Country Report Thailand

Transcription

1 Country Report Thailand The 4 th ASEAN & Japan High Level Officials Meeting on Caring Society: Support to Vulnerable People in Welfare and Medical Services Collaboration of Social Welfare and Health Services, and Development of Human Resources Tokyo, Japan August 2006 Dr. Narongsakdi Aungkasuvapala Deputy, Permanent Secretary Dr. Suvaj Siasiriwattana Director, Bureau of Policy and Strategy Ministry of Public Health Thailand

2 Contents 1. Population Health Status and Trends 3 2. Current Health Care System 5 3. National Health Policy and Development 8 4. Universal Health Care Coverage Policy (30-baht Policy) Support to Children and Women in the Context of Health Services Summary References 20 Page 2

3 1. Population Health Status and Trends Over the past 30 years, Thailand has achieved remarkable progress in basic-health care, with significant declines in infant and maternal mortality rates, to the effect that the country is projected to meet many of the Millennium Development Goals (MDGs). The total population size has tripled between , and yet the mortality rates have declined. Life expectancy at birth for males and females has increased from 60 and 66 years in 1980 to 70 and 75 years in 2000, respectively. The infant mortality rate decreased from 84.3 per 1,000 live births in 1960 to 22 per 1,000 live births in The decrease of the infant mortality rate is a result of a successful immunization program and the provision of maternal and child health services. The five majors causes of death among Thai people of all ages, as of the year 2004, were neoplasms, including benign tumors and malign cancers, infectious and parasitic diseases, external causes and other accidents, diseases of the circulatory system, and diseases of the respiratory system. Table 1: Characteristics of Thailand s population, Characteristics P Total population ( 000) 26,260 34,397 44,825 54,548 62, male -female 13,154 13,104 17,124 17,274 22,329 22,496 27,062 27,487 30,885 31,171 Dependency ratio Population under 15 years of age (%) Population aged years (%) Population over 60 (%) Population in urban areas (%) Population per km Life expectancy at birth (years) -male -female Infant mortality rate (per 1,000 live births) Source: Bureau of Policy and Strategy, MOPH. 3

4 The societal trends and perspective that are suggested by marriage statistics are further verified by observed trends in fertility and family size. Fertility has dropped considerably in recent years, from 33.1 births per 1,000 women in 1993 to 24.8 in Like fertility, family size has also been decreasing. There are two entirely diverse causes, one linked to tradition, and another one reflecting current tendencies. Like in many Asian cultures, some children have tended to live with their parents long into adulthood, accepting the responsibility of caring for their parents in their old age. Of much greater impact, today, is the pursuit of educational and career development by members of the younger generation. Hence, the proportions of both young men and women, who enter marriage upon attainment of certain educational and professional accomplishments, have grown. As a consequence, in recent years family size has been decreasing, from an average of 5.6 in 1960 to 4.4 in 1990 and, furthermore, 3.9 in Young adults tend to leave their homes for work in Bangkok or other urban areas. This often leaves elderly parents in rural communities with less personal support. Projections estimate that as much as 15.9% of the population will be above the age of 60 by the year It shows that Thailand will quickly have an aging population. This resembles the demographic trend observed in many developed countries of Europe and North America as well as in Japan. Thailand will, in the foreseeable future, face the same challenges. In this regard, Thailand is getting prepared to care for ever more of her citizens who will live longer, by fostering advances in health and medical care. 4

