Editor Dr. Suwit Wibulpolprasert

Assistant Editors Dr. Supakit Sirilak Ms. Panbaudee Ekachampaka Mr. Nitis Wattanamano

ISBN: 978-616-11-1026-0 Website http://www.moph.go.th/ops.thp

Prepared by Bureau of Policy and Strategy, Ministry of Public Health Number of copies 1,000 Printing Office WVO Office of Printing Mill, War Veterans Organization of

Supported by Ministry of Public Health Thai Health Promotion Foundation (Health Information System Development Programme) II L i s t o f C h a p t e r A u t h o r s

CHAPTER 1 Chakri Dynasty and Thai Public Health by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 2 Thailand Country Profile by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 3 Health Policy and Strategy in Thailand by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 4 Situations and Trends of Health Determinants by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 5 Health Status and Health Problems of by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 6 Health Service Systems in Thailand by Pinij Faramnuayphol, Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 7 Governance of Thailandûs Health Systems by Panbaudee Ekachampaka and Nitis Wattanamano CHAPTER 8 Health Promotion System in Thailand by Amphon Jindawatthana and Luechai Sri-Ngernyuang CHAPTER 9 Lessons Learned from the Control of Pandemic (H1N1) 2009 in Thailand by Kumnuan Ungchusak CHAPTER 10 Participatory Development of Healthy Public Policy and Statute on National Health System by Amphon Jindawatthana and Orapan Srisookwatana CHAPTER 11 Health Decentralization by Supakit Sirilak and Yaovaman Suasangthong CHAPTER 12 Support for Access to Essential Drugs and Compulsory Licensing of Drugs by Vichai Chokevivat CHAPTER 13 Economic Dynamics and Health by Jongkol Lertiendumrong CHAPTER 14 Creation of Universal Health Security in Thailand by Phusit Prakongsai CHAPTER 15 Thailand and Global Health By Churnrurtai Kanchanachitra

III IV Preface

For 16 years the Ministry of Public Health of Thailand has published the report entitled çThailand Health Profileé (in Thai and English) regularly every two years since 1995. This is the sixth edition of such a report, which describes the health situations and trends as well as the health systems of the country, linking to environmental factors in an integrated manner. Previous editions of the report have been used widely as a reference by several local and international health agencies, institutions and organizations.

This edition of the report, Thailand Health Profile 2008›2010, deals with the topics related to those included in the previous edition, but several certain issues have been elaborated and three macro-level topics related to policy and strategy of the health systems have also been added. The first topic is çSupport for Access to Essential Drugs and Compulsory Licensing of Drugsé with details on Thailandûs drug accessibility situation and the justification for the govern- ment use of patents on certain essential drugs as well as relevant international agreements and Thai laws, the notifications of the government use of patents, the procurement of the drugs under the government use of patents, and the amounts of such drugs procured and distributed. The second topic is çEconomic Dynamics and Healthé, dealing with the global financial crisis and its impact on the Thai economy, Thailandûs economic stimulus packages, and the economic impact on health and the health service system. The third topic is çThailand and Global Health Systemé, describing the concepts of global health programmes, movements of global health activities, and the roles of Thailand in global health programmes or forums.

The Ministry of Public Health really hopes that this report would serve as a technical reference at the national and international levels, especially for the formulation of the national health development plan that will lead to the design of health policy and strategy as well as health systems development in accordance with changes in the globalized world.

Ministry of Public Health April 2011

V Contents

Page

Preface List of Tables List of Figures Chapter 1 Chakri Dynasty and Thai Public Health 1 1. The Era of Thai Traditional Medicine (TTM) Revival (1782›1851) 1 2. The Era of Civilization 2 3. The Pioneering Era of Modern Medical and Health Services (1917›1929) 4 4. The Era of the Inception of the Ministry of Public Health (MoPH) 5 5. The Reign of King Rama IX (1946›present) 5 6. Royal Activities Related to Health 11 Chapter 2 Thailand Country Profile 13 1. Location, Territory and Boundary 13 2. Topography and Climate 14 3. Population, Language and Religions 15 4. Economy 15 5. Thai Administrative System 16 Chapter 3 Health Policy and Strategy in Thailand 21 1. Rights to Health of the People 21 2. Fundamental State Policies on Health According to the Constitution 21 3. Statute on the National Health System, 2009 23 4. The Tenth Health Development Plan 24 5. Health Plan of Action under the National Administration Plan 29 6. The Millennium Declaration 29 Chapter 4 Situations and Trends of Health Determinants 33 1. Economic Situations and Trends 34 2. Educational Situations and Trends 41 3. Situations and Trends of Population, Family and Migration 48 4. Quality of Life of Thai People 64

VI Page 5. Situation and Trends of Environment and Livelihood 67 6. Political and Administrative Situations and Trends 88 7. Situations and Trends of Technology 96 8. Health Behaviours 97 Chapter 5 Health Status and Health Problems of Thai People 153 1. Overall Health Status Indicators 153 2. Major Health Problems 167 Chapter 6 Health Service Systems in Thailand 239 1. Health Workforce 240 2. Health Facilities 269 3. Health Technologies 281 4. Health Expenditure 290 5. Accessibility of Health Services 302 6. Efficiency and Quality of Health Service Delivery 309 7. Equities in Health Services 315 Chapter 7 Governance of Thailandûs Health Systems 325 1. The National Health System 325 2. Components of the National Health System 326 3. Mechanism for Governance of National Health System 329 4. Agencies Implementing Health Programmes 331 Chapter 8 Health Promotion System in Thailand 371 1. Development of international health promotion in relation to 371 the situation in Thailand: From Ottawa to Bangkok towards Nairobi in Kenya 2. Development of Health Promotion in Thailand 378 3. Reorienting Health Promotion in the Future 387 Chapter 9 Lessons Learned from the Control of Pandemic (H1N1) 2009 in Thailand 389 1. Introduction 389 2. Chronology in Thailand and Abroad 390 3. Strategy for Morbidity Reduction 394 4. Strategies for Morbidity Reduction 397 5. Major Lessons Learned from Emergency and Crisis Management 397 6. Opportunity for Development 401 7. Conclusions 403

VII Page Chapter 10 Participatory Development of Healthy Public Policy and Statute on 405 National Health System 1. Meaning and Evolution of Public Policy 405 2. Participatory Development towards Healthy Public Policy 407 3. Development of Mechanisms for Participatory Healthy Public Policy: From 410 çPrimary Health Careé towards çHealth System Reformé and çNational Health Acté 4. Intent and Acquisition of Statute on National Health System 423 5. Statute on National Health System, B.E. 2552 (2009) 426 Chapter 11 Health Decentralization 431 1. Background 431 2. The Transfer of Health Centres to TAOs 433 3. Conclusion 452 Chapter 12 Support for Access to Essential Drugs and Compulsory Licensing of Drugs 453 1. Introduction 453 2. Background 453 3. Procedures for Operation 455 4. Announcements of the Government Use of Patents for the First 3 Drugs 456 5. Procurement of Drugs under Compulsory Licenses 458 6. Retaliation from Patent-holders 458 7. International Perspectives 459 8. Explanation of Thailand 460 9. The Second wave of the Government Use of Patent 461 10. Implementation of the Change in Government 461 11. Results of the Operations 462 12. Increase in the Access to Patented Drugs 462 13. Systematic Monitoring and Evaluation 464 14. Conclusion 465 Chapter 13 Economic Dynamics and Health 467 1. The 1997 Economic Crisis: Background and Pattern 467 2. The 2008 Economic Crisis: Background and Pattern 470 3. Conclusions 480

VIII Page Chapter 14 Creation of Universal Health Security in Thailand 481 1. Importance of Universal Health Security 481 2. The Impacts of Universal Health Security 487 3. Current Problems and Future of UC Scheme 496 4. Future Directions of the UC Scheme in Thailand 500 Chapter 15 Thailand and Global Health 501 1. The Transition of Health Concept: from within the country to the 501 problem requiring inter-country collaboration and worldwide public-private sector cooperation 2. Pluralistic Dimensions of Global Health 503 3. Global Health Governance 505 4. Changes in the Roles of Global Health Agencies 506 5. Thailandûs Role in Global Health Forums 508 6. Capacity Building for Thai Personnel to Work on Global Health 510 7. Global Health and In-country Networking 510 References 511 Thailand Health Profile 2008›2010 Preparation Committee Members 523

IX Table Table Page Chapter 1 1.1 Royal development projects related to the Ministry of Public Health 12 (by each royal family member) Chapter 4 4.1 Proportion of poverty based on expenditure by locality, 1962-2009 38 4.2 Learning rate of Thai people, 2001-2009 42 4.3 Structure (percentage) of labour force by educational level, 1995›2020 44 4.4 Educational inequalities at the primary, secondary, and tertiary levels, 2000-2007 45 4.5 Learning achievements of primary and secondary school students, 2001-2009 46 4.6 Average scores in international testing of mathematics, science and reading skills in 47 2003, 2006 and 2007 4.7 Percentage of married women aged 15-49 years physically abused by husbands 56 over the past year by age group, 2009 4.8 Child and woman abuse, 2004-2009 57 4.9 Percentage of children aged 13›18 years abused by family members 57 4.10 Economic loss due to self-inflicted and interpersonal injuries in Thailand, 2005 59 4.11 Percentage of migrants by type of migration and current residential region, 1992-2008 62 4.12 Leisure-time spending of Thai people by administrative region, 2001, 2004 and 2009 64 4.13 Human development index for Thailand and some other countries, 1990›2010 66 4.14 Telecommunication infrastructure in some countries, 1996›2007 68 4.15 Internet access by administrative jurisdiction and region in Thailand, 2001, 2003, 68 and 2006›2008 4.16 Comparison of the Internet usage in Asia-Pacific countries, 1998, 2002, 2005, and 2009 69 4.17 Villages with electricity, 1992›2009 70 4.18 Amount of greenhouse gas emitted by various sectors in Thailand, 1994 and 2003 72 4.19 Percentage of water samples with various water-quality levels from the 76 Chao Phraya and other rivers, 1992›2009 4.20 Chemical contamination of fresh foods in fresh markets nationwide under the 81 Food Safety Project, 2003›2009 4.21 Monitoring of chemical safety in fresh vegetables and fruits, 2007›2009 82 4.22 Percentage of drinking water sources of Thai people by residential area, 1986-2009 83 4.23 Quality of water for domestic use in Thailand, 1995-2009 84

X Table Page 4.24 Monitoring of quality of water for domestic use in urban and rural 85 households and çdiamondé health-promoting schools, 2008›2009 4.25 Amount of solid wastes, 1992-2009 86 4.26 Public toilets survey in Thailand: Proportion of public toilets meeting 87 the standards, 2006›2009 4.27 Latrine use behaviours of Thai people, 2006 88 4.28 Political stability scores of ASEAN countries, 2002›2008 88 4.29 Gross Domestic Happiness (GDH) index of Thai people in various aspects, 89 December 2009 › January 2010 4.30 Achievements of public sector development 90 4.31 Efficiency of the state service system in the business sector development 93 in various countries, 1997›2009 4.32 Corruption perceptions index in various countries, 1998›2009 95 4.33 Top ten risk factors: percentage of disability-adjusted life years (DALYs) 98 in three groups of countries by income level, 2004 4.34 Amount of vegetables and fruit consumed by each of Thais aged 15 years 103 and over by age and sex 4.35 Proportion of Thais consuming vegetables and fruit each week 103 4.36 Amount of sugar used in industries, 2008›2009 104 4.37 Percentage of people who like to consume sweet foods 105 4.38 Advertisement values of carbonated drinks and snacks, 2006›2009 106 4.39 Percentage of children and youth regularly consuming fast food 107 4.40 Percentage of people consuming fast food by consumption frequency, 2005 and 2009 107 4.41 Frequency in consuming obesity-causing foods among Thais by sex 109 4.42 Percentage of Thais aged 35 years and over with different food consumption behaviours 110 4.43 Changes and prevalence of cardiovascular disease risk factors among 110 Thais aged 35-59 years 4.44 Percentage of people with dental caries by age group, according to 111 National Dental Surveys, 1984, 1989, 1994, 2000›2001, and 2006›2007 4.45 Average DMFT in various age groups according to National Dental Surveys, 112 1984, 1989, 1994, 2000-2001, and 2006›2007 4.46 Drug distribution in Thailand: percentage of drug values distributed 114 through drug outlets (as percentage of total drug value) 4.47 Percentage of people regularly taking medication by age, sex and type of medicine 116 4.48 Excise tax rate, cigarette sales, taxes collected and number of smokers, 1989›2009 117

XI Table Page 4.49 Number and proportion of smokers, 1976-2009 118 4.50 Market shares of locally produced and imported cigarettes, 1991›2009 120 4.51 Percentage of tobacco product users (in adults ≥15 years old), 2009 121 4.52 Percentage of tobacco users with cessation experience (in adults ≥15 years old) 121 4.53 Percentage of adults exposed to second-hand smoke (SHS) 122 4.54 Alcohol consumption and excise tax levied on local and imported alcoholic beverages, 123 Thailand, 1997›2008 4.55 Structure of market shares of alcoholic beverages, 1997›2008 124 4.56 Number and proportion of alcoholic beverage drinkers, 1991›2009 125 4.57 Alcohol drinking rate among population aged 11 and over by age and sex, 1991›2009 125 4.58 Percentage of drinking population by frequency of drinking, 1996, 2001, 2003, 2004, 126 2006, 2007 and 2009 4.59 Alcohol advertisement billings, 1989›2009 127 4.60 Values of imported liquor by source of origin 128 4.61 Social and economic costs of alcohol consumption in Thailand, 2006 129 4.62 Percentage of Thai people who regularly exercised, 1987›2007 130 4.63 Percentage of people that exercised by type of exercise, 2001, 2004, and 2007 133 4.64 Thais aged 11 years and over classified by illness, hospitalization and exercise 134 behaviours, 2007 4.65 Thais aged 11 years and over who exercised and their incidence of morbidity 135 and hospitalization, 2007 4.66 Number of substance abusers in Thailand by type of substance and use duration, 136 2001, 2003 and 2007 4.67 Proportions of drug rehab clients by type of drug used, 2006›2008 139 4.68 Costs of drug rehabilitation by agency in fiscal year 2007 141 4.69 Proportion (%) of drivers aged 14 years and over using safety belts by type of use 142 4.70 Proportion (%) of motorcyclists aged 14 years and over using helmets while driving 143 4.71 Percentage of youths having had sexual experience, 2006›2007 150 4.72 Percentage of youthsû first sex partners, 2006›2007 150 4.73 Percentage of situations leading to youthsû first sex, 2006›2007 150 4.74 Pattern of healthcare seeking behaviours among Thai people when ill (percent) 151 Chapter 5 5.1 Life expectancy at birth (in years) of Thai people in comparison with those 154 for other countries

XII Table Page 5.2 Life expectancy at birth (in years) of Thai people 155 5.3 Infant mortality rate and child mortality rate for Thailand in comparison 157 with those for other countries, 1980, 2001, 2003, 2004, 2006, 2007 and 2008 5.4 Number and percentage of deaths among Thai people, estimated for the top 160 12 causes, by sex, 2005 5.5 Percentage of people with illnesses by major group of diseases, 1991›2007 161 5.6 Number and percentage of Thai people with disabilities, 1974›2007 163 5.7 Percentage of causes of disability-adjusted life years (DALYs) lost among 165 Thai people by age group, 2004 5.8 Major diseases attributable to disability-adjusted life years (DALYs) 166 lost among Thai people by sex, 2004 5.9 Proportion of disability adjusted life years (DALYs) lost due to chronic NCDs 167 among peoples in 23 developing countries including Thailand 5.10 Coverage of immunization against vaccine-preventable diseases in different 168 target groups, 1982›2008 5.11 Incidence rates of major vaccine-preventable diseases in Thailand, 1977›2009 170 5.12 Projection of the numbers of HIV-infected persons, AIDS cases and deaths, 2005›2011 186 5.13 Avian influenza: numbers of confirmed cases and deaths in Thailand, 2003›2009 190 5.14 Number of cases and laboratory testing results for hand-foot-mouth disease, 2004›2009 191 5.15 Summary of reported deaths due to pandemic (H1N1) 2009, by WHO region, as of 192 14 May 2010 5.16 Incidence of cancers commonly found among Thai females, 1990, 1993, 1996,1999, 2000 and 2001 194 5.17 Percentage of cancers of the reproductive organs recorded at provincial cancer registries, 195 1993, 1996, 1999 and 2001 5.18 Cases and proportions of breast cancer among Thai women by age group, 1983›2009 195 5.19 Percentage of Thai women who have ever taken screening tests for cervical and 196 breast cancers by age group, 2004, 2006, 2007›2009 5.20 Incidence of liver cancer Thailand, 1993, 1996, 1999, 2000 and 2001 197 5.21 Comparison of prevalence of health status and behavioural risk factors for NCDs 200 among Thai people in 2004, 2005 and 2007 5.22 Morbidity rate of kidney diseases by group of illnesses, 2004›2009 205 5.23 Numbers and rates of accidents, deaths and injuries and estimated damages, 1984›2009 209 5.24 Number and percentage of deaths from road traffic accidents by age group, 1996›2009 210 5.25 Numbers of road traffic accidents and motorcycles and proportion of 213 seriously injured drinking motorcyclists, 1991›2009

XIII Table Page 5.26 Cholinesterase test-results and morbidity/mortality due to pesticide 218 poisoning among farmers, 1992›2009 5.27 Morbidity rates due to occupational and environmental diseases by group of illness, 219 1999›2009 5.28 Prevalence of mental disorders, 1997-2009 221 5.29 Nutritional status (weight-for-age, percentage) of children aged 0›6 years by region, 2004›2006 222 5.30 Ranking of disability-adjusted life years lost among Thai elderly persons by sex and cause, 2004 227 Chapter 6 6.1 Number and proportion of doctors lost in relation to newly appointed doctors, 256 Office of the Permanent Secretary, MoPH, 1994›2009 6.2 Health personnel at subdistrict health centres by region, 1987›2003 and 2006›2009 262 6.3 Workloads of doctors, 2002, 2005 and 2007›2009 268 6.4 Health facilities in the public sector, 2009 269 6.5 Private health facilities, 2009 272 6.6 Number of private hospitals by number of beds and region, 2009 273 6.7 Distribution of health centres by region in 1979, 1987, 1996›2003, 2006 and 2009 280 6.8 Distribution of drugstores by region, 1996›2009 281 6.9 Values of locally produced and imported drugs (for human use), 1983-2008 284 6.10 Number and distribution of important medical devices 285 6.11 Ratio of high-cost medical technologies to population and discrepancy index by region, 2009 289 6.12 Ratio of CT Scanners to population and discrepancy index by region, 1999›2009 289 6.13 Health expenditure at current prices, 1980-2008 (million baht) 293 6.14 Health and drug expenditures as a percentage of GDP, 1980-2008 (million baht) 294 6.15 Proportions of health spending as a percentage of overall health expenditure in 295 Thailand by funding source, 1980-2008 6.16 Comparison of health expenditures among some Asian countries 296 6.17 Household health spending pattern (baht/month), 1981-2009 301 6.18 Percentage of Thai people with health security, 1991, 1996, 2001and 2003›2009 302 6.19 Percentage of people with health insurance coverage in municipal and 303 non-municipal areas, 1991, 1996, 2001, 2003, 2004, 2006, 2007 and 2009 6.20 Rate of outpatient service utilization by region, 2001›2009 304 6.21 Rate of inpatient service utilization by region, 1995›2009 304 6.22 Rate of admissions (inpatients/outpatients) by agency of hospitals, 2002›2009 310 6.23 Rate of admissions (inpatients/outpatients) by region, 2001›2009 310

XIV Table Page 6.24 Morbidity rates and proportions of utilization of health facilities by type of 318 medical welfare scheme, 1991, 1996, 2001, 2003›2007 and 2009 6.25 Proportion of health spending in relation to household income, based on 321 household spending, by decile group, 1996›2009 6.26 Percentage of households classified by percentage of household health spending in 322 10 decile groups, 2004 and 2008 6.27 Proportion of households facing catastrophic health spending based on 323 household spending by decile group, 1996›2009 Chapter 7 7.1 Acts under the direct responsibility of the Ministry of Public Health 338 7.2 Numbers of civil servants, permanent employees, and state employees of 341 MoPH and state-supervised agencies under MoPH, 2009 7.3 Number of state employees of MoPH by professional category, 2009 342 7.4 Workforce of the MoPH (excluding state employees permanent / 345 temporary Employees and officials / employees of state-supervised agencies) by major group / profession: number and proportion of actually filled positions, 2009 7.5 Number of temporary employees in MoPH agencies, 2005›2009 347 7.6 MoPHûs budget in present value and real terms (million baht) 352 7.7 The budget of the Ministry of Public Health, 2003›2011 354 7.8 Health budget allocation by major programme, 2002›2011 (in million baht) 356 7.9 Budget received by the Ministry of Public Health, FYs 2001›2011 359 (present value: amount in million baht) 7.10 Number of not-for-profit organizations with funding support from MoPH, 1992-2010 367 7.11 Number of NPOs involved in HIV/AIDS programmes with funding from 368 MoPH 1992›2010 7.12 Projects with financial support from the Global Fund to Fight AIDS, 369 Tuberculosis and Malaria, Thailand, 2003›2014 Chapter 13 13.1 Comparison of mental health scores, 2008 and 2009 472 13.2 Rates of outpatient and inpatient services at various levels of hospitals, 2004›2009 474 13.3 Volumes and averages of health services at hospitals under MoPHûs 475 Office of thePermanent Secretary, fiscal years 2005›2009 13.4 Changes in household income, debt/income ratio, and expenditures by 476 quarter, 2007 and 2009

