1. Phusit Prakongsai Kanitta Bundhamcharoen Kanjana Tisayatikom Viroj Tangcharoensathien International Health Policy Program (IHPP) Presentation to IHPP Journal Club IHPP meeting room, Ministry of Public Health, Thailand January 8, 2009 Regional case studies Financing health promotion in South-East Asia: Does it match with current and future challenges?

2. International Health Policy Program - Thailand 2 Outline of presentation 1.Background and objectives of the case study 2.Burden of non-communicable diseases (NCD) and risk factors 3.Financing health care and health promotion 4.Innovative financing for health promotion 5.Stakeholder views on financing health promotion 6.Conclusions and policy recommendations

3. Background (1) Increasing burden of NCD and risk factors Source: WHO (2006) Preventing chronic diseases: a vital investment

4. International Health Policy Program - Thailand 4 Background (2) Evidence indicates very low investment in health promotion and disease prevention in South-East Asia region The 59 th session of WHO-SEAR regional committee meeting in Dhaka, 2006 – Request member states to adopt alternative, innovative and sustainable sources of financing HP activities, – Request RD to facilitate the establishment of innovative financing mechanisms

5. International Health Policy Program - Thailand 5 Innovative financing HP in five selected countries (1) India: – The National Rural Health Mission is funded by 10% of tobacco tax of the central government – MOH plans to get at least 1-2% tax from tobacco to finance tobacco control-related activities Nepal: – introduction of ‘cigarette tax’ in 1993 – one pisa per stick of cigarettes (then increased to two pisa) – 75% of the fund to BPK Cancer hospital, and 25% to other similar establishments

6. International Health Policy Program - Thailand 6 Innovative financing HP in five selected countries (2) Sri Lanka: – has comprehensive tobacco and alcohol legislation with taxation policy, – Establishment of the National Tobacco and Alcohol authority funded by the central revenue Thailand: – Has comprehensive tobacco and alcohol legislation – Establishment of Thai Health Promotion Foundation, funded by 2% of tobacco and alcohol excised taxes Indonesia: – No comprehensive tobacco or alcohol legislation – No national health accounts

7. International Health Policy Program - Thailand 7 Objectives To conduct case studies on the innovative and sustainable financing mechanisms using information from national health accounts and other sources of information: 1. Reviewed the profile of non-communicable disease burden, 2. Examined current policy concerns among key stakeholders on health promotion and financing health promotion, 3. Assessed current trend of financing sources of health promotion (public vs private) and spending profile, 4. Assessed the structure, function, and achievements of innovative financing HP.

8. International Health Policy Program - Thailand 8 Methods Literature reviews on – Burden of disease, or extensive epidemiological situations of NCD – Revenues generated for alcohol and tobacco, and laws related to taxation and tax rates Reviewed existing National Health Accounts (NHAs) about financing health care in general and HP in particular Conducted self-administered questionnaire survey to achieve key stakeholder views on innovative financing HP Reviewed innovative financing health promotion and country without such innovation, in-depth interviews of key stakeholders will be conducted.

9. International Health Policy Program - Thailand Research findings from this study

10. International Health Policy Program - Thailand 10 DALY Profile of 11 member states of SEAR and the world Source: The World Health Report 2004

11. Country background indicators in five selected countries, HDI rank in 2007 IndicatorsThailandSri Lanka IndonesiaIndiaNepal HDI rank7899107128142 Population in 2015 (million) 66.820251.61,302.532.8 GDP per capita US$ 2,7501,1961,302736272 Pop living below $1 a day (%) <25.67.534.324.1 Health spending per capita, PPPUS$ 2931631189171 Birth attended by skilled health personnel (%) 9996724311 Physicians per 100,000 pop 3755136021

12. Prevalence of selected risk factors in five selected countries Risk factorsGenderIndiaIndonesiaNepalSri LankaThailand Alcohol consumption (litre per cap) 0.290.090.190.285.59 Smoking (%)Male29.469.031.438.240.2 Female2.53.02.02.4 Mean blood pressure (mmHg) Male124123124123119 Female122123121122117 Physical inactivity (%) Male9.324.46.77.36.8 Female15.217.89.713.811.8

13. International Health Policy Program - Thailand 13 Total health expenditure as percentage of GDP 2000-2004

14. International Health Policy Program - Thailand 14 Total health expenditure by financing sources in five selected countries in 2004

15. International Health Policy Program - Thailand 15 Financing health promotion and innovative financing The Health Tax Fund of Nepal raised by earmarked tax of tobacco and alcohol consumption, is managed the BP Koirala Memorial Cancer Hospital, – Approximately 65-70% for Bhaktapur Cancer hospital, – the rest for National Health education, Bir Hospital, Nepal Cancer Relief Society, etc. Revenue of Thai Health Promotion Foundation (THPF) collected from 2% earmarked additional tax from tobacco and alcohol consumption – In 2005, total expenditure was approximately 58 million USD, – The mission is to empower civic society, raise social awareness on major health risk behavior, promote well being of the citizens.