5 2. Current Health Care System The Thai health care system has undergone several reforms. In 1952, the area of responsibility for the Ministry of Public Health was extended by adding the health-care infrastructure and the development of human resources to provide health-care services throughout the country. Various health policies were on the agenda of national development plans, beginning with the First National Economic Development Plan of 1961, and notably the successive National Economic and Social Development Plans, since 1971, and their implementation. Health care is organized and provided by the public and private sectors. The Ministry of Public Health (MOPH) is the principal agency responsible for promoting, supporting, controlling, and coordinating all health service activities. In addition, there are several other agencies playing significant roles in medical and health development programs such as the Ministry of Education, the Ministry of Interior, the Ministry of Defense, the Bangkok Metropolitan Administration, state enterprises, and private-sector enterprises. They operate health facilities including hospitals that provide primary, secondary and tertiary medical services. During the last ten years, private hospitals and clinics have been expanding rapidly in Bangkok and provincial cities. In 2003, public-sector and private-sector health care facilities were categorized as follows: In Bangkok, there were five medical-school hospitals, 29 general hospitals, 19 specialized hospitals and institutions, as well as 61 health centres and 82 health centre branches. Throughout the country, beyond the city of Bangkok, public health facilities included four regional-level medical-school hospitals, 25 regional-level hospitals, 40 specialized hospitals, 70 provincial-level general hospitals under the auspices of the MOPH, and 56 hospitals operated by the Ministry of Defense. These medical facilities were underpinned by 725 community hospitals at district level as well as 214 municipal health centres. At the sub-district (tambon) level, there were 9,765 health centres as well as 66,223 rural and 2,470 urban primary health care centres. The last two types of health facilities 5

6 were managed by village health volunteers (close to 800,000 in 2004) under the supervision of health workers of sub-district health centres. The private sector has also played a significant role in providing curative care. In 2003, there were one private medical school in Bangkok, 346 private hospitals (100 in Bangkok and 246 in other provinces), 11,853 clinics, 12,878 drugstores (1 st and 2 nd class) and 2,106 traditional medicine drugstores. In 2002, the overall ratio of hospital beds to population was 1:206 in Bangkok, compared to the ratio of 1:462 in all other provinces. The ratio of physician to population was 1:3,295 for the whole country, ranging from 1:767 for Bangkok and 1:7,251 for the Northeastern Region. Health Care Financing Thailand s health care system reflects the entrepreneurial market-driven nature of its economy. It is a cross-over system of public-sector and private-sector interfacing in both health-care financing and provision. Overall, the resources allocated to health care have markedly increased recently. The total health expenditure has increased gradually, at a faster rate than the growth of the gross domestic product (GDP). In 2003, the total health expenditure equaled 3.3% of the GDP, of which a higher proportion (61.6%) was covered by the public sector than by the private sector (38.4%). 6

7 Table 2 Health Financing Indicators in 2003 Finance Unit General Government expenditure on health as % of total expenditure on health 61.6 General Government expenditure on health as % of total general government 13.6 expenditure Per capita total expenditure on health at average exchange rate (US$) 76 Per capita total expenditure on health in international dollars 260 Per capita GDP at average exchange rate (US$) 2,490 Per capita GDP in international dollars 7,930 Per capita government expenditure on health at average exchange rate (US$) 47 Per capita government expenditure on health in international dollars 160 Prepaid plans as % of private expenditure on health 14.6 Out-of-pocket expenditure as % of private expenditure on health 74.8 Social security expenditure on health as % of general government expenditure on 32 health External aid 0.3 Total expenditure on health as % of GDP 3.3 Source: World Health Report

8 3. National Health Policy and Development The Government Health-related Policies from 2001 onward The current government, the first administration elected under the provisions of the 1997 Constitution, known as the People s Constitution, and in office since 2001, has mobilized its full potential to implement its policy as mandated by the majority of the electorate. Upon the public-sector reform of 2002, Public Health has been organized into four clusters and eight departments. In the government s pursuit to improve the quality of life for all segments of society the Ministry of Public Health plays a vital role by implementing the 30 baht Universal Health Care Policy. Objectives of the 30 baht Universal Health Care Policy The 30 baht Universal Health Care Policy is focused on creating universal health insurance coverage for the entire population. Prior to its implementation, 20% of the population were not covered by any insurance scheme. The health service benefit package includes inpatient/outpatient treatment at registered primary care facilities and referral to secondary and tertiary care facilities (except emergency cases), dental care, health promotion/prevention services, and drug prescription. To ease the financial burden on patients, users are required to make an out-of-pocket payment of the flat-rated fee of 30 baht (approx. US$ 0.78) per visit, with the exception of the very poor for whom this fee is waived. Health Promotion, Disease Prevention and Control, and Consumer Protection The current government set the national agenda on Health Promotion, Disease Prevention and Control, and Consumer Protection. Health promotion is a key strategy for sustainable health development of individuals, families, communities, and society. Each individual is encouraged to adopt healthy practices such as exercising at least three times/week, eating nutritious and safe food, and staying away from unsafe sex and drugs. 8

