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.

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 1990-2006. Keeping health spending at a relatively low cost (~USD50-100 per capita), Thailand is one of the ‘Good Health at Low Cost’ country. Thailand 2000-05 * GNI < USD5,000 per capita; Births > 100,000/year Source: Rohde et al. (Lancet 2008) Source: Analysis of World Health Statistics

Progress in achieving MDG5 Improving maternal mortality: MMR 1960-2008 Per 100,000 live births

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

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

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

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)

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

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

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

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, 15-24 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

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

Life 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 Source: Synthesis from NSO survey of population changes for 1975, 1985, 1995 and 2005, and MOPH-DOH-THP 2003 for 2000 14

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

Mismatch between increasing burden of disease from NCD and low investment in HP and disease prevention DALYs attributable to risk factors

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

Inequity in geographical distribution of health workforce in Thailand Nurses 280 - 652 653 - 904 905 - 1,156 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

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.

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

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

Thank you for your attention