XV Table Page Chapter 14 14.1 Major events related to health insurance in Thailand, 1972›2002 482 14.2 Key features of various health insurance schemes prior to 2002 484 14.3 Proportions of low-income and non-low-income households that had received 485 LIHCs, 2000 14.4 Proportion of households with different levels of health to total 486 (excluding food) expenditures, 1996›2000 14.5 Utilization of outpatient and inpatient services at various levels of 494 health facilities, 2003›2009 14.6 Data on financial situations of health facilities that submitted 495 complete data in fiscal years 2003›2009 Chapter 15 15.1 Comparison of public health, international health and global health 502 15.2 Comparison of five global health dimensions and focuses 504

XVI Figure

Figure Page Chapter 2 2.1 Map of Thailand 13 2.2 Religions of Thai People, 2008 15 2.3 National administrative system of Thailand, 2010 19 Chapter 3 3.1 Relationship of concept, vision and strategies for health and national development 28 3.2 Goals and timeline in achieving MDGs and MDG Plus 31 Chapter 4 4.1 Linkage and dynamics of factors related to health 33 4.2 Economic growth rate in Thailand, 1961-2010 34 4.3 Gross domestic product per capita, 1960-2009 (market prices) 35 4.4 Proportion of economy in the agricultural, industrial and service sectors, as a 36 percentage of GDP, 1960-2009 4.5 Proportion of poverty based on expenditure, 1962-2009 37 4.6 Income share of Thai people: five income groups 39 4.7 Literacy and illiteracy rates of Thai population aged 15 and over, 1970-2010 41 4.8 Rates of educational continuation by educational level, academic years 1994›2009 43 4.9 Average years of schooling of Thai people, 1996›2009 44 4.10 Population growth rate and projection, Thailand, 1970›2030 49 4.11 Projection of population, Thailand, 1990-2025 49 4.12 Proportion of population by major age group, 1937-2030 50 4.13 Population dependency ratio, 1937-2030 51 4.14 Population pyramids of Thailand in 1960, 1990, 2000, 2010, 2020 and 2030 52 compared to those for Sweden, Denmark, and Japan in 2030 4.15 Average family size and projections, Thailand, 1960-2020 54 4.16 Family warmth index, 2001-2009 55 4.17 Percentage of children aged 6 to <13 years physically and verbally abused by type, 2001 58 4.18 Percentage of children aged 13-18 years physically and verbally abused by type, 2001 58 4.19 Development of pre-school children aged 0-5 years, 1999, 2004, 2007 and 2010 60 4.20 Projection of urban and rural population, Thailand, 2000-2027 61 4.21 Proportion of households with adequate and safe drinking water, 1960›2009 71

XVII Figure Page 4.22 Impacts expected to occur if the worldûs temperatures rise 73 4.23 24-hr average concentration of <10-micron particulate matter on roadsides in 74 Bangkok, 1992›2009 4.24 Noise levels (Leq 24-hr) on roadsides in Bangkok, its vicinity and major provincial cities, 77 1997-2009 4.25 Amounts of chemical imports, 1994›2009 78 4.26 Rates of occupational deaths and injuries in the workplaces, 1974-2009 80 4.27 Percentage of households with sanitary latrines, 1960-2009 87 4.28 Ability and ranking of Thai public sectorûs competitiveness for business sector 92 development, 1997›2009 4.29 Corruption perceptions index, Thailand, 1980-2009 94 4.30 Patterns of burden of disease among Thai people, 1999 and 2004 99 4.31 Proportion of population aged 6 years and above consuming 3 major meals 100 by region, 2005 and 2009 4.32 Proportion of population aged 6 years and above and food consumption 100 behaviour by food group consumed per week, 2005 and 2009 4.33 Percentage of Thais aged 15 year and over consuming vegetables 102 each day by age group, 2008›2009 4.34 Percentage of Thais aged 15 years and over consuming fruit 102 each day by age group, 2008›2009 4.35 Quantity of sugar intake in Thailand, 1983-2009 104 4.36 Proportion of primary school children regularly consuming snacks and 106 carbonated drinks, 2004›2009 4.37 Prevalence rate of obesity in Thailand by age group, 1986, 1995, and 2003 109 4.38 Proportion of drug to health expenditures in Thailand and other countries 113 4.39 Billings of drug, food and cosmetic advertisements, 1989-2009 115 4.40 Average number of cigarettes smoked per day by a regular smoker aged 11 years 119 and over by gender, 2001, 2003, 2004, 2006 and 2007 4.41 Percentage of Thai people who regularly exercised, 1987›2007 130 4.42 Percentage of Thai people who regularly exercised by age group, 1987-2007 131 4.43 Percentage of Thais aged 11 years and over exercising by frequency per week, 132 2003, 2004 and 2007 4.44 Percentage of Thai aged 11 years and over exercising by exercising period, 132 2003, 2004 and 2007 4.45 Percentage of Thai people regularly exercising by period of time of 133 continuous exercise, 2004 and 2007 XVIII Figure Page

4.46 Percentage of Thai aged 11 years and over exercising by reason, 2007 134 4.47 Estimated numbers of substance abusers in Thailand, 2001, 2003, 2007 and 2008 135 4.48 Number of arrested drug-related crime suspects and drug clients, 2003›2009 137 4.49 Proportions of new and old drug-related crime suspects, 2006›2009 138 4.50 Proportions of drug rehab clients at drug rehabilitation facilities in Thailand, 2001›2009 139 4.51 Proportions of first-time drug rehab clients by age group, 2006›2009 140 4.52 Proportions of drug rehab clients by occupation, 2009 141 4.53 Proportion of drunk drivers by sex, 2001, 2002 and 2006 143 4.54 Condom use rate among female commercial sex workers, 1989-2009 145 4.55 Proportion of military recruitsû sex partners in the past year according to survey on 145 HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 4.56 Proportion of male industrial workersû sex partners in the past year according to 146 survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 4.57 Rate of constant condom use during sexual encounters in the past year of military 146 recruits according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 4.58 Rate of constant condom use during sexual encounters in the past year of 147 male industrial workers according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 4.59 Proportion of female industrial workers having sexual encounters with other males 147 in the past year according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 4.60 Proportion of pregnant women attending ANC having sex with other males and 148 constant condom use rate according to survey on HIV/AIDS risk behaviour in Thailand, 1st›8th rounds, 1995›2002 4.61 Rate of constant condom use during sexual encounters with other males in the 148 past year of female industrial workers according to survey HIV/AIDS risk behavior, 1st›15th rounds, 1995›2009 4.62 Proportion of male secondary school students (Mathayomsueksa 5 or grade 11) 149 having sex in the past year according to surveys on HIV/AIDS risk behaviours in Thailand, 2nd›15th rounds, 1996›2009 4.63 Rate of constant condom use during sexual encounters in the past year of male 149 secondary school students (Mathayomsueksa 5 or grade 11) according to survey on HIV/AIDS risk behaviours in Thailand, 2nd›15th rounds, 1996›2009

XIX Figure Page Chapter 5 5.1 Maternal mortality ratio, Thailand, 1962›2009 156 5.2 Infant mortality rate for Thailand, 1964›2006 158 5.3 Child mortality rate in Thailand, 1990›2009 159 5.4 Proportion of people with disabilities (first five major types), 2002 and 2007 162 5.5 Percentage of disabled people aged 7 years and over with top 5 difficulties by 163 type of difficulties and degree of difficulty, 2007 5.6 Mortality rates due to major causes of death, Thailand, 1967›2009 164

5.7 Coverage of immunization: BCG, DPT3, OPV3, HB3 measles among children and 169

TT2+ booster among pregnant women, 1982›2008 5.8 Incidence of neonatal tetanus and measles in Thailand, 1977›2009 171 5.9 Incidence of pertussis, diphtheria, and poliomyelitis in Thailand, 1977›2009 171 5.10 Incidence and mortality rates of hepatitis B in Thailand, 1979›2009 172 5.11 Incidence and mortality rates of diarrhoea in Thailand, 1977›2009 173 5.12 Incidence and mortality of pneumonia in children under five in Thailand, 1990›2009 174 5.13 Incidence and mortality rates of leptospirosis in Thailand, 1981›2009 175 5.14 Morbidity rate of leptospirosis by region in Thailand, 1985›2009 175 5.15 Incidence of leprosy in Thailand, 1977›2009 176 5.16 Morbidity/mortality rate of rabies in Thailand, 1977›2009 177 5.17 Incidence and mortality rates of dengue haemorrhagic fever, Thailand, 1977›2009 178 5.18 Case-fatality rate of dengue haemorrhagic fever, 1977›2009 178 5.19 Incidence and mortality rates of malaria in Thailand, 1977›2009 179 5.20 Incidence and mortality rates of encephalitis in Thailand, 1977›2009 180 5.21 Prevalence rate of filariasis, Thailand, 1992›2009 181 5.22 Microfilaria positivity rate in alien workers, 1977›2009 181 5.23 Prevalence of HIV infections in blood donors and pregnant women at the 183 ANC clinics in government hospitals, 1989›2009 5.24 Prevalence of HIV infections in direct and indirect female CSWs, 184 male clients at STI clinics, and injecting drug users, Thailand, 1989›2009 5.25 Prevalence of HIV infections in Thai male military recruits, 185 November 1989 › November 2010 5.26 Rates of reported AIDS cases by region, Thailand, 1984›2009 186 5.27 Projections of the number of persons living with HIV/AIDS each year, 187 cumulative number of HIV-infected persons, and number of new infections, Thailand, 1985›2020

XX Figure Page 5.28 Rate of newly registered tuberculosis patients in Thailand, 1985›2009 188 5.29 Percentage of tuberculosis infections in HIV/AIDS patients in Thailand, 1989› 2009 188 5.30 Incidence of sexually transmitted infections and condom use rate among female 189 commercial sex workers, Thailand, 1977›2009 5.31 Morbidity rate of hand-foot-mouth disease, 2001-2009 190 5.32 Top 10 commonly found cancers in Thailand, 2003 193 5.33 Incidence of cervical and breast cancers among females in Bangkok, 1993›2001 194 5.34 Incidence of lung cancer in Thailand, 1985›2001 197 5.35 Percentage of lung cancer patients registered for treatment at the 198 National Cancer Institute, 1986›2008 5.36 Rate of hospitalizations of patients with heart diseases, cancers, , 199 and stroke, 1985-2009 5.37 Prevalence of chronic diseases that are major health problems among 201 Thai people, 1991›2009 5.38 Prevalence of diabetes and hypertension as well as appropriate treatment among 202 Thai people, 2004 and 2009 5.39 Mortality rate due to emphysema, 1989›2009 203 5.40 Projection of chronic obstructive pulmonary disease prevalence, Thailand, 2001›2010 204 5.41 Number of patients with coronary artery disease treated at the 204 Chest DiseaseInstitute, 2005›2009 5.42 Number of Patients with valvular heart disease treated at the 205 Chest Disease Institute, 2005›2009 5.43 Morbidity rates of renal failure in males and females, 2004›2009 206 5.44 Mortality rate of liver disease and cirrhosis, Thailand, 1977-2009 206 5.45 Death and injury rates from road traffic accidents, Thailand, 1984›2009 208 5.46 Proportion of deaths from road traffic accidents by sex, 1996›2009 211 5.47 Major causes of road traffic accidents, 2009 211 5.48 Causes of road traffic accidents by traffic-police charge, 2009 212 5.49 Trends in GDP growth, fuel use for transportation, injuries and deaths 214 from road traffic accidents, 1994›2009 5.50 Proportion of serious injuries from traffic accidents among riders/ 215 drivers and passengers with and without safetybelt/helmet use, 2000›2009 5.51 Proportion of severe injuries among motorcycle riders with and 215 without alcohol drinking, 2000›2009 5.52 Rate of deaths from accidental drowning in Thailand, 1977›2010 216

XXI Figure Page

5.53 Percentage of reported deaths from accidental drowning by age and gender in 217 Thailand, 1996›2010 5.54 Rate of outpatient visits with mental and behavioural disorders, 1983›2009 220 5.55 Rate of admissions of patients with psychosis and mental disorders, Thailand, 1981-2009 220 5.56 Rate of suicides, 1992-2009 221 5.57 Proportion of underweight primary schoolchildren, 1989›2008 223 5.58 Proportion of anaemic pregnant women (Hct <33%), 1988›2005 224 5.59 Situation of iodine deficiency disorders among primary schoolchildren, 1989›2004 225 5.60 Percentage of pregnant women with iodine deficiency (iodine in urine <10 mg/dl), 2000›2008 225 5.61 Percentage of newborns with low birth weight (under 2,500 grams), 1990›2009 226 5.62 Mortality rates due to major causes of death in the elderly, 1985›2009 228 5.63 Percentage of elderly persons with chronic diseases by disease and sex, 2007 230 5.64 Rates of hospitalization due to common illnesses among elderly persons, 2004›2009 231 5.65 Prevalence of chronic diseases and cardiovascular disease among 232 Thais aged 60 years and over, 2008›2009 5.66 Proportions of diagnosis and treatment efficacy 2008-2009 among elderly 233 persons with diabetes and hypertension 5.67 Estimated numbers of elderly persons aged 60 years and over with 233 chronic diseases rated to cardiovascular diseases, 2008›2009 5.68 Rate of hospitalizations with dementia among elderly persons, 2004-2009 234 5.69 Prevalence of dementia among elderly persons by age and sex, 2008›2009 235 5.70 Proportion of elderly persons with visual impairment by sex and age group, 2008 236 5.71 Proportion of elderly persons with hearing impairment by sex and age group, 2008 236 5.72 Prevalence of falls among elderly persons during the part 6 months in 237 2007 and 2008›2009 Chapter 6 6.1 Relationships of inputs, health service delivery and capacity of health service systems 239 6.2 Aspects in the analysis of health workforce situation 240 6.3 Ratios of population to health-care provider, 1979›2009 241 6.4 Ratios of population to dentist, 1999›2009 (from 2 sources of data) 242 6.5 Proportions of doctors by agency, 1971›2009 243 6.6 Proportions of doctors by agency and region, 2008 244 6.7 Proportions of dentists by agency, 1971›2009 245 6.8 Proportions of dentists by region, 2008 246

XXII Figure Page

6.9 Proportions of dentists by agency, 2001›2009 (according to DoH database) 246 6.10 Proportions of pharmacists by agency, 1971›2009 247 6.11 Proportions of pharmacists by region, 2008 248 6.12 Proportions of professional nurses by agency, 1971›2009 249 6.13 Proportions of professional nurses by agency and region, 2008 250 6.14 Proportions of part-time health-care providers in the private sector, 2003›2009 250 6.15 Proportions of medical general practitioners and specialists, 1971›2009 251 6.16 Proportions of general and specialized dentists, 1971›2009 252 6.17 Numbers of medical student admissions and newly graduated doctors, 1997›2009 253 6.18 Numbers of dental students admitted and dental graduates, 1997›2009 253 6.19 Numbers of pharmacy students admitted and graduates, 1997›2009 254 6.20 Numbers of nursing students admitted and graduates, 1997›2009 255 6.21 Population/doctor ratios by region, 1979›2009 257 6.22 Population/dentist ratios by region 1979›2009 258 6.23 Population/dentist ratios by region, 1999›2009 (based on DoH database) 259 6.24 Population/pharmacist ratios by region, 1979›2009 260 6.25 Population/professional nurse ratios by region, 1979›2009 261 6.26 Disparities of population/health-care provider ratios for Bangkok and the 263 Northeast, 2001›2009 6.27 Geographical distribution of doctors and dentists: population/ 264 doctor and population/dentist ratios, 2008 6.28 Geographical distribution of pharmacists and nurses: population/ 265 pharmacist and population/nurse ratios, 2008 6.29 Proportion of health personnel by type of hospitals, 2009 266 6.30 Beds/doctor ratios and doctors/hospital ratios by type of hospitals, 2008 267 6.31 Numbers of beds and doctors, and beds/doctor ratio at 267 community hospitals, 1977›2009 6.32 Proportions of community hospitals by hospital size, 1999›2009 271 6.33 Proportion of private hospitals by hospital size, 2009 273 6.34 Number of private hospitals newly established and closed down, 1994›2009 274 6.35 Proportions of hospitals by agency, 1973›2008 275 6.36 Proportions of hospital beds by agency, 1973›2008 275 6.37 Proportions of hospitals by agency and region, 2008 276 6.38 Proportions of hospital beds by agency and region, 2008 277 6.39 Bed-occupancy rates by agency, 2006›2009 278

XXIII Figure Page 6.40 Population/bed ratios by region, 1979›2008 278 6.41 Bed-occupancy rates by region, 2006›2009 279 6.42 Geographical distribution of population/bed ratios by province, 2007 279 6.43 Percentage of GMP›certified drug manufacturers, 1989›2010 282 6.44 Percentages of locally produced and imported drugs (for human use) 1983›2008 283 6.45 Values of drugs exported from Thailand (current prices), 1989-2009 285 6.46 Number of MRI devices in the private and public sectors in Thailand 286 6.47 Values of imported and exported medical devices, Thailand, 1991›2009 287 6.48 Numbers of high-cost medical technologies, Thailand, 1976›2009 288 6.49 Overall, public and private health expenditures, 1995›2008 290 6.50 Overall health and drug expenditures and proportion of drug expenditure to 291 health expenditure, all in relation to GDP, 1995›2008 6.51 Proportions of public and private health expenditures, 1980›2008 292 6.52 The national health budget and MoPH budget, 1984›2011 297 6.53 Household health expenditure, 1981›2009 299 6.54 Proportion of household health spending when attending health facilities, 1986›2009 300 6.55 Relationship between the rate of outpatient service utilization and population/ 305 doctor ratio at provincial level, 2007 6.56 Relationship between the rate of inpatient service utilization and population/ 305 bed ratio at provincial level, 2007 6.57 Geographical distribution of outpatient (OPD) service utilization rates and 306 inpatient service (admission) rates at provincial level, 2007 6.58 Proportions of outpatients (visits) by agency of hospitals, 2002›2009 307 6.59 Proportions of inpatients by agency of hospitals, 1995›2009 307 6.60 Proportions of outpatients by level of MoPH health facilities, 1977›2009 308 6.61 Numbers of outpatients (OPD visits) by level of MoPH health facilities,1995›2009 309 6.62 Average length of stay of inpatients by agency of hospitals, 1995›2009 311 6.63 Average length of stay of inpatients by region 1995-2009 312 6.64 Geographical illustration of average length of stay by province, 2007 313 6.65 Mortality rates of inpatients with diabetes, hypertension, cerebrovascular disease, 314 ischemic heart disease, COPD, asthma and tuberculosis, 2005›2010 6.66 Mortality rates of inpatients with head injuries, cardiovascular disease and cancer, 2005›2010 315 6.67 Percentage of health facility selection when ill by level of householdûs 316 average monthly income, 2009

XXIV Figure Page 6.68 Percentage of health facility selection when hospitalized by level of 317 householdûs average monthly income, 2009 6.69 Comparison of average household health spending in 10 decile groups of 319 households before and after the launch of the universal health-care scheme 6.70 Percentage of health spending in relation to household income by decile 320 group of income, 1992, 1996, 2002, 2004 and 2008 6.71 Percentage of health spending in relation to household spending by decile group, 321 1996, 2002, 2004, 2007 and 2009 6.72 Proportion of households facing catastrophic health spending, 1996›2009 323 Chapter 7 7.1 Scope and meaning of health system 325 7.2 Components of health system 326 7.3 Linkages of governance mechanisms in the national health system 330 7.4 Evolution of the Ministry of Public Health, 1888-present 332 7.5 Organization chart of Ministry of Public Health 335 7.6 Organogram of Provincial Public Health Administration 337 7.7 Numbers of civil servants, permanent employees, and state employees of 343 MoPH and officials / employees of state-supervised agencies under MoPH, fiscal years 1981›2009 7.8 Proportions of civil servants, permanent employees, and state employees of 344 MoPH and officials / employees in state-supervised agencies under MoPH, fiscal years 1981›2009 7.9 Proportions of all kinds of personnel of MoPH (including temporary employees), 348 fiscal years 2005›2009 7.10 Amounts and proportions of MoPHûs budget compared with the national budget 349 (present value), FYs, 1969›2011 7.11 MoPHûs budget compared with the national budget (baht) 350 7.12 Proportions of security, debt repayment, education and public health budget 351 compared with the national budget, FYs 1969›2011 7.13 Proportion of MoPHûs budget by agency, 2011 355 7.14 Proportion of MoPH budget by major programme, 2011 357 7.15 Budget for free medical services for the poor and underprivileged as percentage 360 of MoPHûs budget, 1979›2001 7.16 Percentage of MoPH budget by budget category, 1959›2011 361