16. International Health Policy Program - Thailand 16 The distribution of HP programs funded by THPF in 2005

17. International Health Policy Program - Thailand 17 Trend of prevalence (percent) of regular smokers among population aged more than 11 years from 1991 to 2006 Sources: Analyses from the Health and Welfare Survey, 1991-2006

18. International Health Policy Program - Thailand 18 Correlation between prevalence of cigarette smoking and percent of excised tax on tobacco and number of cigarette consumption from 1991 to 2006 Tax increase interventions and tobacco control In Thailand

19. Stakeholder views on financing health promotion (1) CharacteristicsIndonesiaNepalSri LankaThailandTotal No. of respondents 372734117232 Male: female62:3884:1674:2677:2175:25 Average age of respondents NA55.955.650.2 Professional background Medical professionals 30%28%37%18%25% Health related administrators -25%17%50%32% Public health38%16%30%25%27% Others32%31%16%7%16%

20. Perception on financing health care and health promotion IndonesiaNepalSri Lanka ThailandTotal Sufficiency of health care finance Inadequate86.593.878.382.183.6 Adequate8.13.119.616.213.8 Don’t know5.43.12.21.72.6 Government priority on HP High priority8.118.815.224.819.4 Moderate16.250.054.359.050.0 Low priority75.731.330.414.529.7

21. Spending on health promotion in relation to burden from NCD IndonesiaNepalSri Lanka ThailandTotal Sufficiency of financing HP in relation to NCD Abundant0000.90.4 Sufficient13.504.315.410.8 Moderate5.425.032.622.222.0 Insufficient62.265.652.252.155.6 Severely insufficient 18.99.44.38.59.5 Don’t know006.50.91.7 No. of respondent373246117232

22. How much should governments spend on health promotion? IndonesiaNepalSri Lanka ThailandTotal Double of current level of spending 24.350.043.526.532.8 Triple43.221.921.716.222.4 Quadruple13.59.44.3 6.5 More than quadruple 18.93.16.59.49.5 Don’t know09.419.611.110.8 missing06.34.332.518.1 No. of respondent 373246117232

23. Desirability of innovative financing for HP Potential sources of financing HP IndonesiaNepalSri Lanka ThailandOverall Earmarked tax from alcohol 3.864.533.954.514.30 Earmarked tax from tobacco 4.114.523.884.414.27 International donor 3.783.913.882.493.17 Domestic donor 3.893.133.272.733.08 Earmarked tax from VAT 3.222.962.482.952.90 General tax 2.953.302.652.782.85 Earmarked tax from SHI 2.683.75NA3.732.83 Earmarked from gasoline 3.032.501.752.662.52 Reallocation from other sectors 1.972.481.952.252.18

24. Feasibility of innovative financing for HP Potential sources of financing HP IndonesiaNepalSri Lanka ThailandOverall Earmarked tax from alcohol 3.924.433.954.214.14 Earmarked tax from tobacco 4.084.343.934.214.15 International donor 3.813.673.772.092.92 Domestic donor 3.892.752.902.402.79 Earmarked tax from VAT 3.223.042.832.392.70 General tax 2.863.122.762.592.74 Earmarked tax from SHI 2.683.07NA3.072.40 Earmarked from gasoline 3.142.621.882.122.30 Reallocation from other sectors 2.032.111.831.621.79

25. International Health Policy Program - Thailand 25 Opinions on key barriers to introducing innovative financing for HP Lacking of vision and commitment to improving population health among politicians and policy makers, Limitations of financial and human resources for HP and disease prevention, Bureaucratic system and poor management of the government, Poverty and lack of community participation, Lacking of knowledge and inadequate information on the magnitude of NCD and its impact on public health.

26. International Health Policy Program - Thailand 26 Conclusions Current level and profile of spending on health promotion and disease prevention does not match huge disease burden from NCD, Among these five countries, Thailand paves advanced step towards innovative financing health promotion, – Nepal had an opportunity to reorient towards primary prevention rather than focusing on hospital-based cancer treatment, – Sri Lanka, the introduction of tobacco and alcohol tax could be a potential source, – The introduction of social health insurance in Indonesia provides an opportunity to ensure that disease prevention and health promotion services are included in the benefit package of SHI.

27. Disease Control Priorities in Developing Countries 2006 (second ed) – DCP2 Comprehensive literature reviews on cost-effectiveness interventions ใน 4 four groups: – Infectious disease, reproductive health, and under-nutrition – Non-communicable disease and injury, – Risk factors, – Consequences of disease and injury It also provides recommendations on health system strengthening, and effective management for high priorities of disease prevention and health promotion. http://www.dcp2.org/pubs/DCP

28. International Health Policy Program - Thailand 28 Policy recommendations from the case study Mobilize more resources through increased public investment for health promotion, explore potential feasibility to establish innovative financing for health promotion through introducing earmarked tax from tobacco and alcohol, Ensure that public health insurance schemes cover health promotion in their benefit packages, Well prepare good evidence when the window of opportunity is opened, Increase value of money, namely efficiency gained through existing spending on health promotion and reorient programs towards primary prevention focus.

29. International Health Policy Program - Thailand 29 Policy recommendations from the regional consultation in Jakarta (1) Member states Need to mobilize more resources through increased public investment for health promotion, with a need to reorient towards primary prevention and promotion focus. Have to explore potential feasibility to establish innovative financing for health promotion through: – general revenue; – introducing dedicated tax from tobacco and alcohol; – ensuring health insurance funds to cover the prevention and health promotion in their benefit packages.

30. International Health Policy Program - Thailand 30 Policy recommendations from the regional consultation in Jakarta (2) WHO WHO, in collaboration with regional institutions, needs to develop a guide/methodology for collecting and analysis of information on financing HP, Should widely disseminate the experience of use of the dedicated tax and alternative financing, Provide technical support for capacity building for policy and program development.

31. International Health Policy Program - Thailand 31 Thank you for your kind attention