9 Thailand has employed the principles of good manufacturing practice (GMP) for drug, food and cosmetic products and, recently, for toxic substances. The effort has been aimed at raising the manufacturing standards to international level. As of December 2005, 85 percent of the drug producing industrial enterprises obtained the GMP certification. Promotion of Thai Traditional & Herbal Medicine and Alternative Medicine Policy support for the development of traditional and herbal medicine was launched through the Fourth National Economic and Social Development Plan, , and was reinforced through successive government policies as well as national pharmaceutical ventures. The period of 1994 to 2000 was designated as the Decade of Thai Traditional Medicine Development focused on research and development of health-related products and health technologies, resulting in an increased capacity of producing traditional medicines and in training on Thai traditional massage. Knowledge of the therapeutic potency and usage of herbal medicinal products has become a valuable heritage of local wisdom which has been transferred from generation to generation. Many Thai people still rely on the efficacy of herbal remedies as well as traditional medicinal practices. Use of herbal medicinal products has increased remarkably along with the global trend of resorting to therapies using natural substances deemed superior to modern medication. Holding a large natural resource of medicinal plants, Thailand is attuned to this global trend. Numerous academic and governmental research organizations have been conducting studies of herbal medicinal products or traditional medicinal practices. Local, indigenous knowledge has become increasingly recognized as a valuable inheritance. Study and research on the potency of medicinal plants has been geared to extracting and purifying their principal substances and active components. New manufacturing technology has been applied to produce herbal remedies of high efficacy and in appropriate dosage. The government has promoted traditional and herbal medicine by integrating it into primary health care. Accordingly, all herbal traditional prescriptions have become subject to regulation. Research and development (R&D) applying modern technology resulted in innovative, modern herbal medicinal products. 9

10 For almost one century, Thai traditional medicine had been a non-formal medicalcare system without any substantial support and development from the government. Only in the last two decades did the Ministry of Public Health launch ventures to develop the whole system of indigenous medicine. In 1993, the National Institute of Thai Traditional Medicine was established, and in 2002 it was reorganized as the Department of Thai Traditional Medicine and Alternative Medicine. Strengthening the Country s Health Related Capability for Income Generation and Export In recent years, the One Tambon One Product (OTOP) Project has become an effective means to encourage villagers to use local resources and skills for the production of qualitatively competitive goods, ultimately fit for export. The Ministry of Public Health and the private health sector have also participated in this project by advising villagers how to produce health-related goods such as preserved food, herbal concoctions, and Thai traditional remedies, as well as training to develop skills required to practice massage. These also include many health resorts and spas providing traditional medical care. Hospitals at all levels nationwide are now in the process of emulating international standards of general and special health services such as dental care, elective surgery (hip or knee replacement), and plastic surgery. In 2002, the province of Phuket was designated not merely as an Asian hub of tourism but explicitly as a health-tourism hub of Asia. 10

11 4. Universal Health Care Coverage Policy (30-baht Policy) Launching of the 30-baht Policy (UC) The fragmented funding and provision of health care made it difficult to provide equitable services, and contributed to inefficiencies and variable levels of quality of care. The implications of reform of the Thai health care system were taken into consideration by the government in 2001, with regard to financing, delivery of services, and consumer rights. The main objectives and characteristics of the Universal Health Care Policy are: universal coverage, single standard, and sustainable system. To ensure the effectiveness of the system, strong emphasis has been placed on both resource and technology efficiencies, underpinned by adequate and stable budget allocation to secure the system s financial affordability. Legislation was initiated so as to ensure policy sustainability. The government drafted a pertinent law, the National Health Security Act, which was duly enacted in November 2002, to ensure sustainability in terms of policy, financing, and institutional support. Implementation of the Universal Health Care Policy In its start-up phase, beginning in April 2001, the 30-baht Universal Health Care Policy covered six provinces. Coverage was expanded to include 21 provinces, as of June 2001, followed by its expansion, in October 2001, to all but one province. Finally, the province with the capital city of Bangkok was included, in January As of December, 2005, a total of 47 million people were covered by this scheme. The remainders comprise eight million people who include civil servants and their dependents (spouses, parents, and children) and eight million workers covered under the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Health Insurance Scheme (SSS), respectively. The above three schemes differ with regard to eligible population segment, services provided, and financing as well as payment systems. As funding mechanism, a capitation grant was chosen to finance the UC scheme. A capitation grant based on a rate of 1,202 baht per registered capita per year was prepaid to 11