XXV Figure Page 7.17 Linkages and network of the management information system, MoPH 362 7.18 MoPHûs monitoring and evaluation system 364 Chapter 9 9.1 Estimated numbers of infected persons, patients and deaths due to pandemic 400 H1N1 2009, Thailand, July 2009 9.2 Number and proportion (%) of lab confirmed H1N1 pandemic cases to all 402 ILI patients attending outpatient services at 13 sentinel hospitals from the 29th week of 2009 to the 6th week of 2010 (19 July 2009 › 7 February 2010) Chapter 10 10.1 The çtriangle that moves the mountainé strategy 409 10.2 Systems and mechanisms for health assembly 414 10.3 Linkages of systems and mechanisms for health impact assessment in Thai society 418 10.4 Essence of the National Health Act, B.E. 2550 (2007) 424 Chapter 11 11.1 Guidelines for health decentralization 434 11.2 Steps for LGOûs readiness assessment on public health management 440 Chapter 12 12.1 Use of antiretroviral efavirenz (600 mg) under the universal coverage (UC) 463 of healthcare scheme, 2006›2010 12.2 Use of antiretroviral lopinavir/ritronavir (200/50 mg) under the universal coverage (UC) 463 of healthcare scheme, 2006›2010 Chapter 13 13.1 Suicide rate per 100,000 population, Thailand, 1998›2009 473 13.2 Targets of investment on public health service system development 478 Chapter 14 14.1 Coverage of various health security systems, 1991›2009 488 14.2 Proportion of eligible persons in the three health insurance schemes by their 489 economic status 14.3 Utilization of outpatient (ambulatory) services of people by income quintile, 490 2001›2005 14.4 Utilization of inpatient services (hospital admissions) of people by income quintile, 491 2001›2005

XXVI Figure Page 14.5 Comparison of benefits from state health resources received by population groups 492 with different economic status, 2001›2010 14.6 Proportion of health spending in relation to GDP and amounts of health investment 496 in the public and private sectors, 1994›2007 14.7 Estimated national health spending as a percentage of GDP, Thailand, 1994›2026 497 14.8 Disparities in medical services among patients under the three health insurance systems 498 14.9 CSMBS medical expenditures, 1990›2008 499 Chapter 15 15.1 Linkages among global health agencies providing management and financial support 505 15.2 Investments in health of various agencies, 1990›2006 507

XXVII Acronyms

AAAH Asia-Pacific Action on Human Resource for Health ACMECS Ayeyawady-Chao Phraya-Mekong Economic Cooperation Strategy AEFT Adverse event following Immunization AEM Asian Epidemic Model AFRO Africa Regional Office AFTA ASEAN Free Trade Area AHB Area Health Board AIDS Acquired Immune Deficiency Syndrome AMRO Americas Regional Office ANC Ante-Natal Care APEC Asia-Pacific Economic Cooperation APEIR Asian Partnership on Emerging Infectious Disease Research ARV Antiretroviral Drugs ASEM Asia-Europe Metting BCG Vaccine against Tuberculosis BMA Bangkok Metropolitan Administration BMI CABG Coronary Artery Bypass Graft CDC Centers for Disease Control and Prevention CDL Committee on Decentralization to Local Government Organizations CEO Chief Executive Officer CMR Child Mortality Rate COHRED Council on Health Research for Development COPD Chronic Obstructive Pulmonary Disease CPI Corruption Perceptions Index CSMBS Civil Servants Medical Benefits Scheme CSWs Commercial Sex Workers CUP Contracting Unit of Primary Care DALYs Disability Adjusted Life Years DDC Department of Disease Cotrol DFID Department of State the department for International Development of the United Kingdom DHF Dengue Haemorrhagic Fever DHSS Department of Health Service Support DLA Department of Local Administration

XXVIII DMFT Decoyed, Missing and Filled Teeth DMH Department of Mental Health DMS Department of Medical Services DMSc Department of Medical Sciences DOA Department of Agriculture DOH Department of Health DPT Vaccine against Diphtheria, Pertussis and Tetanus DRG Diagnosis Related Group DTAM Department for Development of Thai Traditional & Alternative Medicine EC European Community ECOSOC Economic and Social Council EMIT Emergency Medical Institute of Thailand EPI Expanded Programme on Immunization ESWL Extracorporal Short-Wave Lithotripter EU European Union EURO Europe Regional Office FCTC Framework Convention on Tobacco Control FDA Food and Drug Administration FETP Field Epidemiology Training Programme FY Fiscal Year GATS Global Adult Tobacco Survey GAVI Global Alliance for Vaccines and Immunization GDF Gross Domestic Happiness GDP Gross Domestic Product GIS Geographical Information System GMP Good Manufacturing Practices GPO Government Pharmaceutical Organization GSP Generalized System of Preferences HA The Institute of Hospital Quality Improvement and Accreditation HAI Healthcare Accreditation Institute HALE Healthy Life Expectancy HB Hepatitis B HC Health Centre HDI Human Development Index HEC Office of the Higher Education Commission HIA Health Impact Assessment HIV Human Immunodeficiency Virus

XXIX HPPF Healthy Public Policy Foundation HRDO Human Resource for Health Development Office HSPG Health Service Practice Guidelines HSRC The National Health System Reform Commission HSRI Health Systems Research Institute HSRO The National Health System Reform Office HWS Health and Welfare Survey ICT Information and Communication Technology IDD Iodine Deficiency Disorders IFCS Intergovernmental Forum on Chemical Safety IGWG Intergovernmental Working Group on Public Health Innovation and Intellectual Property IHPP International Health Policy Programme ILO International Labour Organization IMD International Institute for Management Development IMF International Monetary Fund IMR Infant Mortality Rate IPSR Institute for Population and Social Research JICA Japan International Cooperation Agency KEI Knowledge Ecology International KKU Khon Kaen University KPI Key Performance Indicator LGOs Local Government Organizations LIHC Low-income Health Card MAP World Bank Multi-Country Aids Program MBDS Mekong Basin Disease Surveillance Network MCH Maternal and Child Health MDGs Millennium Development Goals MDT Multiple Drug Therapy (for leprosy) MMR Maternal Mortality Ratio MOC Ministry Operations Centre MoPH Ministry of Public Health MPL Maximum Permissible Level MPR Microfilaria Positivity Rate MRI Magnetic Resonance Imaging MWA Metropolitan Waterworks Authority n.a. Not Available NAFTA North America Free Trade Area

XXX NCDs Non-Communicable Diseases NESAC National Economic and Social Advisory Council NESDB National Economic and Social Development Board NGO Non Government Organization NHA National Health Assembly NHAOC National Health Assembly Organizing Committee NHC National Health Commission NHCO National Health Commission Office NHRC National Health Reform Commission NHRO National Health Reform Office NHSB National Health Security Board NHSO Nation Health Security Office NLEM National List of Essential Medicines NPOs Nonprofit Organizations NSO National Statistical Office NSTDA National Science and Technology Development Agency NTI Nuclear threat Initiative OECD Organization for Economic Co-operation and Development ONEP Office of the Natural Resources and Environmental Policy and Planning OPS Office of the Permanent Secretary OPV Oral Polio Vaccine ORT Oral Rehydration Therapy OTC Organization for Trade Cooperation PAO Provincial Administrative Organizations PCR Polymerase Chain Reaction PCU Primary Care Unit PEPFAR U.S. Presidentûs Emergency Plan AIDS Relief of the U.S. PHS Provincial Health Survey PISA Programme of International Students Assessment PWA Provincial Waterworks Authority RDI Recommended Daily Intake RRT Renal Replacement Therapy SARS Severe Acute Respiratory Syndrome SEARO South-East Asia Regional Office SHS Second-Hand Smoke SIRNET Social Inequity Reduction Network SMR Standardized Mortality Ratio

XXXI SPC Survey of Population Changes SRRT Surveillance and Rapid Response Team SSF Social Security Fund SSS Social Security Scheme STIs Sexually Transmitted Infections TAO or SAO Tambon or Subdistrict Administrative Organizations ThaiHealth Thai Health Promotion Foundation THPHs Tambon Health Promoting Hospitals TIMSS Trends in International Testing of Mathematics and Science Study TRF Thailand Research Fund TRIPS Trade-Related Aspect of Intellectual Property Rights TT Tetanus Toxoid UC Universal Coverage UN United Nations UNAIDS United National Programme on HIV/AIDS UNCTAD U.N. Conference on Trade and Development UNDP United Nation Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization USAID U.S. Agency for International Development USTR U.S. Trade Representative VAVP Motor Vehicle Accident Victims Protection VHC Voluntary Health Card VHCs Village Health Communicators VHIP Voluntary Health Insurance with Government Subsides Project VHVs Village Health Volunteers WHA World Health Assembly WHO World Health Organization WPRO Western Pacific Regional Office WTO World Trade Organization

XXXII CHAPTER 1 CHAKRI DYNASTY AND THAI PUBLIC HEALTH

The development of public has been associated with the monarchy institution since the Sukhothai period and with that in the Rattanakosin (Bangkok) period in particular. Thus, this chapter focuses on the relationships between the Royal House of Chakri or Chakri Dynasty and the public health system in Thailand, which are phased into different eras as follows: 1. The Era of Thai Traditional Medicine (TTM) Revival (1782-1851) The reigns of King Rama I through King Rama III (the first through third Kings) of the Rattanakosin period were a period of national reconstruction with efforts in assembling various technical disciplines for use as references for study and national development. 1.1 The Reign of King Rama I (1782-1809) King Rama I (Phrabat Somdet Phra Buddha Yodfa Chulaloke the Great) graciously had Wat* Photharam (Wat Pho) renovated as a royal monastery, renamed it Wat Phra Chetuphon Vimolmangklaram, and had traditional medicine formulas as well as body exercise or stretching postures (ruesi dadton) assembled and inscribed on cloistersû walls. Regarding official drug procurement, the Department of Pharmacy (Krom Mo Rong Phra Osot) was established, similar to that in the Ayutthaya period. The medical doctors who were civil servants were called royal doctors or physicians (mo luang) and other doctors who provided medical services to the general public were called private doctors (mo ratsadon or mo chaloei sak). 1.2 The Reign of King Rama II (1809-1824) King Rama II (Phrabat Somdet Phra Buddha Loetla Nabhalai) graciously had traditional medicine textbooks gathered again by inviting all experts/practitioners to assemble indications of various medicines. Anyone having a good medicine formula was requested to present it to the King. Then the royal doctor department would select and inscribe the good ones in the Royal Formulary for the Royal Pharmacy (Tamra Luang Samrab Rong Phra Osot) for the publicûs benefit. In 1816, the King graciously promulgated the Royal Pharmacists (Phanakngarn Phra Osot Thawai) Law, under which royal pharmacists had powers to seek medicinal plants throughout the country; and no one could raise any objection. Such doctors were generally members of the families whose medical practices had been passed on for generations. *Wat means Buddhist monastery

1 1.3 The Reign of King Rama III (1824 - 1851) King Rama III (Phrabat Somdet Phra Nangklao Chao Yuhua) graciously had Wat Phra Chetuphon renovated and had traditional medicine formulas inscribed on marble tablets affixed to the walls of the temple and cloisters, describing the causes and cures of illnesses. Rare medicinal herbs were planted so that the people could study and use for self-care without confining them for use only in any particular family. The Wat is thus considered the çfirst open universityé in Thailand. In 1828, the fifth year in the reign of King Rama III was regarded as the time that Western medicine began to play a key role in medical and health care in the country. The Western medical care including dangerous infectious disease prevention was provided to the people. Dr. Dan Beach Bradley, generally known to the people as çMo Bradleyé, an American Christian missionary who came to Thailand in 1835, initiated a disease prevention programme for the first time in the country with smallpox inoculation. Then, in 1838, the King advised the royal doctors to learn the inoculation techniques from Dr. Bradley in order to provide immunization services to civil servants and the public. In 1849, Dr. Samuel Reynolds House, commonly known as Mo House, another doctor of the American missionary introduced the use of ether as anaesthetic for the first . 2. The Era of Civilization During the reigns of King Rama IV through King Rama VI, there were diplomatic relationships with Western countries and more Christian missionaries. The Kings visited foreign countries and brought back various kinds of civilization for application in the Kingdom, which steadily became modernized; so did the medical and health system. 2.1 The Reign of King Rama IV (1851 - 1868) During the reign of King Rama IV (Somdet Phra Chomklao Chao Yuhua or King Mongkut), the Thai medical service was divided into two systems: traditional medicine and modern medicine. Three American doctors (Drs. Bradley, House and Lane) lived in Thailand for a long time during that period. Dr. House played an active role in the control of cholera by using water mixed with tincture in effectively treating the patients orally. Although the Western medical service was more widely provided, for example in obstetric care, it was unable to change the values of the people as Thai traditional medicine had been used culturally for generations and was part of Thaisû lifestyle. 2.2 The Reign of King Rama V (1868 - 1910) Previously, there was no public hospital to provide curative care to sick people as only temporary hospitals were set up at various places to care for patients during epidemics. After the epidemic had subsided, such hospitals were abolished. King Rama V (Phrabat Somdet Phra Chulachomklao Chao Yuhua or King ) graciously initiated a medical care programme for the poor by establishing a Hospital Manage-

2 ment Committee in 1886 under the Chairmanship of the Kingûs brother, Prince (Krommamuen) Siriwachsangkat. A hospital was constructed and completed in 1888 and royally named it çSiriraj Hospitalé in commemoration of his son, Prince Siriraj Kakuttaphan, who had died of dysentery. Later on, the King graciously established a Nursing Department responsible for the management of Siriraj Hospital, replacing the Hospital Management Committee in 1889. The Department was then under the Ministry of Education (Krasuang Dharmmakan) with the Kingûs brother, Prince (Krommamuen) Damrong Rajanupab, as the Director-General. During that period, a number of major medical service events occurred: In 1889, a medical school (Phaetthayakorn School) was established at Siriraj Hospital, whose curriculum included both Western and traditional medicine. And in 1895, the first Thai Medical Textbook (Tamra Paetsart Songkroh) covering both types of medical practices was published. In 1896, a midwifery school was established with the personal funds of Queen Sri Bajarindra in the Siriraj Hospital compound. In 1897, a new edition of the Medical Textbook was published whose contents mostly dealt with Western medicine. In 1905, a subdistrict administrative system (sanitary district) was implemented on a pilot scale for the first time in Tambon Tha Chalom (Tha Chalom subdistrict) of . In 1907, two medical textbooks (called Wetchasart Wanna and Paetsart Songkroh) were pub- lished; both were considered the çfirst national medical and pharmaceutical textbooksé of Thailand. A Medical Division was set up to take responsibility for epidemic control and smallpox inocula- tion for the people in the provinces. 2.3 The Reign of King Rama VI (1910 - 1925) During the reign of King Rama IV (Phrabat Somdet Phra Mongkutklao Chao Yuhua or King Vajiravudh), a number of medical and health activities were initiated as follows: In 1911, King Chulalongkorn Memorial Hospital was built with funding from the Kingûs personal accounts and the Thai Red Cross Society (then known as Sapha Unalom Daeng). In 1912, the Pasteur Institute was established to be responsible for rabies prevention and control; and Vajiravudh Hospital was established. In 1914, under the Ministry of Interior, pharmacies (Osot Sapha) were set up to provide curative care and dispense drugs; and later each pharmacy was renamed çHealth Centreé (Suk Sala). Eight preparations of common household remedies were produced for use by the people and the revenue received was used for procuring additional medicines for the poor, which was regarded as the first çuser feeé system in the country. In 1916, the Nursing Department was renamed çPublic Protection Departmenté (Krom Prachaphiban) under the Ministry of Interior. In 1916, His Royal Highness (HRH) Prince Jainad Narendhorn (or Chainat Narenthorn) revised the medical education system by adding more clinical practices while withdrawing traditional medicine as the Western and traditional medical systems were incompatible and it was difficult to identify knowledgeable Thai

3 traditional medicine practitioners/teachers who were willing to teach. In 1917, the Army Medical School was established. In 1918, the medical and sanitation programmes, previously under the Ministry of Interior and the Ministry of City Affairs (Nakhon Ban), were merged and named the Public Health Department on 27 November, with Prince Jainad Narendhorn as the first Director-General. In 1920, the Queen Saovabha Memorial Institute was established; and the Thai Red Cross Society was registered as a member of the International Federation of Red Cross and Red Crescent Societies on 8 April. In 1922, the Junior Red Cross Division and the Nursing School were established under the Thai Red Cross Society. In 1923, the Medical Practice Act was promulgated to control medical services and practices so that there would be no harm done by unknowledgeable or untrained practitioners. Later the law became present-day laws such as the Medical Premises Act, the Control of the Practice of the Art of Healing Act, and several medical care related professional acts. 3. The Pioneering Era of Modern Medical and Health Services (1917-1929) The Kingûs father, Somdet Phra Mahitalathibet Adulyadej Vikrom Phra Boromarajchanok (com- monly known as His Royal Highness Prince Mahidol of Songkla), was the first Thai prince to become seriously interested in medicine and public health. That was because he had deemed that the medical and health services were not modernized; and the people were highly vulnerable to illnesses, particularly communicable diseases. With his firm resolution to provide modern medical care to the people, he dedicated himself to the foundation and development of medicine by resigning from the and then studying medicine and public health at Harvard University in the United States of America. Through his steady perseverance, he graduated with a Certificate of Public Health and a Doctor of Medicine degree (cum laude). He then returned to Thailand to perform numerous medical and health activities that were extremely beneficial to the country and Thai people. He donated funds for such medical programmes as construction of a medical school, a hospital and a dormitory for nurses. His personal financial support was provided as fellowships for doctors and nurses to study abroad. He served as a Thai delegate in the negotiation with the Rockefeller Foundation on assistance for Thai medical service development. His support for medical research involved the initiation of the medical research and development programme at Siriraj Hospital. Besides, he participated in teaching medical and nursing students, and served as a medical resident at Siriraj Hospital and Chiang Maiûs McCormick Hospital. He supported maternal and child health (MCH) services by drawing up a project to modify Vajira Hospital to become a large maternity hospital to serve as a training centre for nurses, midwives, public health nurses, social welfare workers and traditional birth attendants, so that there would be more MCH personnel. Throughout his life, HRH Prince Mahidol undertook activities to promote the nationûs medical and health services that are greatly beneficial to all Thai citizens. With his prestige and ingenuity, he was named

4 çthe Father of Thai Modern Medicineé; and a university that mainly produced medical and health personnel was named çMahidol Universityé in commemoration of his good deeds. 4. The Era of the Inception of the Ministry of Public Health (MoPH) 4.1 The Reign of King Rama VII (1925-1934) During the reign of King Rama VII (Phrabat Somdet Phra Pokklao Chao Yuhua, commonly known as King Prajadhipok), a ministerial rule on modern and traditional medical practices was enacted, specifying that: 4.1.1 Modern medical practitioners were those who used healing arts based on knowledge from international textbooks that had progressed through studies, research, and experiments of scientific experts worldwide. 4.1.2 Traditional medical practitioners were those who used healing arts based on the observa- tions and skills that had been verbally passed on from previous generations or the ancient notebooks with no scientific experiments. In 1926, the Public Health Department was reorganized and divided into 13 divisions, namely Administration, Finance, Advisors, Editing, City Protection, Engineering, Health, Pharmacy, Narcotics, Mental Illness Hospital, Sanitation Promotion, City Sanitary Doctors (Medical Services), and Vajira Hospital. 4.2 The Reign of King Rama VIII (1934-1946) During the reign of King Rama VIII (Phrabat Somdet Phra Chao Yuhua Ananda Mahidol), the Ministry of Public Health was established as a result of the enactment of the Ministries and Departments Reorganization Act (Amendment No. 3) of B.E. 2485 (1942). More research studies on traditional remedies were conducted in 1942 and 1943 while World War II was expanding to Southeast Asia, resulting in drug shortages. Professor Dr. Ouay Ketusingh conducted a study on the use of antimalarial herbal medicine at Sattahip Hospital. After the war had ended, the problem of drug shortages remained; thus the government decided to set a policy for the MoPH Government Pharmaceutical Organization (GPO) to also produce herbal medicines. 5. The Reign of King Rama IX (1946-present) 5.1 His Majesty King Bhumibol Adulyadej (Rama IX), the present King, has been interested in and concerned about the well-being, particularly health conditions, of all citizens. His Majesty has initiated numerous projects including those on disease prevention, health promotion, curative care and rehabilitative services. All Thai citizens highly appreciate his graciousness. Even foreigners also realize and appreciate his health initiatives as evidenced by WHOûs presentation of the Health For All Gold Medal in 1992 and the presentation of Gold Medal of Appreciation by the International Commission on Iodine Deficiency Disorder Control, for his advice on the concept and direction for disseminating iodized salt to prevent iodine deficiency

5 among the people. Besides, in 2001 the Franklin and Eleanor Roosevelt Institute and the World Committee on Disability presented His Majesty with a Franklin Delano Roosevelt International Disability Award in recognition of Thailandûs achievements of major targets of the UNûs global plan of action on persons with disabilities. And on 26 May 2006, UN Secretary-General Kofi Annan visited Thailand and presented His Majesty with the UNDP Human Development Lifetime Achievement Award in commemoration of His Majestyûs great intelligence and ability in initiating royal development projects aimed at improving the quality of life of Thai people in a sustainable manner throughout His reign. This was the most prestigious award newly set up and presented by the United Nations to honour His Majesty the King on the occasion of the 60th anniversary of accession to the throne of His Majesty, being the first individual to receive such an award in the world.

