social sector, including social welfare, education, and health Democratic governments with populist policies allow more resources to health – MoPH budget increased from 4% to 8% since 1990 How do we pay to scale up HCS and Univeral Coverage of HI?

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand9 Shift of Budget Allocation from urban hospitals to rural health centers & district hospitals in ’80s Fast tracking rural health No investment in urban areas for 5 yrs.

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand10 Percentage of Nationanl Budget Year Source: Bureau of Budget Peace and Econ gwt saved 30% of budget

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand National budget MoPH budget 29,000 mil. ฿ mil. ฿ (3.4%) 16,225.1 mil. ฿ (4.8%) 335,000 mil ฿ 77,720.7 mil. ฿ (78x) (8.1%) 1,028,000 mil ฿ (35x) Bigger cake and bigger proportion of MoPH Budget

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand12 Rural HCs and hospitals

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand13 Wibulpolprasert S beds rural district hospitals

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand14 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 ( ) : Number of OPD visits (millions) Provincial hospitals Provincial hospitals Rural health centers Rural health centers Community hospitals Community hospitals % (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 hospitals Rural health centers Community hospitals Budget shift Peace, econ gwt, democracy

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand15 Economic growth, peace and democracy, strong NGOs, and established legal framework (National Health Security Act 2002) New financing mechanism: Community, Sin tax Cost control by capitation, use of Essential Generic Drugs, Compulsory Licensing, Collective procurement and bargaining on drugs and medical supplies Ensure quality and responsiveness – HA, TQM Health Promotion: 15% capitation, sin tax based Thai Health Promotion Foundation Do not depend on grants or loans How to ensure sustainability?

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand16 Prices before and after the CL MedicinesOriginal before CL Price ($US) After CLGenericDifferences (times) Effavirenz58/mo24/mo10/mo5.8 Lopi/Rito1,800/yr.1,000/yr.6003 Clopidogrel (tab) Docetaxel (80 mg) Letrozole (tab)

Rate of use of Efavirenz 600 mg. bottles CL 17 Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

Rate of use of Lopinavir/Ritonavir bottles Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

19 Build up basic health infrastructure focus at the PHC in ’70s - ‘80s and financing in late ‘80 until UC of HI in 2001 – gradual but continuous reform Long-term sustainability based on local budget Peace, democracy, econ growth, strong NGOs and established legal frameworks Dedicated spirit of HRH – RDS, CHWs Weaving Disease specific activities with HSS Capacity on health policy and systems researches HS is not only HCS but also Healthy Public Policies “Triangle that moves the mountain” and Tipping points Lessons learnt from Thailand

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand20 “Triangle to move the mountain” “Tipping point” Knowledge generation & management Social movement Political/ Policy linkages Stickiness of the issue Three groups of people Conductive Environment

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand21 Prof. Dr. Prawase Wasi Dr. Sanguan Nittayarumphong Prof. Dr. Sem Pringpuangkaew Influences of a few Shift of budget towards rural HCS Universal Health Insurance

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand22 Five Recommendations from Prince Mahidol Award Conference, February 2008 (1) 1. Need to achieve a balance e.g. Comprehensive vs disease specific approaches Communicable vs non-communicable diseases Public vs non-public sectors Short-term vs long term sustainability and capacity building Treating the consequence vs solving the causes Respond to urgent crisis vs long term consequence 2. Need to build the evidence base 3. Need to promote and support country ownership

Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand23 Five Recommendations from Prince Mahidol Award Conference, February 2008 (2) 4. Need to place more focus on social and environmental determinants of health GHI resources should be used to address not only proximate cause of disease, but also address less proximate cause. 5. Need to develop health system capacity  efficiency and sustainability at all levels of HS; financing, policy development, planning and human resources