12 the health care facility to cover the benefit package during the first two years. The budget under the Universal Coverage Policy was allocated to provinces according to the registered population. The payment mechanism was applied to both public-sector and private-sector facilities. Highest priority was given to channeling allocations to the primary care units based on the registered population figure. Secondary and tertiary hospitals were funded from the budget of and through primary care units for inpatient care, commensurate with their services as determined by the number and type of referred cases. The capitation grant rate was increased to 1, baht for the fiscal year 2004/2005, owing to study findings that showed a capitation grant rate of 1,510 baht as adequate. After the third year of implementation, household surveys revealed that the 30 baht Universal Health Care Policy was strongly supported by the beneficiaries, regardless of their socio-economic status. Future Challenges for 30-baht Policy Thailand might be one of only few countries whose governments have made headway towards accomplishing any universal coverage of health care policy during the economic slowdown period. Attempts to achieve universal coverage have had a long history. It has been advanced during the past five years by adopting the current UC policy and its implementation, in terms of area coverage and package comprehensiveness. Nationwide coverage was achieved within one year and the policy is heading in a sound direction given the accumulated experience and knowledge. However, rapid policy implementation has threatened the sustainability of the policy, to some extent, as the existing health-care infrastructure, including health-care personnel, have had limited capabilities/resources to perform their new roles and functions. Moreover, there still have been problems of underfunded and less-than-ideal quality of medical services. The challenge has remained how to keep the system sustainable and to meet people s expectations of health-care services. Thailand s Universal Health Care Policy is an example of how a middle-income country manages to pursue equity in health-care with remarkable achievements. It is obvious that this policy is welcomed by the public and is fully supported by politicians, thus ensuring a governmental commitment. Both successes and future challenges have been 12

13 identified. The Thai experience may be shared with other countries facing similar challenges. The lessons learned might be useful to other developing as well as developed countries in paving the way to increase investment in health-care and treating public health as a core concern of development. 13

14 5. Support to Children and Women in the Context of Health Services Thailand has participated in the shift of health promotion paradigms, starting with a conventional paradigm that focused on health promotion services such as maternal and child health-care, nutrition, and family planning. It was followed by the paradigm of Health for All by the Year 2000 and the emerging concept of primary health-care. Then, Thailand, as a member of the World Health Organization (WHO), has adopted the WHO guidelines in implementing the national health policy. In November 2004, the government has launched the Healthy Thailand Policy as one component of the National Agenda, with a view to meeting targets defined by MDG Indicators. In 2005, the WHO chose Thailand to host the 6th Global Conference on Health Promotion in August 2005, which was concluded with the adoption of Bangkok Charter on Health Promotion. In praising Thailand as a leader in the field of health-care promotion, she was commended as a source of reference as to how to strengthen public health through health-care promotion at individual, grass-root, village, tambon, district, provincial, and national levels. This was an opportunity for Thailand to share her progress in health-care promotion, in pursuance of the vision of Healthy Thailand while working towards attaining the Millennium Development Goals (MDGs). The Healthy Thailand Policy might be useful as a source of reference for intercountry collaboration among the regions and as a basis for international cooperation towards a global healthy population. Healthy Thailand Healthy Thailand stands for the vision that encapsulates the Medium-term Strategic Plan of the Ministry of Public Health ( ) whose mission, strategies and agenda have been geared toward this component of the National Agenda. Healthy Thailand is a strategic goal set by the Ministry of Public Health to give direction and serve as guideline in efforts to reduce behavioral health-risks and solve major health problems. Although Healthy Thailand is not an entirely new concept for implementing health-care, various related approaches developed and implemented earlier have recently been coordinated and geared toward pro-active ways and means to ensure access to health-care services for the entire population. Healthy Thailand directs all health-care staff and health-related agencies to reinforce specific efforts toward attaining the goal of Healthy 14