Public health activities that have been graciously supported/initiated by His Majesty are numerous, the major ones being the following: 5.1.1 Establishment of the Ananda Mahidol Foundation His Majesty the King graciously had the Ananda Mahidol Foundation established to promote and support Thai nationals who have outstanding academic records to study aboard for an advanced degree in certain subjects. It is hopeful that, upon graduation, such individuals will return to serve the country as experts in their respective fields of study. On a pilot scale, the initiative was financed with the Ananda Mahidol Fund in 1955. Later, on 3 April 1959, His Majesty decided to change the Fundûs name and status to çThe Ananda Mahidol Foundationé and donated 20,000 baht of his personal funds as an endowment, in commemoration of his elder brother, the late King Ananda Mahidol (King Rama VIII), and awarded a first scholarship for studying medicine abroad. At present, Her Royal Highness Princess Maha Chakri Sirindhorn is the President of the Foundation. Between 1959 and 2010, with the Foundationûs fellowships, 287 individuals completed their studies aboard, while 53 were still studying. Among the returnees, 77 are medical doctors and 14 dentists; and among those studying, 7 are medical doctors and 4 dentists. 5.1.2 Establishment of the Rajprachasamasai Foundation In 1954, His Majesty the King graciously granted his private funds with some public donations for the construction of the Ananda Mahidol Building at Siriraj Hospital in commemoration of the late King Ananda Mahidol. Upon completion of the building, there was a funding leftover of 175,065 baht. At the request for funding of the Public Health Minister for building an institute for personnel training and research on leprosy at Phra Pradaeng Hospital in the amount of one million baht, His Majesty gave the remaining funds to initiate such activities for leprosy patients. His Majesty graciously named the place çRajprachasamasai Instituteé. Besides, the King had also been concerned about the education of lepersû children who were not infected, but isolated in a nursery of the Department of Health. Then Rajprachasamasai School was estab- lished for this purpose with the initial funding of one million baht from Their Majesties the King and the Queen. The King presided over the school opening ceremony and later on visited it again several times.

6 5.1.3 Establishment of the Prince Mahidol Award Foundation under the Royal Patronage To cerebrate the 100th birthday anniversary of His Royal Highness Prince Mahidol, the Kingûs father, on 1 January 1992, the Mahidol Award Foundation was established under the Royal Patronage to publicize the prestige of the Prince who undertook activities greatly beneficial for the Thai medical and public health systems and made them as modernized as those in civilized nations. Later on 28 July 1997 the foundation was renamed çPrince Mahidol Award Foundation under the Royal Patronage of His Majesty the Kingé. The Foundationûs objective is to confer an Award upon individuals or institutions which have demonstrated outstanding and exemplary contributions to the advancement of medical and public health services for humanity; two awards are given each year. The Foundation Committee is at present chaired by HRH Princess Maha Chakri Sirindhorn. Between 1992 and 2010, Prince Mahidol Awards were conferred upon 59 individuals or institutions, 26 of whom had had outstanding contributions in the field of medicine and 33 in public health. Among the laureates, 4 were Thai nationals including Dr. Prasong Tuchinda, Dr. Suchitra Nimmannitya, Dr. Wiwat Rojanapithayakorn, and Mr. Mechai Viravaidhya. Some of the Prince Mahidol Award laureates later became Nobel laureates in medicine and public health, i.e. Professor Barry Marshall (in medicine, 2001) from Australia, who found that Helicobacter bacilli was the cause of peptic ulcer and could be effectively treated with antibiotics, and Professor Harald Zur Hausen (in public health, 2005) from Germany, who found that human papilloma virus was the cause of cervical cancer which successfully led to the development of cervical cancer vaccine. To make Prince Mahidol Awards well known all over the world, since 2007 the Prince Mahidol Awards Foundation and many Thai and international organizations such as , the Ministry of Public Health, the Health Systems Research Institute, the World Health Organization, the World Bank, and the Rockefeller Foundation, have organized annual conferences, entitled çPrince Mahidol Award Conferenceé, the theme for each year being an issue of global concern. Besides, in 2009 the Foundation initiated the Prince Mahidol Award Youth Programme for a few selected medical students who have special interest in any field of health sciences to study or work in an academic institution or international organization for one year under the supervision of a Thai mentor so as to create çlife-long mentorshipé. 5.1.4 Establishment of the Princess Srinagarindra Award under the Royal Patronage The Princess Srinagarindra Award under the Royal Patronage of Majesty the King was estab- lished in Commemoration of the Centenary Birthday of Her Royal Highness Princess Srinagarindra, the late Princess Mother, on 19 October 2000, under the presidentship of HRH Princess Galyani Vadhana, the Kingûs elder sister, until her passing. Since 2008, HRH Princess Maha Chakri Sirindhorn has been the president of the foundation, whose objective is to confer a Princess Srinagarindra Award on individual registered nurse(s) and/ or midwife (or midwives) from countries in the South Asia, East Asia and South-east Asia with outstanding

7 performance, nationally and internationally recognized, for the benefit of public health development and peopleûs well-being. The awarding is also to honour the prestige of the Princess Mother to all other countries. Between 2000 and 2010, there were 11 laureates of the Award.

5.2 Her Majesty Queen Sirikit has continuously supported the Kingûs health development projects. Her Majesty the Queen serves as the President of the Thai Red Cross Society and as a patron of associations and foundations involved in medical and health activities such as the Foundation for the Blind, the Foundation for the Mentally Retarded, and the Foundation for the Deaf. Importantly, Her Majesty is the patron of the Polio Immunization Campaign Project, which has steadily reduced the polio incidence; the disease is expected to be eradicated in Thailand in the near future. Besides, Her Majesty was presented with the Lindbergh Award on 16 May 1995 by the Charles A and Anne Morrow Lindbergh Foundation for her internationally recognized work on çcreating a balance between technology and natureé, being the first lady to receive such an award. Her Majesty was recognized for her leadership and support for national and international food safety activities and thus was presented with the Food Safety Awards on a August 2005 by the World Health Organization, which was the first lady to receive such an award. In addition, Her Majesty the Queen has been patronizing and involved in other health activities such as the Royal Medical Services Project, the Village Doctors Project, and support for patients with medical care under the Royal Patronage.

5.3 Her Royal Highness Princess Srinagarindra, the Princess Mother (Somdet Phra Srinagarindra Boromarajajonani), the late mother of His Majesty the King, was one of the important members of the Royal Family who had undertaken or supported numerous activities related to the public health as follows: (1) In 1956, the Princess Mother began to patronize the Foundation for Assistance of the Dis- abled by donating her personal funds for the operations of the Foundation and seeking support from local and international individuals as well as agencies concerned for persons with disabilities. (2) In 1963, the Princess Mother began to patronize the Foundation for Lepers in Lampang Province by donating her personal funds for the construction of Jit Aree School building and a dormitory and providing financial support for the children of lepers as well as for the operations of the school. Consequently, the quality of life of lepersû children and people with poverty has been much improved. (3) In 1967, the Princess Mother accepted the New Life Foundation under her patronage in order to help rehabilitate disabled lepers. (4) In 1969, Mobile Medical Corps (Por Or Sor Wor or mobile medical units) were set up, comprising volunteer doctors, dentists, nurses, health workers and volunteers from both central and provincial levels. The units have been providing curative, preventive, promotive and rehabilitative care to the people in remote areas.

8 (5) In 1973, a Volunteer Flying Doctors Unit was launched and later on became a Radio Medical Services Unit that provided medical consultation to remote health centres via radio communications in 25 provinces. Since 1976, the MoPH had undertaken similar services for other provinces. And in 1996, they were all transferred to be under the MoPH. (6) In 1974, the Princess Mother established the Princess Motherûs Medical Volunteer Foundation with the first royal endowment of one million baht. Later, the Royal Thai Government as well as other public and private agencies from within and outside the country has provided financial support as well as medical supplies and equipment to the Foundation. In 1986, specialized medical services projects were initiated to provide medical/surgical care for patients with cataract, hare lip and cleft palate, congenital heart disease, impacted tooth, and those in need of prosthetic/orthotic services. (7) Dental health services of the Mobile Medical Corps include the annual dental care campaigns and exhibitions on the National Dental Health Day, 21 October each year. (8) In 1992, the Princess Mother donated her private funds of 500,000 baht to establish the Artificial Legs Foundation and HRH Princess Galyani Vadhana also donated another 750,000 baht to produce/ provide artificial legs for poor people free of charge regardless of race and religious belief. In recognition of her prestige and devotion for health promotion of Thai people, in 1990 the World Health Organization presented the Princess Mother with çThe Health For All Gold Medal Awardé. Furthermore, on 21 October 2000, UNESCO honoured the Princess Mother as a person worthy of respect of the world. In addition, on the 100th birthday anniversary, the Princess Mother was named çthe Mother of Thai Public Healthé.

5.4 His Royal Highness Crown Prince Maha Vajiralongkorn is the Honorary President of the Crown Prince Hospitals Foundation. The Crown Prince presided over the foundation stone laying and opening ceremonies of all 21 Crown Prince Hospitals (district-level hospitals in remote areas). With great interest in health activities, the Crown Prince regularly visits the hospitals and gives advice to the MoPH on how to improve hospitalsû efficiency and service quality for the people.

5.5 Her Royal Highness Princess Maha Chakri Sirindhorn (Somdet Phra Debaratrajasuda Sayamborommarajakumari) is particularly interested in improving the nutritional status of children and youths. Thus, several royally initiated projects have been launched such as the Agriculture for School Lunch Project, aiming to help improve the health and nutritional status of children in remote areas particularly those in border patrol police-operated schools. Later on, the Ministry of Education adopted this approach and got it replicated in all other schools nationwide. Besides, the Princess has supported the establishment of the Toddlers Development Project and the Pre-school Child Development Centres with her personal funds to help resolve malnutrition problem among pre-school children and the Nutritional and Health Promotion for

9 Mothers and Children in Remote Areas Project. Moreover, the Princess is the chairperson of the National Commission on Iodine Deficiency Disorder (IDD) Control, which is an important project. With the Princessû interest in seriously resolving the problem, the IDD prevalence has significantly dropped to the level that is no longer a public health problem.

5.6 Her Royal Highness Princess Chulabhorn has been playing an outstanding role as a scientist. Her reputation is internationally recognized and she was awarded the Einstein Gold Medal from UNESCO. The Princess has contributed to several medical and health development activities and established the Chulabhorn Foundation to assist in medical and health education. The Chulabhorn Research Institute was also established by the Princess as a centre for scientists to conduct research studies aimed at developing scientific products or findings that will be beneficial to the nation and resolve urgent health, environmental and agricultural problems. Besides, the Institute has also implemented the Chulabhorn Village Development Project in the southern provinces of Nakhon Si Thammarat and Surat Thani, whose aim is to improve environmental conditions and well-being of the people, based on the primary health care concept including self-reliance approach. Besides, the Princess has also performed other health activities initiated by the late Princess Mother and served as Honorary President of the Princess Motherûs Medical Volunteer Foundation since 22 June 2009.

5.7 Her Royal Highness Princess Galyani Vadhana Krom Luang Naradhiwas Rajanagarindra, the Kingûs elder sister, was the President of the Kidney Disease Foundation of Thailand that promotes and supports preventive/curative care for patients with kidney and urinary tract diseases, and research as well as dissemination of knowledge on such diseases. Besides, the Princess also supported projects initiated by the late Princess Mother. She also served as the Honorary President of the Princess Motherûs Medical Volunteer Foundation since 18 August 1995 until her death on 2 January 2008. She also had outstanding contributions to the international mental health promotion and drug dependence prevention programmes, giving importance to young childhood development (being a patron of the Young Children in Slums Foundation and several other foundations), making donations for setting up supplementary food funds, and providing books and toys for enhancing child development according to their age. The Princess also set up the Mental Health Princess Award to be conferred on someone with outstanding performance on international mental health and drug abuse control. And in recognition of her reputation and contributions, the South-East Asia Regional Office of the World Health Organization presented her with the WHO/SEARO Award on 19 August 2003.

5.8 Her Royal Highness Princess Srirasm, Royal Consort to the Crown Prince, has been especially interested in the promotion of breastfeeding and maternal and child health. The Princess has

10 supported the gathering of pregnant and postpartum women, parents, and elderly persons as a breastfeeding club, a mothers-volunteers club, or a Born of Family Love (Saiyairak Haeng Krobkrua) Club, as well as the establishment of a healthy child care and breastfeeding centre.

5.9 Her Royal Highness Princess Soamsawali has continuously performed royal functions initiated by Their Majesties the King and the Queen, particularly those related to social development. Regarding medical and health activities, Princess Soamsawali is particularly interested in HIV/ AIDS as evidenced by the fact that she always presides over the Thian Song Chai (Candlelight in the Mind) Festival almost every year if she is not engaged in any other more important function. The festival has been held by the Thai Red Cross Society and the Wednesday Friends Club (a club of people living with HIV) on 1 December, the World AIDS Day, every year since 1991. Her kindness has also been extended to all other projects of the Thai Red Cross Society such as the Prevention of Mother-to-Child HIV Transmission Project and the Friends in Need (of çPaé) Volunteers Project.

5.10 Princess Ubol Ratana has been extremely concerned about the publicûs health and the country. She is the President of the To Be Number One Project, which aims to campaign on the prevention and control of drug abuse by raising public awareness nationwide of the understanding of how to resolve the drug abuse problems and to help drug addicts to overcome drug addiction and get a better chance to return to society. 6. Royal Activities Related to Health Beside the aforementioned activities, there are a number of other major health activities initiated and/or supported by Their Majesties the King and the Queen as well as other Royal Family Members in 2010 as follows: Totally, 216 projects are ongoing and another 118 projects have been completed as listed in Table 1.

11 Total

Ongoing

Total

completed

For commemoration

No. of projects

Completed ongoing Total

Royal initiatives

-11 - 33-4

-11 - - --1

2354 3766

1675 49610

Completed Ongoing Total

Name

Total 56 117 173 62 99 161 118 216

Royal development projects related to the Ministry of Public Health (by each royal family member)

Office of the Permanent Secretary, Ministry of Public Health.

His Majesty the King 19 33 52 35 58 93 54 91 Her Majesty the Queen 9 16 25 8 15 23 17 31 HRH the Crown Prince HRH Princess Sirindhorn 19 48 67 10 13 23 29 61 HRH Princess Chulabhorn HRH Princess Galyani Vadhana Princess Ubol Ratana 5 6 11 - 2 2 5 8 HRH Princess Srirasm 1 3 4 - 1 1 1 4 HRH Princess Soamsawali

:

1 2 3 4 5 6 7 8 9

Order

Table 1.1

Source

12 CHAPTER 2 THAILAND COUNTRY PROFILE

1. Location, Territory and Boundary The Kingdom of Thailand is situated in the continental Southeast Asia, just north of the equator, and is part of the Indochina Peninsula (Figure 2.1).

Figure 2.1 Map of Thailand

Laos Myanmar

Chiang Rai

Mae Hong Son Nan Vietnam Chiang Mai

Lampang Loei Nakonpanom Udontani Sakonnakhon Tak Sukhothai Phitsaulok Thailand Khonkaen Ubonratchatani

Surin Nakhon Ratchasima Kanchanaburi Ayuthaya

Nakhon Pathom Bangkok

™≈∫ÿ√’ Rayong Andaman Jantaburi Cambodia Petburi sea Trat

Chumphon Gulf of Ranong Thailand Vietnam Koh Simirun Koh Phangan Koh Samui Surattani Pangar Nakonsritamrat Karbi Puket Trang

Songkhla South China sea Phattani

Naratiwat

Malaysia

13 Thailand covers an area of about 514,000 square kilometres. It is the third largest country among the Southeast Asian nations, after Indonesia and Myanmar. The borders around Thailand are totally about 8,031 kilometres long, of which 5,326 kilometres are inland and the other 2,705 kilometres are coastlines (including 1,840 kilometres of coastlines of the and 865 kilometres on the Andaman seaside). In the North, the northernmost part of Thailand is in Mae Sai District of Chiang Rai Province, bordered by the Union of Myanmar and the Lao Peopleûs Democratic Republic. In the South, the southernmost part is in Betong District of Yala Province, bordered by Malaysia and the Gulf of Thailand. In the East, the easternmost part is in Phibun Mangsahan District of Ubon Ratchathani Province, bordered by the Lao Peopleûs Democratic Republic and the Kingdom of Cambodia. In the West, the westernmost part is in Mae Sariang District of Mae Hong Son Province, bordered by the Union of Myanmar, the Andaman Sea, and the Strait of Malacca. The whole Kingdom is in the same time zone, seven hours ahead of the Greenwich Mean Time. 2. Topography and Climate 2.1 Topography. Thailand can be topographically divided into three different areas: 2.1.1 The plains. Mostly the plain areas are in the Central Region of the country, i.e., basins of the Chao Phraya River and its tributaries (Ping, Wang, Yom and Nan), and the Mae Klong, Phetchaburi, Bang Pakong, Thachin, and Pa Sak rivers. 2.1.2 The highlands. Highland areas are mostly in the Northeast, i.e., the Korat Plateau, includ- ing the Mun and Chi rivers basins. 2.1.3 The mountains. Mostly it is mountainous in the North and the Southeast which cover the Ranges of Daen Lao, Luang Phra Bang, Thanon Thongchai, Phetchabun, and Tanao Si. 2.2 Climate. Thailand has three types of climate as follows: 2.2.1 Tropical rain climate in the coastal areas in the East and the South, with heavy rainfalls all year round and tropical rain forests. 2.2.2 Tropical monsoon climate in the south-western and south-eastern coasts with monsoons and a very high average annual rainfall. 2.2.3 Seasonal tropical grassland or savannah climate with a lot of heavy rains in the south-west monsoon season and droughts in the cold season covering most regions of the country, particularly the Central Region, the North and the North-east. Prevailing winds include the south-westerly monsoon from about mid-May through October and the north-easterly monsoon from November through February. In summary, Thailand has pleasant geographic and climatic conditions, without severe natural disasters like volcanic eruptions, earthquakes, or cold weather.

14 3. Population, Language and Religions The population of Thailand is 63.5 million (2009); almost all residents (98.1%) are of Thai nationality and the rest are of other nationalities such as Chinese, Myanmar and Lao. For communication purposes, the Thai language is officially and commonly used for speaking and writing, while English tends to play a greater role particularly in the business sector. Most of Thai people are Buddhists (93.6%), followed by Muslims (5.4%), Christians (0.9%) and others (Figure 2.2).

Figure 2.2 Religions of Thai People, 2008

Buddhists, 93.6%

Others; and no religion 0.1%

Christians, 0.9% Muslims, 5.4%

Source: Survey on Participation in Cultural Activities, 2008, National Statistical Office, 2009. Note: Survey on population aged 15 years and over by religion.

4. Economy In the past, the Thai economy was agrarian with mostly subsistence farming for household consump- tion and no commercial or export purposes. Regarding industry, the production was previously of local or village handicraft type. Later on in 1856, Thailand entered into the Bowring Treaty with England and other treaties with other Western countries, economic activities began. Since then, peopleûs lifestyles in both urban and rural areas have changed to those of industrial manufacturing for import substitution and eventually for exports. The Thai economic system began to shift to the economic development era with National Economic and Social Development Plans, i.e., from the 1st Plan (1961-1966) through the current 10th Plan (2007-2011). Overall, Thailand is a free market economy and has been a member of the World Trade Organization (WTO) since 1 January 1995.