15 Thailand within the staggered time frame set for each year. Annual targets and indicators were defined to solve particular health problems. For the year 2004, the five target areas were exercise, diet, emotional development, disease reduction, and environmental health. Such target areas have particular relevance, indeed, to both community and family health as well as environmental and occupational health. With regard to mother and child health, health promotion and medical services as well as other health-care interventions, in the short run, and disease prevention and control, in the long run are important to the achievement of MDG targets. Occupational health is of equally vital importance, given the rapid diversification of the national economy and the challenge of competitiveness in the global market. Both environmental and occupational health, intertwined as they are, have broadened the health-care policy by adding modern preventive, curative, rehabilitative, and promotive objectives and tasks. 30-baht Policy in Support of Children and Women The National Health Security Office (NHSO) works as a secretariat office of the National Health Security Board (NHSB) in developing the universal coverage of health care scheme. The type and scope of health services consists of curative and rehabilitative care, health promotion and disease prevention services for the individuals and families, and Thai traditional and alternative medical care as recognized by the Medical Registration Committee. The benefit packages for eligible persons are as follows: Curative and rehabilitative care Health promotion and disease prevention services 1. General examination, curative and 1. Having and using personal health recordbooks rehabilitative services in providing individual health care 1.1 Medical examination, diagnosis, continually. treatment and rehabilitation, including 2. Examination and pre-natal care for alternative medical care. 1.2 Childbirth delivery services, totaling for no more than 2 deliveries. pregnant women for health promotion purposes. 3. Services related to child health, child 1.3 Meals and room charges for inpatients in development and nutrition, including common rooms. 1.4 Dental services: extraction, filling, immunizations according to the national immunization program. 15

16 scaling, plastic-based denture, milk-tooth nerve-cavity treatment, and placement of artificial palate in children with harelip and cleft palate. 1.5 Medicines and medical supplies according to the national drug list. 1.6 Referrals for further treatment among health facilities. 2. High-cost medical services, including artificial organs and prostheses (both inside and outside the body), as indicated in the payment criteria set by the NHSB. 3. Care for accident or emergency case can go for medical care at any health facility (participating in the scheme) located nearest to the scene. Source: Jongudomsuk, 2003, Annual physical checkups for the general public and high-risk groups (according to the Medical Council guidelines for medical checkups of 2000, as recommended by the Royal Medical Colleges). 5. Antiretroviral medications for the prevention of mother-to-child transmission of HIV, as indicated in guidelines set by the NHSB. 6. Family planning services. 7. Home visits and home health care. 8. Provision of knowledge about health care for patients at the individual and family levels. 9. Counseling and support for people s participation in health promotion. 10. Oral health promotion and disease prevention: 10.1 Oral health examination; 10.2 Advice on dental health; 10.3 Fluoride treatment among population groups at risk of dental caries such as children, elders, and patients taking radiation in the head and throat areas Sealant application of dental pits for children under 15 years of age. However, the benefit packages do not cover the following services: infertility treatment, artificial fertilization, transgender operation, cosmetic surgery without medical indications, and excessive examination, diagnosis or treatment without any medical indications. Moreover, in 2005 the NHSO has allocated 200 million baht budget to cover special medical services for disables provided by the contracted hospitals. 16

17 Domestic violence health policy and women and children s health Overall, implementing domestic violence policy is directed by the Convention on the Elimination of all forms of Discrimination against Women (CEDAW), which Thailand has ratified. Policy formulation and implementation of domestic violence policy comes under the concept of the elimination of all forms of violence against women and children, which is coherent with the global movement in this regard. International conventions related to violence against women have guided principles and the direction of policy formulation and implementation. Several laws, regulations, and strategic plans designed to eliminate violence against women and children have been drafted. However effective measures to alleviate domestic violence per se have not existed until recently. At present, there is a movement to introduce bills on domestic violence and an effort to launch a project on the Cohesive Family. However, since domestic violence has not been recognized as an item on the national agenda by the government and Thai society, there is a lack of support in terms of budgeting and giving clear directions and guidelines for working together. In Thailand, there is quite a long history of collaboration among government officials, non-government workers, politicians, academics and survivors of domestic violence in working together to combat domestic violence. Especially in the past four-to - five years, community members, private business sectors and mass media have become involved in working on this issue. The Ministry of Public Health has launched a health service under the name of One-Stop Crisis Center (OSCC); overall there is a center in each provincial hospital in the whole country. However, most OSCCs still cannot provide holistic care to the victims. Most OSCC services still concentrate on treatment of physical symptoms and cannot extend their service to provide services for perpetrators nor focus on preventive aspects of domestic violence. The Bangkok Metropolitan Administration is in the most advantageous position because their autonomous administration has a more advanced domestic violence program, which incorporates the provision of health care and social service together with community and school-based preventive programs. However, the implementation of its programs has just started and has not been prioritized. The Ministry of Social Development and Human Security has played its role in terms of coordinating with other Ministries and setting various policies. The Ministry has implemented its work under the concept of Women and Development and Strengthening Family Cohesion rather than Gender-Based Violence and Women s Participation in 17

18 Domestic Health Policy. The Ministry also provides social services including shelters and occupational rehabilitation, which emphases serving children as a client group. The Ministry of Justice and the Royal Thai Police have concentrated their work on criminalizing the perpetrators. However, there is a change in the trend of their work from viewing these matters merely as crimes to considering them as health issues. Instead of criminalizing the perpetrators, behavioral modification and healing intervention programs are offered to the perpetrators. Non-Government Organizations (NGOs) have worked together with university scholars for advocacy and consciousness raising on the issue of domestic violence as well as modeling innovative programs on domestic violence. Community-based domestic violence programs are the result of collaborating effort between NGOs and university scholars. NGOs also play a role in terms of counseling in social and legal aspects. In conclusion, although GOs and NGOs have a long history of working together, they still work on the basis of different concepts and approaches and they do not know each other s roles, capacities, rules, regulations, and limitations. As a result, collaboration at the policy, program and implementation are not well developed. The strong point of domestic violence health policy communities in Thailand is that every stakeholder in a community collaborates at a certain level in implementation of domestic violence health policy. However, some dimensions of their work should be strengthened as follows: 1) The National strategic plan and program should be launched with collaboration from all stakeholders; GOs, NGOs, and communities. All women s domestic violence health policy communities should work under the same concept, gender-based violence, and should move in one direction. 2) Domestic violence policy should include holistic aspects. Advocacy and campaign work as well as preventive programs should be implemented continuously. Coordination in terms of strategic planning at the policy level should be strengthened in order to facilitate the work of an interdisciplinary team staff. 3) Provision of domestic violence health services by establishing OSCCs should be implemented together with conducting research and documenting lessons learned. These health services should provide technical support for integrated services including programs on treatment, prevention, rehabilitation and healing of victims, perpetrators, and others affected by domestic violence. 18

19 The health services should also include community awareness raising on the issues of women s domestic violence in order to promote a positive environment for the victims to live happily in society. 4) Provision of support systems, information centers and counseling services are needed. The National Information Center on Women s Domestic Violence should be established to provide data-based information on the prevalence and types of women s domestic violence. Counseling services for domestic violence problems should be more widely provided because they are in need. 19

20 6. Summary Globally, health status of children and mother is considered to be the most important indicator in comparing the level of development in health status among countries. Thailand has invested in mother and child health care for many decades, many health determinants have been reduced especially access to health services both curative, promotive, and preventive care however, their health is still reduced by many determinants such as poverty, and domestic violence. Although government policy and measures on gender equality, programs on empowerment the women, and the concept of solving violence against women and children have been introduced, there is still a need to support women s development and women s network. The need lies in the coordination between the government and nongovernmental agencies in all dimensions: health, justice, and social welfare to work together to further improve health of Thai women and children. 7. References Bureau of Policy and Strategy. Health Policy in Thailand Bangkok: The War Veterans organization under the Royal patronage of His Majesty the King (Office of Printing Mill), Jongudomsuk. (Editor). Co.Ltd., Annual Report Nonthaburi:Lake & Fountain Printing Jongudomsuk. (Editor) Annual Report Nonthaburi: S.R.C. Envelope Co.Ltd., Wibulpolprasert, Suwit (Editor). Thailand Health Profile, Bangkok: Printing Press, Express Transportation Organization, World Health Organization. World Health Report France: Raphael Crettaz,