15 As a result of economic development, the Thai economy grew at an average rate of 7.8% annually during the period of more than three decades from 1961-1996, the first economic crisis occurred in 1985-1986 due to rising oil prices and Thailand had to seek the help from the International Monetary Fund (IMF) for the first time. Later on, the economy grew rapidly to 8.3% per annum, particularly during 1991-1995, resulting in Thailand becoming a middle-income country. And during the period 1996-1997, a second economic crisis erupted with a severe economic recession, Thailand had to seek assistance from the IMF again in the form of US$17.2 billion loans with a number of economic structural reform terms and conditions. Since the 1997 economic crisis, the Thai economic growth contracted considerably, i.e. -1.7% in 1997 and -10.8% in 1998, but rapidly recovered to over 4% in 1999-2000 and slightly dropped in 2001, and rose to over 5% since 2002. As a result, the government could repay all the IMF loans on 31 July 2003, two years before the repayment due dates. And the Thai economy slowed down again during in 2005 and the third economic crisis occurred in 2008-2009; the severe recession resulted in the negative economic growth of -2.2% in 2009 (Figure 4.2) due to the global economic crisis, pandemic influenza A (H1N1) 2009, affecting tourism and spending, rising oil prices and unstable political situation of the country. Economic Outlook for 2010 According to the forecast of the National Economic and Social Development Board (NESDB), the Thai economy will rise to 7.0% as a result of the global economic recovery, governmentûs continuous economic stimulus measures and the rising confidence in the economic system. Overall, the inflation is expected to rise to 3.0%-3.5% with a current account surplus of US$ 15.1 billion or 4.9% of GDP. 5. Thai Administrative System Thailand is a democratic country, having the King as Head of State, a constitutional monarchy under the Constitution of the Kingdom of Thailand of B.E. 2550 (2007), promulgated on 24 August 2007, as the 18th constitution of the country. The Constitution divides the sovereign power into three independent branches, namely, the Legisla- tive, the Executive, and the Judiciary powers. Besides, under the constitution, there are seven independent constitutional organizations established for scrutinizing and counterbalancing such powers (Figure 2.3). 5.1 Central Administration 5.1.1 The King is the Head of State, exercising the legislative power through the National Assembly or parliament, the administrative or executive power through the Cabinet or Council of Ministers, and the judicial power through the Courts. 5.1.2 The Cabinet is the governmental body responsible for state administrative or governmental functions. 5.1.3 The central administrative system, according to the Reorganization of Ministries, Sub- Ministries and Departments Act of B.E. 2545 (2002), consists of 20 ministries as follows:

16 (1) Office of the Prime Minister (2) Ministry of Defence (3) Ministry of Finance (4) Ministry of Foreign Affairs (5) Ministry of Tourism and Sports (6) Ministry of Social Development and Human Security (7) Ministry of Agriculture and (8) Ministry of Transport Cooperatives (9) Ministry of Natural Resources and (10) Ministry of Information and Environment Communication Technology (11) Ministry of Energy (12) Ministry of Commerce (13) Ministry of Interior (14) Ministry of Justice (15) Ministry of Labour (16) Ministry of Culture (17) Ministry of Science and Technology (18) Ministry of Education (19) Ministry of Public Health (20) Ministry of Industry

Under all ministries, there are totally 154 departmental state agencies including 144 department, 2 non-departmental agencies headed by a director-general and eight departmental level state agencies, not being under the Prime Ministerûs Office or any ministry, namely, the Office of His Majestyûs Principal Private Secretary, the Bureau of the Royal Household, the Office of National Buddhism, the Office of the Royal Development Projects Board, the Office of the National Research Council, the Royal Institute, the , the Anti-Money Laundering Office. Moreover, there are 58 state enterprises, 29 public organizations established under the Public Organization Act of B.E. 2542 (1999), and 15 agencies established by specific laws as agencies under the supervision of a minister (Figure 2.3) 5.2 Provincial Administration The provincial administration means official functions of various ministries and departments as delegated to the regional or provincial level, under the supervision of the provincial governor with assigned officials from various central administrative agencies. Certain provincial administrative functions only are carried out by provincial level officials with delegations from the central administration. Such functions, however, are subject to scrutiny and revision by relevant central level agencies, i.e. the permanent secretary and minister of each ministry, that have the final decision-making authority. According to the provincial administration law, the provincial administration consists of 75 provinces (changwat) and 878 districts (amphoe). 5.3 Local Administration The local administration means autonomous administrative authority of the people in each administrative jurisdiction, under the law, with at least four characteristics as follows: 5.3.1 Being a juristic person.

17 5.3.2 Having all or some local administrators or local council members elected by the people. 5.3.3 Having their own revenue and budget. 5.3.4 Having administrative autonomy under the laws. In Thailand, there are four types of local administrative bodies, namely, Provincial Administration Organizations (75), Municipalities (2,008), and special types of local administration, i.e. Bangkok Metropolitan Administration (1), Pattaya City (1), and Tambon or Subdistrict Administration Organizations (5,767).

18 organizations

Constitutional

sion of Thailand Office of the National Anti- Corruption Commission

of Thailand

Rights Commission of Thailand

Thailand

Office of the National Eco- nomic and Social Advisory Council

1. Office of the Election Commis-

2.

3. Office of the Auditor-General

4. Office of the National Human

5. Office of the Ombudsman of

6. Office of the Attorney General 7.

Senate

Administration (1)

Organizations (5,767)

Legislative Branch

National Assembly

Local Administration

Organizations (75)

2.1 City (25) 2.2 Town (142) 2.3 Tambon* (1,841)

3.1 Bangkok Metropolitan

3.2 Pattaya City (1) 3.3 Tambon Administration

1. Provincial Administration

2. Municipalities (2,008)

3. Other local authorities

House of Representative

Upgraded from all Sanitary Districts in 1999.

1. Provinces (75) 2. Districts (878)

:*

Provincial Administration

Cabinet

Notes

Executive Branch

His Majesty the King

Executive

Independent

The Office of the Securities and Exchange Commission Office of the National Broadcasting and Telecommunications Commission Office of the National Telecommunications Commission Office of Insurance Commission Office of the Energy Regulatory Commission Thai Public Broadcasting Service Deposit Protection Agency

1 2

3

4

5 6

7 8

Public organizations (29) State- supervised agencies (15, such as HSRI, Thai Health, NHSO, NHCO, etc.)

-

-

(58)

State

enterprises

Central Administration

Courts

National administrative system of Thailand, 2010

(154 )

20 Ministries

Judicial Branch

Departments

Figure 2.3

19 20 Chapter 3 Health Policy and Strategy in Thailand

1. Rights to Health of the People The 2007 ,1 the highest ranked public law of the country, has provisions guaranteeing rights and freedom of the people in physical, mental, and social aspects which could not be violated by the State. The State has the duty to protect such rights and freedom including those related to health in five aspects (in seven Sections of the Constitution) as follows: 1. An equal right to receive standard public health services including the prevention and eradication of harmful communicable diseases without charge in a thorough, efficient and timely manner (Section 51). 2. The right to survive and to receive physical, mental and intellectual development for children and youths, potentially in the suitable environment with due regard to their participation (Section 52). 3. The right to access and utilize with dignity public welfare, public utilities, and appropriate aid from the State (Sections 53, 54 and 55). 4. The right to receive information and explanation and to express opinions if any government agency, state agency, state enterprise or local government organization implements any project or activity that may affect the quality of the environment, health, and life (Section 57). 5. The right to participate with the State and communities in the preservation and utilization of natural resources and biological diversity and in the protection of the quality of the environment in such a way that it is not hazardous to health (Section 67). 2. Fundamental State Policies on Health According to the Constitution According to the 2007 Constitution, the fundamental state policies are prescribed with the intention for the State to provide basic services to the people and all governments are required to implement for national development. They are regarded as fundamental policies of the country, not of any particular govern- ment by formulating a plan for the administration of state affairs. The government has to report to the Parliament on what and when it will do in administering the country accordingly. Basically, the fundamental state policies are divided into 9 elements: (1) national security policy; (2) state administration policy; (3) religious, social, public health, education and culture policies; (4) law and justice policies; (5) foreign policies; (6) economic policy; (7) land use, natural resources and environment policies; (8) science, intellectual property and energy policies; and (9) public participation policy. The government is required to report on the imple- mentation of the fundamental state policies to the Parliament once a year.

1 The 18th Constitution published in the Government Gazette and came into force on 25 August 2007.

21 Health policies are mainly under religious, social, public health, education and culture policies and some are also under another five elements of the state policies. Such health policies are considered to be the foundation for the State to improve Thai peopleûs health status, covering six sections and classified as three groups as follows: 2.1 Policies on support for the protection and development of children and youths, provision of welfare for specific target groups, and health system development focusing on health promotion and support for learning, dissemination, treatment and development of local and Thai wisdom [Sections 80(1), (2), (6) and 86(2)]. Section 80(1) of the Constitution prescribes that the State shall çprotect and develop children and youths, promoting childhood nourishment and education, promoting the equality between women and men, create and develop family integrity and the strength of communities, as well as provide aids and welfare to the elderly, the indigent, the disabled or handicapped and the destitute person for their better quality of life and ability to become self-relianté. In this regard, the MoPH is responsible for 10 indicators: 4 related to the rearing and education of preschool children; 4 related to the solidarity of families and communities; and 2 related to the aid and welfare for the elderly, the indigent, and the disabled or handicapped. Section 80(2) of the Constitution prescribes that the State shall çpromote, support and develop health systems with due regard to the health promotion for sustainable health conditions of the public, provide and promote standards and efficient public health services thoroughly, and encourage the private sector and the communities to participate in health promotion and prove public health services, and the person having duty to provide such service whose act meets the requirements of professional and ethical standards shall be protected as provided by lawé. The MoPH is responsible for 28 indicators related to peopleûs sustainable well-being. Section 80(6) of the Constitution prescribes that the State shall çencourage and raise the awareness of national unity and learning, and promote and disseminate the arts, tradition and culture of the nation as well as good values and local wisdomé. The MoPH is responsible for 1 indicator related to the increase in the number of registered TTM practitioners. Section 86(2) of the Constitution prescribes that the State shall çsupport an invention or exploration of new wisdom, preserve and develop local wisdom and Thai wisdom, and protect intellectual propertiesé. The MoPH is responsible for the protection of intellectual property. 2.2 Policies on environmental protection for health. Section 85(5) prescribes that the State shall çconduct the promotion, conservation and protection of the quality of the environment under the sustainable development principle, and control and eliminate pollution which may affect health, welfare and quality of life of the public by encouraging the general public, local communities and local governments to participate in the determination of the operation guidelinesé. The MoPH is responsible for 2 indicators related to the morbidity rate of pollution-related illnesses and the decrease in the incidence of silicosis

22 compared with that for the previous year. 2.3 Policies on the protection of the monarchy and the promotion of sufficiency economy philosophy and public participation [Sections 77, 83 and 87(1)]. Section 77 of the Constitution prescribes that the State shall çprotect and uphold the institution of kingship and the independence and integrity of its jurisdictions and shall arrange for the maintenance of necessary and adequate armed forces and ordnances as well as up-to-date technology for the protection and upholding of its independence, sovereignty, security of State, institution of kingship, national interests and the democratic regime of government with the King as Head of State, and for national development. The MoPH is responsible for 1 indicator, i.e. percentage of completed royal commemoration activities or ceremonies on various occasions. Section 83 of the Constitution prescribes that the State shall çencourage and support the implemen- tation of sufficiency economy philosophyé. The MoPH is responsible for 3 indicators, i.e. percentage of villages with health management actions; percentage of children and youths practising health behaviours according to the National Health Disciplines; and percentage of people with proper behaviour in consuming health products. Section 87(1) of the Constitution prescribes that the State shall çencourage public participation in the determination of public policy and the formulation of economic and social development plans at both national and local levelsé. The MoPH is responsible for 1 indicator, i.e. public benefits projects undertaken with public participation. 3. Statute on the National Health System, 2009 With reference to the movement towards health system reforms during the past decade, networks of participating organizations and members involved in the reform efforts have reached the consensus that, in order for the health system of the country to have a clear, correct, and forceful direction, covering all dimensions of health and involving active participation of people from all sectors, it is necessary to have in place a statute on the national health system that expresses the will and commitment of the society and serves as the framework and guidelines for all sectors concerned to formulate national health policies, strategies and action plans. So the 2007 National Health Act requires that the 2009 Statute on the National Health System be set up as a guide for national health system development. All relevant public and private agencies are required to take further actions under their responsibilities (as per Section 48 of the Statute). The Statute was enacted on 2 December 2009 and will be valid for the overall health system until 2020, containing 12 chapters as prescribed in Section 47 of the Act, namely: Chapter 1 - Philosophy and basic concepts of the health system Chapter 2 - Desirable characteristics and goals of the health system Chapter 3 - Provision of health security and protection

23 Chapter 4 - Health Promotion Chapter 5 - Prevention and control of diseases and health-threatening factors Chapter 6 - Public health services and quality control Chapter 7 - Promotion, support, use and development of local health wisdom, Thai traditional medicine, indigenous medicine, and other alternative medicines Chapter 8 - Consumer protection Chapter 9 - Generation and dissemination of a body of health knowledge Chapter 10 - Dissemination of health information Chapter 11 - Formation and development of public health personnel Chapter 12 - Healthcare financing

Besides, the 2007 National Health Act prescribed that çHealth Assemblyé is the process in which the public and related state agencies exchange their knowledge and cordially learn from each other that leads to the recommendations of healthy public policy. The Act also adopts the çtriangle that moves a mountainé strategy, emphasizing the three coordinated powers of knowledge generation, social mobilization and political support, as prescribed in Section 25(3) that the National Health Commission shall organize a National Health Assembly at least once a year (two sessions of NHA were held in 2008 and 2009) and also organize (specific locality or specific issue health assembly (see details in Chapter 10, Development of healthy public policy with public participation and the statute on the national health system). 4. The Tenth Health Development Plan The 2007 Constitution of Thailand prescribes the directive principles for the development of Thai peopleûs health in Chapter 5, Part 4, on religious, social, public health, educational and cultural policies. In this regard, the MoPH, in coordination with all other relevant sectors, has translated such directive principles into the Tenth National Health Development Plan, 2007-2011, as briefly described below. 4.1 The concept and content of the plan This is a strategic plan that signifies the importance of building up the concept and new approach of health imagination aimed at creating a unified health system in a more desirable and distinct manner. Overall, it intends to develop health in a holistic way, incorporating physical, mental, social and spiritual aspects as well as social mobilization for health promotion, based on the çsufficiency economyé philosophy which helps the system to move towards the good livelihood and health development in all dimensions, in all sectors at all levels, in accordance with the national development direction. The Tenth National Health Development Plan establishes a sufficiency health system in a green and happiness-creating health culture, a medical and health service system satisfactory to clients with happy healthcare providers, and an immunity system for minimizing the impact of illnesses and health threats.

24 4.2 The image and desirable characteristics of the Thai health system The sufficiency health system, according to the sufficiency economy philosophy, is a holistic development system linking to each other the economic, social, cultural and moral dimensions with the following characteristics: (1) Having a strong foundation as a result of having acquired health sufficiency at the family and community levels. (2) Having rational carefulness and estimation in health financing at all levels. (3) Using appropriate technologies with a thorough knowledge, emphasizing Thai wisdom and self-reliance principles. (4) Using an integrated approach for health promotion, disease prevention, medical treatment, rehabilitation, and consumer protection. (5) Having an immunity system that provides health security and protection. (6) Having morality and ethics, i.e. straightforwardness, non-greediness, and sufficiency. 4.3 Vision of the Thai Health System Vision: çAiming for sufficiency health system in creating good health, good services, good society, and happy/sufficient livelihood.é 4.4 Mission The Tenth National Health Development Plan has laid down four development missions: creating thinking integrity, creating health consciousness, creating transparent management system, and creating partici- patory mechanism for development. 4.5 Objectives of the Tenth National Health Development Plan (2007 - 2011) (1) To promote good health as a lifestyle for all age groups, from çwomb to tombé, emphasizing health sufficiency at the family and community levels. (2) To create a good healthcare system, based on the humanized healthcare principle, with quality and friendship, paying attention to the suffering of patients and the delicacy of humanity. (3) To build a good society, or a green and happiness society, with health security for the people to feel warm and secure in normal, illness and critical situations. (4) To create a sufficient and sustainable livelihood that is peaceful with no exploitation for people to grow up in a learning society with cultures favourable for health, peace and development towards the highest potential of humanity. 4.6 Goals of the sufficiency health system development under the Tenth National Health Development Plan (2007-2011) The ten major goals of the Thai health system development leading to sufficiency health system are as follows:

25 (1) Unity and good governance in the management of a balanced and sustainable health system. (2) A proactive health promotion programme that is able to establish fundamental factors required for healthy livelihood. (3) Holistic health culture as well as happy and sufficiency lifestyle. (4) Strong community health system and primary care network. (5) Efficient medical and healthcare system, using technically justifiable and appropriate tech- nology for the comfort of patients and the happiness of care providers. (6) Health security with equity, universal coverage, and high quality. (7) Protection and preparedness system for minimizing the impact of illnesses and health threats in a timely manner. (8) Diverse healthcare alternatives integrating Thai and international wisdom, based on all the facts and self-reliance principles. (9) Knowledge-based health system with knowledge management programmes in all aspects. (10) Society that does not neglect but cares for the indigent and underprivileged, paying respect to the human value and dignity. 4.7 Strategies for the development of Thai health system To establish the sufficiency health system in a healthy and happy society, six development strategies are laid down as follows (Figure 3.2):

Strategy 1: Establishment of unity and good governance in the management of health system. Strategy 2: Creation of health culture and happy lifestyle in a society of well-being. Strategy 3: Establishment of a medical and health service system with patientsû comfort and providersû happiness. Strategy 4: Establishment of immunity or protection system for minimizing the impact of illnesses and health threats. Strategy 5: Creation of diverse health alternatives with integrated Thai and international wisdom. Strategy 6: Establishment of knowledge-based health system with knowledge management principles.

26 :

Strategy 6

ment principles.

Establish a system for examination, monitor- ing and evaluation Create and support learning organizations and the application of the knowledge man- agement concept in all health agencies Support research and development Improve health infor- mation systems so that they are up to date and reliable

Establishment of know

-

-

- -

with knowledge manage-

ledge-based health system

:

Strategy 5

integrated Thai and international wisdom.

Accelerate the development of herbal medi- cines for use efficaciously and adequately Promote the integration of alternative health care into the national health security system Promote local wisdom and community health system for self-healthcare by establishing learn- ing centres of indigenous and alternative medi- cine, medicinal herbs and fragrant plants gar- dens and community centres for chronic pa- tient care, and campaigning on consumption of healthy foods Support research and development for creat- ing knowledge about alternative health care Establish a system for medical technology assessment Create several alternatives for the treatment of illnesses so as to reduce the use of medica- tions and excessive/high-cost medical technologies Improve educational systems and curriculums on Thai traditional medicine Promote and support legal mechanisms for the protection and monitoring of the viola- tion of Thai traditional medicine wisdom and Thai medicinal herbs

Creation of diverse health alternatives with

- - -

- - -

- -

:

threats.

Strategy 4

illnesses and health

Enhance the efficiency of emergency medical service system Develop a prepared- ness plan on medical and health care at all levels Create a mechanism and process of healthy public policy Build up the capacity for the surveillance, prevention, control and treatment of emerging and re- emerging diseases

or protection system for

-

-

-

-

minimizing the impact of

Establishment of immunity

:

happiness.

Strategy 3

health service system with

Accelerate community health development and a primary care system in a proactive manner Strengthen efforts for devel- opment of service quality Reduce conflicts that lead to litigation by improving com- munications Adjust the administrative and working system for boosting morale and incentives of operational staff Promote innovations in health financing Raise the service quality in all health security systems Enhance the quality of emergency medical services and tertiary care Promote the ideology of health professions in the educational system and in the workplace

Establishment of a medical and

-

- -

-

- - -

-

patientsû comfort and providersû

:

Strategy 2

society of well-being.

Accelerate proactive health promotion activi- ties Expand voluntary work for health Promote community health clubs or groups and civil society organiza- tions Conduct continuous cam- paigns to raise health awareness and culture Promote spiritual and in- tellectual well-being

and happy lifestyle in a

Creation of health culture

-

- -

-

-

:

system.

Strategy 1

Build up the unity of health system Promote and support the decentralization of health actions to local government organiza- tions Establish a good gover- nance system and orga- nizational culture of working Promote health leader- ship at all levels

management of health

good governance in the

- -

-

-

Establishment of unity and

The strategies for the development of Thai health system have development tactics as follows:

27 Figure 3.1 Relationship of concept, vision and strategies for health and national development

Strategy 1: Establishment of unity and good governance in the management of health system.

Vision çGreen and happiness societyé Strategy 4: Strategy 2: Establishment of Creation of health immunity or protection culture and happy system for minimizing lifestyle in a society the impact of illnesses of well-being. People-centred and health threats. Strategy 3: development Strategy 5: Establishment of Creation of diverse medical and health health alternatives service system with with integrated Thai patientsû comfort çSufficiency health system in and international and providersû creating good health, good services, wisdom. happiness. good society, and happy/sufficient livelihood in a sustainable manneré Strategy 6:Establishment of knowledge-based health system with knowledge management principles. Principal concept: Sufficiency economy philosophy and health resulting from having a good society

Source: Steering Committee on Tenth National Health Development Plan Formulation (2007-2011), May 2007.

28 5. Health Plan of Action under the National Administration Plan Four-Year Plan of Action (2009-2012), Ministry of Public Health 5.1 Concept and Content of the Plan This is a strategic plan formulated only by the MoPH in accordance with the Royal Decree on Good Governance Principles and Procedures of 2003. The plan specifies responsible agencies and budget for use in preparing an annual work plan and an annual performance agreement/certification. The plan focuses on the translation of policies, targets, indicators, tactics and operating proce- dures in the 2009-2011 National Administration Plan, especially item 3.2 related to MoPH, into the MoPH Plan of Action for 2009-2012. It is a budget plan, prepared as a rolling plan that has to be revised each year, based on the actual budget allocated and projected for the next three years, by all agencies under the ministry. 5.2 Vision of the MoPH The MoPH is the core agency responsible for improving health systems with quality, efficiency and equality, through the participation of people, communities and society with health consciousness, for all Thaisû healthy condition, according to the sufficiency economy philosophy in achieving the goal of green and happiness society. 5.3 MoPH Service Delivery Targets In its Four-year Plan of Action for 2009-2012, MoPH sets five targets for services with indicators and strategies in its operations, which include 58 products/projects, with a total budget of 1.014 trillion baht, of which 81.9 billion baht is for investments in health. 6. The Millennium Declaration 6.1 Concept and content of the Millennium Declaration In September 2000, leaders from 189 countries all over the world including Thailand adopted the United Nations Millennium Declaration which is the mission of the world community in pursuing sustain- able development emphasizing the fight against poverty, hunger, illiteracy, illness, gender inequality, and degradation of national resources and environment. For Thailand, in addition to using the adopted declaration, the philosophy of sufficiency economy has been used as a guide for integrated national development. 6.2 Millennium Development Goals (MDGs) The MDGs are used for dividing the development responsibilities between developed and developing countries, between the United Nations as well as international development agencies and govern- ments of countries, and between development partners in each country for ensuring that the goals are achieved. The goals include 8 major goals and 48 indicators to be achieved by the year 2015:

29 Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development

In 2004, Thailandûs report on the achievements of MDGs revealed that it had progressed and achieved almost all the goals, particularly those related poverty and hunger, gender inequality, HIV/AIDS and malaria, almost 10 years ahead of schedule. So additional targets and indicators so-called çMDG-Plus targetsé were developed for use in the Thai context, including those directly and indirectly related to health develop- ment as shown in Figure 3.2.

30 Figure 3.2 Goals and timeline in achieving MDGs and MDG Plus

Meeting of leaders from 189 adopting Millennium Declaration Human development counties (Sept. 2000) Goals of development 1. Eradicate extreme poverty and hunger Millennium Declaration 2. Achieve universal primary education Goals 3. Promote gender equality and empower women For all 8 goals, in 2004, 4. Reduce child mortality Thailand had achieved Basic principles 5. Improve maternal health almost all MDGs 6. Combat HIV/AIDS, malaria and other Division of responsibilities diseases among developed and 7. Ensure environmental sustainability Beginning developing countries 8. Develop a global partnership for MDG Plus concept development

To be achieved by 2015

Double the proportion of women in the national parliament, TAOs, and Reduce poverty to less than Universal upper executive positions in the civil service 4% by 2009 by 2006 secondary education by 2015 Universal lower Reduce the infant Increase the share of secretary education mortality rate to 15 per renewable energy to 8% 2006 1,000 live births by 2006 of the commercial primary energy by 2011

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Reduce maternal Reduce malaria incidence in 30 Reduce by half the under-five mortality mortality ratio to 18 per border provinces to less than 1.4 rate in highland areas, selected northern provinces and 3 southernmost 100,000 live births by per 1,000 population by 2006 provinces by half between 2005 and 2006 2015 Increase the proportion of municipal waste recycled to 30% Reduce by half the maternal mortality ratio in highland areas, selected by 2006 northern provinces and 3 southernmost provinces by half between 2005 and Reduce HIV prevalence among 2015 reproductive adults to 1% by 2006

Source: Modified from Thailand Millennium Development Goals Report, 2004, p.10. Office of the National Economic and Social Development Board.

31 32 1. Economic Situations and Trends 1.1 Economic Growth Over the three decades before 1997, the average annual economic growth was higher than 7% and the gross domestic product (GDP) per capita increased 28-fold, in particular after 1986. After the 1997 economic crisis, the annual economic growth declined to -1.7% in 1997 and -10.8% in 1998 (Figure 4.2), and the crisis drastically affected the GDP per capita (Figure 4.3). So, Thailand has adopted a number of monetary and financial measures to resolve the problems, resulting in a positive growth of 4.2% in 1999 and 7.1% in 2003, but a drop to -2.2% in 2009 due to the 2008 global economic crisis and a recovery to 7% is expected in 2010 as a result of the global recovery.

Figure 4.2 Economic growth rate in Thailand, 1961 - 2010

Percentage 15 10.48 10 8.21 8.28 7.11 7.27 7.1 7.0e 5.5 5.4 6.3 5.2 5 7.24 4.2 4.6 4.5 4.9 5.46 2.5 2.1 0 Year 1961-1966-1971-1976-1981-1986-1991-1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1965 1970 1975 1980 1985 1990 1995 -1.7 -2.2e -5

-10 -10.8 -15

Source: Office of the National Economic and Social Development Board (NESDB). Note: e Estimated figure.

34 Figure 4.3 Gross domestic product per capita, 1960-2009 (market prices)

e Baht e 160,000 P

143,567.7 150,000 GDP / capita 142,626.5

140,000 135,537.2

130,000 125,355.5 120,000

110,000 103,793.2 100,000 90,000 87,134.3

79,702.8

76,702.2 80,000 75,268.2

70,000 61,414.9 60,000 50,000 48,987.1 40,000 38,786.3

28,602.4

30,000 21,528.4

19,606.1

17,355.5

14,260.7

20,000 11,044.5

8,160.6

6,929.8

4,456.2

4,077.0

3,858.1

3,525.7

2,779.4

2,509.9

10,000 2,238.7 0 Year

1960

1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009

Source: Office of the National Economic and Social Development Board. Notes: 1. P Preliminary figure; e estimated figure. 2. Since 1994, the data on GDP have been adjusted.

1.2 Economic Structure The Thai economic structure has been transformed in such a way that the proportions of the industrial and service sectors grow faster than the agricultural sector (Figure 4.4). However, since 1990, the proportions of production in the agricultural, industrial and service sectors have not changed so much.

35 Figure 4.4 Proportion of economy in the agricultural, industrial and service sectors, as a percentage of GDP, 1960-2009

Service Agricultural Industrial Percentage 70

61.3

60.7

P

60.2

60.13

60.46

60.09

59.52

58.4

58.16

57.98

57.7

56.7 60 56.23

55.2

55.5

55.25

54.3

54.2

53.84

53.64

53.7

53.5

53.4

52.53

49.78

48.77 50 47.72

P

39.79

40 37.13

36.5

35.6

35.0

35.0

34.5

33.9

34.1

33.49

32.0

31.51

29.4

28.3

28.1

27.5

27.16

27.01

26.68

25.84

30 25.89

25.36

24.5

23.88

23.24

22.91

21.32

P

20 16.18

14.99

13.98

13.72

14.1

12.75

12.52

12.3

12.2

20.0

21.51

11.6

11.6

11.0

10.8

10.6

10.7

10.3

10.3

9.4

19.15

19.68

18.14

18.55 10 17.57

15.95

15.66 0 Year

1960

1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009

Source: Office of the National Economic and Social Development Board. Notes: p Preliminary figure.

1.3 Income Distribution and Poverty The poverty situation in Thailand has been on a positive trend; the proportion of people living with poverty dropped from 57.0% in 1962 to 14.7% in 1996 as a result of the rapid economic growth during that period. But after the 1997 economic crisis, the poverty prevalence rose to 20.9% in 2000, but dropped to 8.1% in 2009 (Figure 4.5) due to the economic recovery. However, even though the poverty prevalence has been steadily declining, the proportion of poverty in the rural areas is three times greater than that in the urban areas (Table 4.1).

36 Figure 4.5 Proportion of poverty based on expenditure, 1962 - 2009

Percentage 60 57 50 42.2 39.0 40 31.0 33.7 30 28.4 20.9 18.9 17.5 20 14.7 14.9 11.2

9.6

8.9

8.1 10 8.5

0 Year

1992 1994

1988 1990

1996 1998 2000 2002 2004 2006 2008 2009

1962/1963 1968/1969

1975/1976

Sources: Data for 1962/63-1975/76 were derived from Ouay Meesook. Income, Consumption and Poverty in Thailand, 1962/63 to 1975/76. Data for 1988-2009 were derived from the Household Socio-Economic Survey, analyzed by the Social Database and Indicator Development Office, NESDB. Notes: Studies on poverty in Thailand in different periods had different assumptions.

37 Table 4.1 Proportion of poverty based on expenditure by locality, 1962-2009

Year Urban area, % Rural area, % Whole country, %

1962/63 38 61 57 1968/69 16 43 39 1975/76 14 35 31 1988 23.7 49.7 42.2 1990 20.5 39.2 33.7 1992 12.1 35.3 28.4 1994 9.9 22.9 18.9 1996 6.8 18.2 14.7 1998 7.1 21.9 17.5 2000 8.6 26.5 20.9 2002 6.4 18.9 14.9 2004 4.6 14.2 11.2 2006 3.6 12.0 9.6 2007 3.3 10.6 8.5 2008 2.9 11.5 8.9 2009 3.0 10.4 8.1

Sources: Data for 1962/63-1975/76 were derived from Ouay Meesook. Income, Consumption and Poverty in Thailand, 1962/63 to 1975/76. Data for 1988-2009 were derived from the Household Socio-Economic Survey, analyzed by the Social Database and Indicator Development Office, NESDB.

During the economic crisis, the income distribution became more inequitable. The 20% lowest income group had their income proportion declining from 4.2% in 1996 to 3.9% in 2000, while the 20% highest income group had their income proportion rising from 56.7% to 57.6% during the same period. But in 2001›2009, the trend in income distribution improved slightly (Figure 4.6).

38 Figure 4.6 Income share of Thai people: five income groups

70

59.5

58.5

57.7

57.3

57.6

56.7

56.5

60 56.1

55.63

55.4

55.0

54.9

54.9

55.2

54.2

51.47 (1) (2)

49.8 (1) 49.26 (1) (2) (2) (2) 50 (1) (1) (2) (2)(2) (2) (2) (2) (1) (1) (1) 40

30 20% highest income group 20% lowest income group

Share of income (percent) 20

10 7.9

6.05

5.41

4.8

4.55

4.51

4.5

4.2

4.2

4.4

4.2

4.2

4.1

4.0

3.8

4.03

3.9 (1) 3.8 (1) (1) (1) (1) (1) (2) (2) (2)(2)(2)(2)(2) (2) (2)(2) (2) 0 (1) Year

1975

1962

1981 1992 1988 1994 1990 1986

1996 1998 2000 2002 2004 2006 2007 2009

Year 1962 1975 1981 1986 1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2004 2006 2007 2009 20% highest 7.9 6.05 5.41 4.55 4.51 4.1 3.8 4.0 4.2 4.2 3.8 3.9 4.2 4.2 4.5 4.03 4.4 4.8 income group 20% lowest 49.8 49.26 51.47 55.63 55.0 57.3 59.5 57.7 56.7 56.5 58.5 57.6 55.4 55.2 54.9 56.1 54.9 54.2 income group Income 6.3 8.1 9.5 12.2 12.2 14.0 15.6 14.4 13.5 13.5 15.4 14.8 13.2 13.2 12.2 13.9 12.5 11.3 disparities (times) Sources: (1) For 1962-1992, from the Office of the National Economic and Social Development Board and the Thailand Development Research Institute. (2) For 1994-2009, from the Economic and Social Household Survey of the National Statistical Office, analyzed by the Development Evaluation and Dissemination and Social Database and Indicator Development Bureau of the Office of the National Economic and Social Development Board. Note: For 2006, 2007 and 2009, the negative income figures were adjusted as zero.

1.4 Global and Regional Economic Cooperation In the globalization era, the world has entered into the free trade system and consolidated regional trade organizations so as to establish negotiating power for competition. This has resulted in move- ments in establishing economic cooperation mechanisms, in which Thailand is involved, such as the ASEAN

39 Free Trade Area (AFTA), the Asia-Pacific Economic Cooperation (APEC), the Asia-Europe Meeting (ASEM), the Southern Triangle for Economic Cooperation, the Mekong Committee (for development cooperation among six countries), and the Ayeyawady-Chao Phraya-Mekong Economic Cooperation Strategy (ACMECS). In other regions, such organizations include the North America Free Trade Area (NAFTA) and the European Community (EC). At the global level, there are international trade agreements coordinated by the World Trade Organization (WTO). This has tremendously led to greater liberalization and competition. In particular, devel- oped countries have generated new non-tariff barriers, such as environmental measures, child labour employ- ment and human rights.

Such economic changes have affected the Thai health system as follows: (1) Rising health expenditure. The national health spending rose from 3.8% of GDP in 1980 to 6.48% in 2008 (see Chapter 6, Health Financing). (2) Roles of the public and private sectors in health-care delivery. Since 2001, when the govern- ment began to implement the universal health-care scheme, at public health-care facilities the number of outpatients rose three-fold in 2009, while the number of inpatients changed only slightly. (3) Income disparities between the rich and the poor resulting in inequalities in health resource distribution. Despite the increase in resources and infrastructure for health care, the inequalities in resource distribution are still high as a result of the rapid expansion in the private health sector, draining human resources from the rural to urban areas and from the poor to the rich (see Chapter 6, Health Resources). Such inequalities have resulted in the rural poor and urban slum dwellers having inadequate health care from the state health system. (4) Mental health problems are on the rise. Even though the crisis has been over, mental health problems are on a rising trend, the prevalence of mental disorder rising from 440.1 per 100,000 population in 1997 to 578.1 per 100,000 population in 2009 (see the section on mental health indicators in Chapter 5). (5) Government budget for health is rising. The state health budget varies with the economic situation. During the period of economic boom, the health budget was rising, the Ministry of Public Healthûs budget being 7.7% of the national budget. But during the economic crisis, the government budget for health had a declining trend. Since 2001 the government has implemented the universal health-care policy and the government health budget, particularly the operating budget, has risen steadily. As a result, the proportion of overall MoPH budget (including that for universal health-care) has risen from 6.7% in 2001 to 9.1% in 2011 (see Chapter 7, MoPH Budget). (6) Free trade and international economic agreements. Trade competition and discrimination are more widespread with some negative impact on the products and health-care industries. It has also resulted in an increased level of social and health cooperation, for example, in joint efforts for the prevention and control of infections diseases in humans and animals (SARS, avian flu, etc.). If there is no suitable preparedness plan, a transboundary transmission of such diseases among countries may occur.

40 2. Educational Situations and Trends 2.1 Knowledge, Capability and Skills of Thai People 2.1.1 Literacy Rate The literacy rate among Thai population aged 15 and over rose from 78.6% in 1970 to 94.1% in 2007 (Figure 4.7), ranking third among 10 ASEAN member countries,1 after Brunei and Singapore. Its illiteracy rate was recorded at 5.9% in 2007; and it is estimated that the literacy rate will be as high as 97% in 2010.

Figure 4.7 Literacy and illiteracy rates of Thai population aged 15 and over, 1970 - 2010

Percentage e

97.0

100 95.7

95.0

94.7

94.1

93.8

93.5

93.5

92.6

92.6 93.1 (4)

87.2 (2) 90 (1) (2)(2)(2)(2) (1) (2) (3) (2) (1) 80 78.6 (1) 70

60 Literacy 50 Illiteracy 40 30

21.4 20

(1) 12.8

e

7.4

6.9

6.5

6.5

5.9

7.4

6.2 (1) 5.3 10 5.0

4.3 3.0 (4) (1) (2)(2)(2)(2) (1) (2) (2) (3) (2) 0 Year

1980

1970

1995 1990 1996

1994

1997

2000 2001 2003 2005 2007

2010

Sources: (1) Data for 1970, 1980, 1990 and 2000 were derived from the Population and Housing Censuses. National Statistical Office. (2) Data for 1994-1997, 2001, 2003 and 2007 were derived from UNDP, Human Development Reports, 1997-2009. (3) Data for 2005 were derived from the report on population characteristics from the population change survey, 2005-2006, National Statistical Office. (4) UNESCO, Principal Regional Office for Asia and Pacific, Literacy in Asia and the Pacific.

1 UNDP, Human Development Report, 2009.

41 2.1.2 Learning Rate The learning rate of Thai people is rather low at only 44.4% (2009) and there are wide disparities between urban and rural residents (Table 4.2).

Table 4.2 Learning rate of Thai people, 2001-2009 Unit: Percent Region and area 2001 2002 2003 2004 2005 2006 2007 2008 2009 Urban 53.2 52.9 54.9 55.4 56.6 57.2 58.0 58.1 58.1 Rural 27.2 28.7 30.1 32.1 32.2 34.1 35.5 36.7 37.9 Whole country 35.9 36.9 35.5 39.9 39.8 41.3 42.5 43.4 44.4

Source: Data from the Workforce Survey of the National Statistical Office, analyzed by the Bureau of Development Evaluation and Dissemination, NESDB. Note: Learning rate is the level of literacy and basic computation required for using such skills in resolving daily-life problems among the people aged 15 years and over completing Mathayomsueksa 3 (grade 9) or equivalent in proportion to the total population of the same age group.

Nevertheless, when considering the reading rate among Thai people, it was found that only 35.4 million (61.2%) read regularly in 2003 and the trend rose to 69.1% in 2005, but dropped slightly to 66.3% in 2008 (Report on Reading of Population Survey, 2008, National Statistical Office).

2.2 Education Opportunities 2.2.1 Educational Continuation The rates of students continuing their education from primary (Prathomsueksa 1 to 6 or Grades 1 to 6) to lower-secondary (Mathayomsueksa 1 to 3, or Grades 7 to 9), from lower to upper- secondary (Mathayomsueksa 4 to 6, or Grades 10 to 12), and from upper-secondary to higher education tended to be rising during the pre-economic crisis period. But the rates dropped during the crisis and rose again after the crisis was over (Figure 4.8).

42 Figure 4.8 Rates of educational continuation by educational level, academic years 1994 › 2009 Percentage 130 Lower-secondary education 120 Upper-secondary education Higher education 110

100 97.2 98.5 98.9 98.5 96.2 94.4 95.7 92.5 92.8 92.7 92.5 93.2 93.4 91.5 94.5 89.9 90.0 90.4 90 92.2 88.3 88.0 90.1 91.2 87.2 86.8 86.7 84.9 87.3 83.3 82.5 88.2 86.0 84.8 80.2 82.0 81.0 86.4 85.9 85.8 83.1 83.3 80 82.1 80.7 81.1 80.2 80.8 80.5 78.1 0 Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources:1.Office of the Education Council, Ministry of Education. 2. Operations Centre, Ministry of Education.

With the higher rate of educational continuation, coupled with an increase in the average duration of education among Thai population aged 15 and over from 6.8 years in 1996 to 8.1 years in 2009 (Figure 4.9), the proportion of labour force (2009) with primary schooling has dropped to 56.2%. It has been projected that the proportion of workers with primary education will drop further to only 39.9% in 2020, while those with higher education will rise from 15.4% in 2009 to 22.5% in 2020 (Table 4.3).

43 Figure 4.9 Average years of schooling of Thai people, 1996 › 2009

Years of schooling 10

7.8 7.8 7.8 7.9 8.0 8.1 8 7.2 7.4 7.6 7.6 6.8 7.1 6

4

2

0 Year 1996-1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Office of the Education Council. Table 4.3 Structure (percentage) of labour force by educational level, 1995 › 2020

Educational level 1995(1) 1997(1) 1999(1) 2001(1) 2003(1) 2005(1) 2009(1) 2010(2) 2020(2) Primary and lower 78.0 75.2 69.8 66.3 63.8 61.4 56.2 55.9 39.9 Lower-secondary 8.9 10.1 12.0 12.7 13.7 13.8 15.2 14.7 14.6 Upper-secondary 3.3 3.6 5.0 6.2 7.2 8.1 9.8 8.7 14.3 Vocational 4.7* 4.8* 5.0* 3.4* 3.3* 3.3* 3.4* 6.6 8.7 Higher 5.1 6.2 8.2 11.3 11.9 13.4 15.4 14.1 22.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Sources: (1) Data for 1995›2009 were derived from the Report of the Workforce Survey, 3rd Round, National Statistical Office. (2) Data for 2010-2020 were derived from the Report on Thailandûs Social and Economic Trends, Thailand Development Research Institute. Note: *Including graduates from vocational and teacher-training colleges for 1995-2009. 2.2.2 Education Equalities among Boys and Girls At present, boys and girls have a better educational opportunity compared with those in 2000/2001. In 2007, the proportion of boys attending primary school was equal to that for girls; on the contrary, at the higher level there were more female students than male students. However, the educational equalities among boys and girls in Thailand are lower than those in some other ASEAN and European countries (Table 4.4). 44 Table 4.4 Educational inequalities at the primary, secondary, and tertiary levels, 2000-2007 2000/2001 2007 Group/country Ratio of female-to-male students Ratio of female-to-male students Primary Secondary Tertiary PrimarySecondary Tertiary WHO/SEAR Sri Lanka 1.00 NA NA 1.00 NA NA Maldives 1.01 1.13 NA 0.97 1.07 NA Indonesia 0.99 0.96 0.77 0.96 1.01 1.00 Bangladesh 1.02 1.05 0.55 1.08 1.06 0.57 Thailand 0.93 1.01 1.12 1.00 1.10 1.21 India NA NA 0.66 0.96 0.83 0.72 Myanmar 0.99 0.95 1.75 NA NA NA Nepal 0.87 NA 0.27 1.01 0.93 NA Bhutan NA NA NA 1.00 0.93 0.51 North Korea NA NA NA NA NA NA ASEAN Malaysia 1.00 1.11 1.08 0.99 1.10 1.22 Vietnam 0.94 NA 0.74 NA NA NA Philippines 1.01 1.18 1.10 0.98 1.10 1.24 Indonesia 0.99 0.96 0.77 0.96 1.01 1.00 Singapore NA NA NA NA NA NA Brunei NA NA 1.96 0.99 1.04 1.88 Thailand 0.93 1.01 1.12 1.00 1.10 1.21 Cambodia 0.90 0.59 0.38 0.93 0.82 0.56 Laos 0.92 0.81 0.59 0.90 0.79 0.72 Myanmar 0.99 0.95 1.75 NA NA NA Worldwide: Top Ten Norway 1.00 1.01 1.52 1.00 1.01 1.57 Australia 1.01 1.03 1.24 1.00 0.96 1.29 Iceland 1.00 1.05 1.74 0.99 1.03 1.86 Canada 1.00 1.01 1.35 1.00 NA NA Ireland 1.00 NA 1.27 0.99 1.05 1.27 Netherlands 0.99 1.00 1.07 0.98 1.02 1.09 Sweden 0.99 1.04 1.52 1.03 1.00 1.57 France 1.00 1.02 1.23 0.99 1.02 1.27 Switzerland 0.99 0.95 0.78 1.00 0.96 0.93 Japan 1.00 1.01 0.85 1.00 1.00 0.88 Sources:- Human Development Report 2003, UNDP. - Human Development Report 2006, UNDP. - Education for All, Global Monitoring Report 2010, UNESCO.

45 2.3 Quality of Education The Thai educational system tends to focus on memorization rather than the strengthening of analytical skills for problem solving and self-study, resulting in low educational achievements, below 50% for both primary and secondary levels (Table 4.5). Besides, the Thai educational quality cannot compete with that in other countries as evidenced in the results of the evaluation of mathematics, science and reading skills under the Programme of International Students Assessment (PISA) for 2003 and 2006 and the study on Trends in International Testing of Mathematics and Science Study (TIMSS) in 2007, which revealed that Thai students had lower scores than those of other neighbouring countries participating in the programme except for Indonesia (Table 4.6). As a result, a lot of Thai people lack analytical skills which are a basis for creating life skills, leading to failure or inability to resolve problems or situations related to health risks. Table 4.5 Learning achievements of primary and secondary school students, 2001-2009 Average score (%) Level and subject 2001 2002 2003 2004 2005 2006 2007 2008 2009

Prathom 6 51.83 51.09 44.36 38.44 NA 39.82 43.09 44.03 36.22 Thai 54.35 50.63 46.93 41.59 NA 42.74 36.58 42.02 38.58 English 49.56 47.4 43.1 35.81 NA 34.51 38.67 38.67 31.75 Mathematics 46.95 49.88 43.44 38.47 NA 38.87 47.55 43.76 35.88 Science 56.44 56.44 43.97 37.89 NA 43.17 49.57 51.68 38.67 Mathayom 3 39.49 42.86 42.54 38.26 NA 36.32 36.66 36.91 28.28 Thai 46.27 46.65 55.39 41.59 NA 43.94 48.05 41.04 35.35 English 38.95 45.33 39.56 35.09 NA 30.83 28.68 34.56 22.54 Mathematics 32.36 39.08 36.09 38.47 NA 31.15 34.7 32.64 26.05 Science 40.36 40.36 39.12 37.89 NA 39.37 35.21 39.39 29.16 Mathayom 6 44.86 43.24 41.61 38.26 35.23 36.79 37.19 36.67 32.02 Thai 55.52 50.01 44.49 41.59 48.62 50.33 50.7 46.42 46.47 English 45.76 42.45 39.14 35.09 29.81 32.37 30.93 30.64 23.98 Mathematics 35.21 34.6 33.99 38.47 28.46 29.56 32.49 35.98 28.56 Science 42.96 45.89 48.82 37.89 34.01 34.88 34.62 33.65 29.06 Overall 45.39 45.73 42.84 38.32 37.31 37.64 38.98 39.2 32.2

Sources:1.Educational Testing Bureau, Office of the Basic Education Commission, Ministry of Education. 2. National Institute for Educational Testing Services, Ministry of Education. Note: There was no testing for primary and lower-secondary education levels in 2005.

46 Table 4.6 Average scores in international testing of mathematics, science and reading skills in 2003, 2006 and 2007

PISA 2003 PISA 2006 TIMSS 2007 Country Mathematics Science Reading Mathematics Science Reading Mathematics Science Hong Kong 550 540 510 547 542 536 572 530 Singapore ------593 567 Taiwan ------598 561 Japan 534 548 498 523 531 498 570 554 Korea 542 538 534 547 522 556 597 553 Malaysia ------474 471 Thailand 417 429 420 417 421 417 441 471 Indonesia 360 395 382 391 393 393 397 427 Number of participating 40 40 40 57 57 57 48 48 countries Sources:1.Programme for International Student Assessment (PISA) 2003 and 2006. 2. Trends in International Testing of Mathematics and Science Study (TIMSS) 2007.

The changes in the educational system have affected the Thai health system in the following aspects: 1. Some Thai people lack the ability to screen health information in a well-informed manner resulting in the practice of risky health behaviours. At present, many Thais consume foods and drinks that are unhealthy such as alcohol, junk food, and tobacco (see Chapter 4, health behaviours). 2. Educational attainment of Thai labour force; in 2009, as many as 56.2% of Thai workers had completed only primary schooling which affects the development of labour and health. A lot of workers are unable to care for and protect their own health resulting in a rise in occupational injuries. In additional, the underprivileged such as rural and urban poor residents have no access to the educational system; a number of them have access to neither primary schooling nor health services; so they are faced with a lot of health problems.

47 3. Situations and Trends of Population, Family and Migration 3.1 Population Structure Changing to Be an Elderly Society The success in Thailandûs family planning campaigns has led to an increase in the contracep- tive prevalence rate from 14.4% in 1970 to 79.4% in 2009, resulting in a drastic reduction in the total fertility rate to below the replacement level (a couple having two children, only enough to replace themselves). And as a result, the population growth has continuously dropped from 3.2% prior to 1970 to 0.41% in 2009, below the level of 0.54% projected for 2030 (Figure 4.10). Such a decrease in the population growth has affected the number and age structure of population. Thailand will have a population of 70.6 million in 2025 (Figure 4.11), while the proportion of children aged 0-14 tends to drop whereas the working-age and elderly proportions are likely to escalate (Figure 4.12). This describes the phenomenon of declining dependency ratio for children but rising for the elderly. Although the overall dependency ratio keeps falling until 2010, it will rise again due to a greater proportion of the elderly (Figure 4.13). This will result in a change in Thailandûs population pyramid from an expansive or wide-base to a constrictive or narrow-base one, similar to those in developed countries (Figure 4.14). Thailand thus has a tendency to very rapidly become an elderly society within 20 years (from 2010 to 2030). In 2010, Thailand begins to become an elderly society,2 while other developed countries except Japan spent more than 60 years to be so,3 resulting in the working-age population bearing a higher burden in taking care of the elderly. So the government has to develop a plan and strategy preparing to enter an elderly society, preparing young people to become active ageing people. Moreover, the health-care system has to be prepared to cope with chronic diseases and illnesses of the elderly, Studies are to be carried out to forecast the budget required for elderly health care, particularly under the universal health security scheme, due to the fact that the elderly tend to be sick or disabled and in need of institutional-based long-term care with a greater proportion of budget, compared to that for other age groups. This is to ensure that it will not pose a budgetary burden for the country in the long run. So the government has to formulate measures to control such health products and services for the elderly which tend to become more widespread in the future.

2 The United Nations has defined that, for a country to become an elderly society, its ratio of population aged 65 years or over to the entire population ranges from 7% to 14% and it fully becomes an elderly society when the ratio exceeds 14%. 3 World Population Prospects, The 2002 Revision Volume 1: Comprehensive Table, United Nations. In: Suwannee Kamman, çThe last chance of Thailand: 6 years in the development of Thai people to be advanced in a sustainable manneré, NESDB.

48 Figure 4.10 Population growth rate and projection, Thailand, 1970›2030

Percentage 3.5 3.2 3 2.5 2.5 2.1 2 1.7 1.5 1.4 1.1 0.97e 1 0.8 e 0.59 0.54e 0.5 0.41 0 Year

2010

2020

2030

2005-2006

Before 1970

End of 4th Plan End of 8th Plan

End of 6th Plan End of 7th Plan

End of 5th Plan

End of 3rd Plan Sources:1.Data before 1970 were derived from Niphon Debavalya, Before Getting the 1970 Population Policy. 2. Data for the end of the 3rd-8th Plans were derived from the Department of Health, MoPH. 3. Data for 2005/2006 were derived from the Population Change Survey, National Statistical Office. 4. Data for 2010-2030 were derived from Population Projections, Thailand, 1990-2030, NESDB. Figure 4.11 Projection of population, Thailand, 1990 - 2025 Population (millions) 77 74

70.6 71 70.1

68.9

68 67.3

63.5

63.4 65 63.0

62.8

62.4 62 62.2

59.6

58.9

58.1

59 57.3

56.6 56 55.8 53 50 Year

1990 1991 1992 1993 1994 1995

2000

2005 2006 2007 2015 2008 2009 2010 2020

2025

Source: Population Projections, Thailand, 2000-2025, NESDB. Note: For 1990 and 2009 data were derived from the Bureau of Registration Administration, Ministry of Interior.

49 Figure 4.12 Proportion of population by major age group, 1937-2030

Ages 0 - 14 Ages 15 - 59 Ages 60 and over Percentage 80 70 66.1 66.3 67.5 65.8 62.2 61.5 60 56.2 52.7 53.5 52.4 50 50 42.4 42.3 43.1 40 45.1 38.3 30.6 30 25.0 24.3 23.1 20.6 20 16.7 11.9 13.5 9.5 10.9 17.5 10 4.8 4.2 4.5 4.8 5.4 7.2 0 Year

1937 1947

1960

1970

1980

1990

2000 2005 2010

2020

2030

Sources:1.Data for 1937, 1947, 1960, 1970, 1980, 1990 and 2000 were derived from the Population and Housing Censuses, National Statistical Office. 2. Data for 2005 were derived from the Population Change Survey 2005/2006, National Statistical Office. 3. Data for 2010, 2020 and 2030 were derived from Population Projections, Thailand, 2000-2030, NESDB.

50 Figure 4.13 Population dependency ratio, 1937 - 2030

Total dependency ratio Dependency ratio of children Dependency ratio of the elderly aged 0-14 Percentage 120

100.1 100 91.5 86.8 86.8 90.3 80 77.8 79.1 81.1 82.7 62.9 68.1 57.7 60 51.2 51.4 51.8 46.1 47.9 40.9 40 36.8 34.9 30.3 26.6 22.0 20 16.5 17.6 25.2 11.6 14.4 7.8 7.8 8.8 9.8 9.7 0 Year

1937 1947

1960

1970

2000 1980 2005 2010

2025

2030

1990

Sources:1.Data for 1937, 1947, 1960, 1970, 1980, 1990 and 2000 were derived from the Population and Housing Censuses, National Statistical Office. 2. Data for 2005 were derived from the Population Change Survey 2005/2006, National Statistical Office. 3. Data for 2010-2030 were derived from Population Projections, Thailand, 2000-2030, NESDB.

51 Figure 4.14 Population pyramids of Thailand in 1960, 1990, 2000, 2010, 2020 and 2030 compared to those for Sweden, Denmak, and Japan in 2030

1960 1990 Thailand Thailand Male 70+ Female Male70+ Female 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19

0-4 Percent Percent 0-4 10 8 6 420246810 10 8 6 420246810

2000 2010 Thailand Thailand + Male70+ Female Male70 Female 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 Percent Percent 0-4 10 8 6 420246810 10 8 6 4 2 0 2 4 6 8 10

2020 2030 Thailand Thailand Male 70+ Female Male 70+ Female 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 Percent Percent 0-4 10 8 6 4 2 0 2 4 6 8 10 10 8 6 4 2 0 2 4 6 8 10

52 Figure 4.14 Population pyramids of Thailand in 1960, 1990, 2000, 2010, 2020 and 2030 compared to those for Sweden, Denmak, and Japan in 2030 (contûd)

Sweden

Male70+ Female 60-64 45-49 30-34 15-19 0-4 Percent 10 8 6 4 2 0 2 4 6 8 10

Denmark Japan Male Female Male Female 70+ 70+ 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 Percent0-4 Percent 10 8 6 4 2 0 2 4 6 8 10 10 8 6 4 2 0 2 4 6 8 10

Sources:1.Data for 1960, 1990 and 2000 were derived from the Population and Housing Censuses. 2. Data for 2010, 2020 and 2030 were derived from the Population Projections for Thailand, 2000- 2030, NESDB. 3. Unied Nations (2008). World Population Prospects: The 2008 Revision, http://esa.un.org/unpp

53 3.2 Thai Families 3.2.1 Family Structure The Thai family structure has become diverse and complex mostly being a nucleus family rather than extended family; and there are more and more one-member families whose rate has risen from 2.0% in 1960 to 16.4% in 2010 (Yothin Sawaengdee. Changes in Thai householdsû population structure, 2005). The average family size has dropped to 3.3 persons in 2009 and is expected to drop further to 3.09 persons in 2020 (Figure 4.15).

Figure 4.15 Average family size and projections, Thailand, 1960-2020

Average 8

5.7 6 5.6 5.2 4.4

e

3.8

3.6

3.5

3.4 4 3.4 e

3.3 3.3 3.3 3.09

2

0 Year

1960 1970 2008 2009 2010

1980 2020 2000 2001 2002 2004 2006

1990

Sources:1.For 1960›2000, Population and Housing Censuses, National Statistical Office. 2. For 2001›2009, Household Socio-Economic Surveys, National Statistical Office. 3. For 2010›2020, Reports on Trends in Thailandûs Economic and Social Status, Thailand Develop- ment Research Institute. 3.2.2 Family Relationship: Getting Weaker The national development under the capitalism focussing on industrial development as well as consumerism and competition has changed the Thai family livelihood. More and more women have to work outside the home to financially support the family, resulting in family members having less time for living together and helping each other as evidenced in the decline in the level of family warmth index in the past seven years from 66.3% in 2001 to 62.9% in 2009, which is regarded as low and in need of improvement (Figure 4.16). And such a problem is reflected by the rising rate of divorces, from 10.5% in 1994 to 36.3% in 2009. It is noteworthy that even though the population is growing, the number of marriages each year has fallen from 492,683 couples in 1994 to only 300,878 couples in 2009 (Bureau of Registration Administration, Ministry of Interior). This is due to rising numbers of delayed marriages and cohabitation without wedding registration.

54 Figure 4.16 Family warmth index, 2001-2009

Percentage 69 68.1 68 67.0 67 66.3 66.1 66.1 66 65 63.9 64 62.98 63 62.2 61.9 62 61 60 59 58 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Development Evaluation and Dissemination, NESDB. Notes:1.Family warmth index is measured with three elements: role of family, family relationship, and self- reliance. 2. The scores for different levels: very good for 90.0›100%, good for 80.0›89.9%, moderate for 70.0›79.0%, requiring improvement for 60.0›59.9%, and requiring urgent improvement for ≤ 59.9%. Such a change in the family structure and relationship has an impact on the Thai health system as follows: 1) Rising numbers of abandoned children and elders have negatively affected their physical and mental health. The problems of weak and fragile family have caused more and more child and elder abandonments. It has been found that the rate of abandoned children has risen from 30.33 per 100,000 population in 1993 to 40.5 per 100,000 in 2009 (Department of Social Development and Welfare, Ministry of Social Development and Human Security). The data, however, did not include a number of other abandoned children. And many elderly persons are left to live alone, the rate rising from 3.6% in 1994 to 7.8% in 2007 and almost half (43.3-55.8%) had a problem when living by themselves as when they get older, their working capacity or health condition may be unfavourable to leading a good life or earning a living. Most of the problems are loneliness (51.2%) and having no caregiver when ill (27.5%) (report on elderly personsû survey in Thailand, 2007, National Statistical Office), resulting a negative physical and mental health impact on children and the elderly as many of them cannot get access to health services.

55 2) More family violence deteriorating women and childrenûs physical and mental health status. As a lot of people cohabiting without marriage registration or traditional wedding, they are not prepared to live a marriage life, lacking family-life and problem-solving skills. Whenever such a problem arises, more people tend to end up with physical or mental assaults and sexual abuse. The 2009 NSO survey on reproductive health among married women aged 15-49 years showed that over the past year, 2.9% of them were abused by this husband; the largest proportion (6.3%) being those aged 15-19 years (Table 4.7). However, it is noteworthy that the reported family violence was lower than actuality. According to be MoPHûs Reliable Centre (Soon Phueng Dai), the number of assaulted children and women rose from 6,951 in 2004 to 23,839 in 2009, or from 19 cases per day to 65 cases per day for the same period (Table 4.8), almost half of them were physically and sexually abused.

Table 4.7 Percentage of married women aged 15-49 years physically abused by husbands over the past year by age group, 2009

Age group (years) Women physically abused by husband in past year (%) 15 - 19 6.3 20 - 24 2.8 25 - 29 2.4 30 - 34 2.7 35 - 39 3.3 40 - 44 2.9 45 - 49 2.3 Total 2.9

Source: Report on fertility health survey, National Statistical Office.

56 Table 4.8 Child and woman abuse, 2004-2009

Type of abuse 2004 2006 2007 2009 Number % Number % Number % Number % Physical 2,888 41.5 7,961 50.1 8,389 44.0 11,163 46.8 Mental 503 7.2 750 4.7 1,001 5.2 1,486 6.2 Sexual 3,132 45.0 6,799 42.8 7,393 38.8 10,065 42.2 Social (abandoned) 132 1.9 189 1.2 288 1.5 220 0.9 Deceived ------225 0.9 Unspecified 296 4.3 183 1.2 1,996 10.5 680 2.9 Total 6,951 100.0 15,882 100.0 19,067 100.0 23,839 100.0 Average, cases/day 19 44 52 65

Source: Reliance Centre, MoPH, 2007. Moreover, according to the 2001 survey on health and social conditions of Thai children, among children aged 6›<13 years, 27.9% were physically abused by their family (being hit with a belt or hard object, followed by getting the hair pulled or pinched, being slapped on the face, or being thrown at with an object) and 31.1›45.9% were verbally abused (being hoaxed/scolded with obscene words) (Figure 4.17). For children aged 13›18 years, only 7% were physically abused by the family (being hit with a belt or hard object, or being thrown at) and 32.1›51.5% were verbally abused similar to that for the previous age group (Figure 4.18). This is also reflected in the 2005 report on surveillance of risk factors of Thai children aged 13›18 years, which showed that, among 301,557 children, 10% were abused 1 or 2 times per year by a family member, mostly during the lower-secondary school years (Table 4.9). Table 4.9 Percentage of children aged 13›18 years abused by family members Children abused (%) Number of times abused per year M. 1 M. 2 M. 3 M. 4 M. 5 M. 6 1›2 times 13.35 11.47 10.62 8.63 7.19 6.00 3›5 times 2.84 2.26 1.83 1.38 1.10 0.91 6›10 times 0.80 0.55 0.46 0.23 0.24 0.20 11 times or more 1.10 0.75 0.60 0.41 0.34 0.25 Source: Report on surveillances of risk factors of Thai children, 2005. National institute of Development Administration. Note: M. = Mathayomsueksa; M. 1›6 means grade 7 through grade 12, respectively.

57 Figure 4.17 Percentage of children aged 6 to <13 years physically and verbally abused by type, 2001

Percentage 50 45.9 45 Physical Verbal 40 35 31.1 30 27.9 25 20 14.3 15 8.7 10 6.6 4.3 5 1.0 Types of 0 abuse Hit with belt Thrown at Hair pulled Kicked, Others Hoaxed Scolded with Compared as or hard with object or face punched or obscene animal and object slapped stepped words denounced as bad

Source: Ladda Mohsuwan et al., Health and social conditions of Thai children. Thailand Health Fund, 2004.

Figure 4.18 Percentage of children aged 13-18 years physically and verbally abused by type, 2001

Percentage 60 Physical51.5 Verbal 50 40 32.1 30 20.0 20 7.8 7.2 10 5.2 4.3 1.0 Types of 0 abuse Hit with belt Thrown at Hair pulled Kicked, Others Hoaxed Scolded with Compared as or hard with object or face punched or obscene animal and object slapped stepped words denounced as bad

Source: Ladda Mohsuwan et al., Health and social conditions of Thai children. Thailand Health Fund, 2004.

58 3) Economic loss due all types of abuse When considering the economic loss due to self-inflicted and interpersonal violence in Thailand for 2005, it was found that the cost of injuries was 33,848 million baht, or 0.4% of the 2005 gross domestic product (GDP); 90% of which was due to loss of productivity; and the cost of medical care for such injuries was estimated at 1,948.9 million baht (Table 4.10). But even though there was no clear estimated cost of family violence, it was regarded as part of self-inflicted and interpersonal injuries. Table 4.10 Economic loss due to self-inflicted and interpersonal injuries in Thailand, 2005

Direct medical care cost Indirect cost: Loss of productivity Age, For self-inflicted For interpersonal For self-inflicted For interpersonal Total years injuries injuries injuries injuries (million baht) (million baht) (million baht) (million baht) 0 › 4 1.8 5.1 - - 6.9 5 › 14 8.0 18.9 - - 26.9 15 › 29 334.0 788.6 5,530.2 7,020.2 13,673.0 30 › 44 143.5 395.3 7,155.6 6,674.1 14,368.5 45 + 81.1 172.6 2,719.5 2,799.5 5,772.7 Total 568.4 1,380.5 15,405.3 16,493.8 33,848.0 Source: Kanitta Boonthamcharren et al. Cost of Injuries Due to Interpersonal and Self-Directed Violence in Thailand, 2005 Note: Loss of productivity means injury or premature death and being unable to work to increase national productivity. Therefore, the government should develop a medical service system to help more and more women and children who are domestically assaulted and carry out effective measures for creating family well-being.

3.2.3 Child-Rearing Pattern in Family The child-rearing pattern has also changed; parents do not take care of their children as they have no time for such a matter. So, more and more parents would take their children to be under the care of non-family members. A survey in 2008 on children and youths of the National Statistical Office revealed that among 1.8 million children aged 3›4 years three-fourths (73.0%) were attendees in a pre-schooling programme at a child development centre, or nursery. The results corresponded to the pre-elementary school attendance rate among children aged 3›5 years, which rose steadily from 39.3% in 1992 to 74.0% in 2008 (statistics on education in school system, Ministry of Education).

59 As most parents have no time to closely look after their children, they have to take the children to the educational system with teachers taking care of them while parents are at work. Some have to leave their children at a child-care centre, which might be substandard. According to the MoPHûs Department of Health, in fiscal year 2009, of all 17,119 child development centres, 8,813 or 51.5% had their standards at the good and very good levels. While the other 8,306 or 48.5% were at the basic level and in need of improvement. And the 2007 evaluation of services system of 30 child development centres under local government organiza- tions, conducted by Sirikul Isaranurak in five provinces (Phrae, Buri Ram, Chon Buri, Suphan Buri and Trang), revealed that child caregivers had to perform many duties, for example, as cooks and cleaners, which were an additional workload in addition to taking care of children. It was found that 56.7% of the centres allowed the children to buy crispy snacks for eating, indicating the inadequate control of nutritional practice,4 which affected child development. According to the 2010 survey on health status and development of pre-school children (aged 0›5 years), their level overall development (normal or according to age) declined from 71.7% in 1999 to 67.7% in 2007 and rose to 70.3% in 2010 (Figure 4.19).

Figure 4.19 Development of pre-school children aged 0-5 years, 1999, 2004, 2007 and 2010

Percentage 80 71.7 72.0 70.3 70 Normal 67.7 60 Delayed 50 40 32.3 30 28.3 28.0 29.7 20 10 0 Year 1999 2004 2007 2010

Source: Survey on Health Status and Development of Pre-school Children (0-5 years of age) 2007 and 2010, Department of Health, MoPH. Note: Child development is measured by using Denver II.

4 Sirikul lsaranurak et al. Evaluation of services system of 30 child development centres under local goverment organizations, 2007.

60 3.3 Migration 3.3.1 Rural-to-Urban Migration The national development with industrialization emphasis plays a major role in causing rural people to migrate to cities to seek jobs in the industrial and service sectors. This situation has resulted in a rapid expansion of suburban communities around major cities and it has been forecasted that, in 2027, 47.2% of the total population will reside in urban areas (Figure 4.20). Most of the migrants will move to Bangkok, followed by to Bangkokûs vicinity, as well as to the eastern seaboard area.

Figure 4.20 Projection of urban and rural population, Thailand, 2000-2027

Percentage Rural 100 Urban 80 68.87 67.45 65.73 63.86 62.00 60 52.8

36.14 38.00 47.2 40 31.13 32.55 34.27

20

0 Year 2000 2005 2010 2015 2020 2027

Source:1.Population Projections, Thailand, 2000-2025, NESDB. 2. Bureau of Area Development Strategy and Planning, NESDB, 2008. Note: The 2027 population estimate includes residents in all municipal areas and peri-urban communities.

The 1997 economic crisis resulted in the shutdown or downsizing of a lot of business operations, leading to the reverse of labour migration from urban to rural domiciles, particularly to the Northeast and the North. In 1997, the migration of Thai population from urban to rural areas was as high as 37.2% of all migrants, while only 13.4% migrated from rural to urban areas. After the economic expansion in 2002, the proportion of urban-to-rural migration dropped to only 33.0% while the rural-to-urban migration rose to 19.2%. But in 2008, the urban-to-rural migration was as high as 37.5% while the rural-to-urban migration was only 14.3% (Table 4.11).

61 Table 4.11 Percentage of migrants by type of migration and current residential region, 1992-2008

Current residential region Type of migration Total Bangkok Central North Northeast South

All migrants 100.0 100.0 100.0 100.0 100.0 100.0 Urban to urban 15.8 30.3 22.7 14.7 8.3 19.7 Rural to urban 1992 15.5 NA NA NA NA NA 1994 15.0 78.4 9.8 10.0 6.9 14.4 1997 13.4 74.1 10.5 8.8 5.9 15.9 2002 19.2 67.0 21.1 14.1 9.6 18.6 2007 13.6 55.1 18.7 10.9 6.4 16.2 2008 14.3 67.3 18.2 10.5 7.5 15.5 Unknown1 to urban 0.5 2.4 0.4 0.6 0.3 0.5 Rural to rural 30.7 - 35.4 34.9 25.9 36.8 Urban to rural 1992 32.2 NA NA NA NA NA 1994 33.4 - 28.2 38.1 47.0 20.9 1997 37.2 - 32.0 39.6 55.5 20.3 2002 33.0 - 24.9 38.0 47.2 24.3 2007 36.2 - 24.6 40.8 53.7 15.8 2008 37.5 - 22.9 37.5 56.4 25.7 Unknown1 ➠ rural 1.2 - 0.4 1.8 1.6 1.8

Sources: Data for 1992, 1994, 1997, 2002, 2007 and 2008 were derived from the Reports on Surveys of Population Migration, 1992, 1994, 1997, 2002, 2007, and 2008. National Statistical Office. Note 1 Including immigrants from foreign countries.

62 Due to more rural-to-urban migration, the migrants have to change their rural lifestyles and adopt urban lifestyles. This has led to health problems among some workers who cannot properly adjust themselves to the changing conditions; such problems are mental disorders, peptic ulcer, hypertension, and certain diseases or conditions commonly found in urban slums, i.e. child malnutrition, diarrhoea and tubercu- losis. In addition, most of the migrant workers working in factories are more likely to be exposed to occupa- tional diseases related to industrial chemicals, such as cancer and chemical poisoning. A number of them have to live in an unhygienic environment and some of those who are involved in commercial sex are at increased risk of contracting and spreading HIV/AIDS. The increasing rural-to-urban migration has created problems of mega-cities requiring a suitable urban development planning approach; and health services have to be provided to cover all target groups.

3.3.2 Transnational Labour Migration At present, there is more transnational labour migration than in the past. More Thai workers tend to seek jobs overseas; the number of such workers rose from 61,056 in 1990 to 202,296 in 1995, but after the economic crisis the number dropped to only 147,711 in 2009 (Bureau of Overseas Workers Administration, Department of Employment). The number would be much greater if illegal workers were taken into account. Lately, they are more likely to go to work in Taiwan, Singapore, Malaysia, and the Middle East. Nevertheless, a lot of foreign workers have migrated to work in Thailand, both legally and illegally, especially low-wage labourers from neighbouring countries such as Myanmar, Laos, China and Cambodia. At present, the government allows the registration of alien workers. In 2009, there were 1,314,382 registered foreign workers: 1,078,767 (82.1%) from Myanmar; 124,761 (9.5%) from Laos; and 110,854 (8.4%) from Cambodia. The prov- inces with the highest numbers of workers from Myanmar are Bangkok, , Chiang Mai, Surat Thani, and Samut Prakan, each having 58,613 to 250,891 workers (Department of Employment). However, it is estimated that there are a lot of unregistered workers. As Thailand has had more and more alien workers particularly along the borders, several infectious diseases are widespread such as malaria, diarrhoea, HIV/AIDS, poliomyelitis, and anthrax. Certain diseases that Thailand could once be able to control have re-emerged, such as filariasis; it was reported that 3% of Myanmar workers along the border were carriers of such a disease.

63 4. Quality of Life of Thai People 4.1 Consumption and Lifestyle Values The influence of western culture has resulted in the deterioration of good Thai values such as giving more importance to materialism, imitating foreign-style consumption, neglecting Thainess, becoming extravagant and luxurious. Teenagers tend to have an attitude towards becoming rich fast, lacking endurance, living a casual life, and lacking knowledge about changes. According to the child watch report for 2005-2006, 50% of teenagers spent their time hanging out at shopping malls, going to night entertainment places, movies, owning a mobile phone, eating fast-food, and surfing the Internet, chatting and playing games. As a result, they seem to overspend in relation to their economic status; some consume items non-beneficial to health and intelligence such as tobacco, alcohol and narcotic substances. The media tends to play a more active role in shaping Thai peopleûs lifestyle and leisure-time spending, particularly television and the Internet, while radio seems to be less significant in this regard (Table 4.12).

Table 4.12 Leisure-time spending of Thai people by administrative region, 2001, 2004 and 2009

Time spent by each person, hours/day Time spending category Municipal area Non-municipal area Whole country 2001 2004 2009 2001 2004 2009 2001 2004 2009 - Watching TV or videos 3.2 2.9 2.9 2.7 2.6 2.6 2.9 2.7 2.7 - Getting info from the 2.0 2.0 2.1 1.7 1.8 1.9 1.9 1.9 2.0 Internet - Going to sports, movies, 1.7 2.3 2.2 1.8 2.5 2.6 1.8 2.4 2.5 music events - Socializing with others 1.8 2.6 2.3 1.7 2.0 1.9 1.7 2.2 2.1 - Doing hobbies 1.6 1.9 2.2 1.5 1.9 2.2 1.6 1.9 2.2 - Playing sports 1.5 1.6 1.4 1.5 1.5 1.2 1.5 1.6 1.3 - Listening to music/radio 1.5 1.4 1.5 1.4 1.4 1.5 1.4 1.4 1.5

Source: Reports on Surveys of Leisure-Time Spending among People Aged 10 Years and Over, 2001, 2004 and 2009. National Statistical Office. Note: The surveys were conducted on population aged 10 years and over.

64 4.2 Beliefs and Culture The influx of foreign cultures into Thailand together with globalization, the use of new knowledge and technology in production and livelihood while such technology cannot be created in-country, and the lack of rational screening and selection of such cultures have made most Thai people become under the influence of consumerism, taking advantage of others to be winners, and competing with each other. And unfortunately, the Thai culture relating to solicitude and respect for seniority tends to be diminishing to the level that a plan on conserving Thai culture has to be developed. According to the 2005 cultural participation survey, most of the culture-deteriorating behaviours include open sexual expression, followed by pre-marital sex. In addition, very little of certain local culture and wisdom has been transmitted to the new generation resulting in a lack of cultural preservation. Moreover, the new generation is less interested to learn, resulting in a lack of further development of local wisdom for widespread use, for example in the field of Thai herbal medicine. 4.3 Comparison of Quality of Life of Thai People with Those in Other Countries The United Nation Development Programme (UNDP) has developed a Human Development Index (HDI), a quality of life measurement, based on social factors (education, life expectancy at birth and economic factors - GDP per capita). In 1990, the quality of life of Thai people stood at the çmoderateé level, ranking 74th (HDI = 0.715) among 173 countries worldwide, and fourth among ASEAN member states after Singapore, Brunei and Malaysia. In 1995, the HDI ranking of Thailand rapidly jumped from 74th in 1990 to 59th among 174 nations, and stayed at the çhighé level, ranking third (HDI = 0.838) among ASEAN nations, after Singapore and Brunei (Table 4.13). The major factor contributing to such a higher ranking is its high level of economic growth. After the economic crisis, the quality of life of Thai people worsened between 1998 and 2010; Thailandûs HDI dropped from çhighé to çmoderateé level (HDI = 0.654›0.784) and the ranking fell from 59th to 66th›92nd among 174 countries and 4th among the 10 ASEAN member states, after Singapore, Brunei and Malaysia (Table 4.13).

65 HDI

0.638

value

2010

rank

Ingroup

75

10 10 0.885

rank

Actual

country

Group and

Germany

HDI

value

2007

rank

Ingroup

rank

Actual

country

Group and

HDI

value

2005

rank

Ingroup

rank

Actual

country

Group and

HDI

value

1999

rank

Ingroup

rank

Actual

country

Group and

HDI

value

1998

rank

Ingroup

rank

Actual

country

Group and

HDI

value

1995

rank

Ingroup

rank

Actual

country

Group and

HDI

value

1990

rank

Ingroup

Human development index for Thailand and some other countries, 1990-2010

rank

Actual

: Human Development Report, 1993-2010.

country

Group and

WHO/SEAR WHO/SEAR WHO/SEAR WHO/SEAR WHO/SEAR WHO/SEAR WHO/SEAR Thailand 74 1 0.715 Thailand 59 1 0.838 Thailand 74 1 0.768 Thailand 66 1 0.757 Thailand 78 1 0.781 Thailand 87 1 0.783 Thailand 92 2 0.654 Sri Lanka 86 2 0.663 Sri Lanka 90 2 0.716 Maldives 86 2 0.751 Maldives 77 2 0.739 Sri Lanka 99 2 0.743 Maldives 95 2 0.771 Sri Lanka 91 1 0.658 Maldives 112 4 0.497 Maldives 95 3 0.683 Sri Lanka 99 3 0.730 Sri Lanka 81 3 0.735 Maldives 100 3 0.741 Sri Lanka 102 3 0.759 Maldives 107 3 0.602 Indonesia 108 3 0.515 Indonesia 96 4 0.679 Indonesia 112 4 0.682 Indonesia 102 4 0.677 Indonesia 107 4 0.728 Indonesia 111 4 0.734 Indonesia 108 4 0.600 Myanmar 123 5 0.390 Myanmar 131 5 0.481 India 127 5 0.590 India 115 5 0.571 Myanmar 132 6 0.583 Bhutan 132 5 0.619 India 119 5 0.519 India 134 6 0.309 India 139 6 0.451 Myanmar 131 6 0.549 Myanmar 118 6 0.551 India 128 5 0.619 India 134 6 0.612 Bangladdesh 129 6 0.469 Bhutan 159 9 0.150 Bhutan 155 9 0.347 Bhutan 136 7 0.511 Nepal 129 7 0.48 Bhutan 133 7 0.579 Myanmar 138 7 0.586 Bhutan - - - Nepal 152 8 0.170 Nepal 152 8 0.351 Bangladdesh 139 8 0.502 Bhutan 130 8 0.471 Nepal 142 8 0.534 Bangladdesh 146 8 0.543 Myanmar 132 7 0.451 Bangladdesh 147 7 0.189 Bangladdesh 147 7 0.371 Nepal 143 9 0.499 Bangladdesh 132 9 0.47 Bangladdesh 140 9 0.547 Nepal 144 9 0.553 Nepal 138 8 0.428 DPR Korea - - - DPR Korea - - - DPR Korea - - - DPR Korea - - - DPR Korea - - - DPR Korea - - - DPR Korea - - - ASEAN ASEAN ASEAN ASEAN ASEAN ASEAN ASEAN Singapore 43 1 0.849 Singapore 28 1 0.896 Singapore 24 1 0.881 Singapore 26 1 0.876 Singapore 25 1 0.922 Singapore 23 1 0.944 Singapore 27 1 0.846 Brunei 44 2 0.847 Brunei 35 2 0.880 Brunei 32 2 0.848 Brunei 32 2 0.857 Brunei 30 2 0.894 Brunei 30 2 0.920 Brunei 37 2 0.805 Malaysia 57 3 0.790 Malaysia 60 4 0.834 Malaysia 61 3 0.772 Malaysia 56 3 0.774 Malaysia 63 3 0.811 Malaysia 66 3 0.829 Malaysia 57 3 0.744 Thailand 74 4 0.715 Thailand 59 3 0.838 Thailand 74 4 0.768 Thailand 66 4 0.757 Thailand 78 4 0.781 Thailand 87 4 0.783 Thailand 92 4 0.654 Philippines 92 5 0.603 Philippines 98 6 0.677 Philippines 77 5 0.744 Philippines 70 5 0.749 Philippines 90 5 0.771 Philippines 105 5 0.751 Philippines 9 Vietnam 115 7 0.472 Vietnam 122 7 0.560 Vietnam 108 6 0.671 Vietnam 101 6 0.682 Vietnam 105 6 0.733 Indonesia 111 6 0.734 Indonesia 108 6 0.600 Indonesia 108 6 0.515 Indonesia 96 5 0.679 Indonesia 109 7 0.670 Indonesia 102 7 0.677 Indonesia 107 7 0.728 Vietnam 116 7 0.725 Vietnam 113 7 0.572 Myanmar 123 8 0.390 Myanmar 131 8 0.481 Myanmar 125 8 0.585 Myanmar 118 8 0.551 Myanmar 132 9 0.583 Laos 133 8 0.619 Laos 122 8 0.497 Cambodia 148 10 0.186 Cambodia 140 10 0.422 Cambodia 136 9 0.512 Cambodia 121 9 0.541 Cambodia 131 8 0.598 Cambodia 137 9 0.593 Cambodia 124 9 0.494 Laos 141 9 0.246 Laos 136 9 0.465 Laos 140 10 0.484 Laos 131 10 0.476 Laos 130 10 0.601 Myanmar 138 10 0.586 Myanmar 132 10 0.451 Japan 1 1 0.983 Canada 1 1 0.960 Canada 1 1 0.935 Norway 1 1 0.939 Iceland 1 1 0.968 Norway 1 1 0.971 Norway 1 1 0.938 Canada 2 2 0.982 France 2 2 0.946 Norway 2 2 0.934 Australia 2 2 0.936 Norway 2 2 0.968 Australia 2 2 0.970 Australia 2 2 0.937 Norway 3 3 0.979 Norway 3 3 0.943 U.S.A. 3 3 0.929 Canada 3 3 0.929 Australia 3 3 0.962 Iceland 3 3 0.969 New Zealand 3 3 0.907 Switzerland 4 4 0.978 U.S.A. 4 4 0.943 Australia 4 4 0.929 Sweden 4 4 0.936 Canada 4 4 0.961 Canada 4 4 0.966 U.S.A. 4 4 0.902 Sweden 5 5 0.977 Iceland 5 5 0.942 Iceland 5 5 0.927 Belgium 5 5 0.935 Iceland 5 5 0.959 Iceland 5 5 0.965 Iceland 5 5 0.895 U.S.A. 6 6 0.976 Finland 6 6 0.942 Sweden 6 6 0.926 U.S.A. 6 6 0.934 Sweden 6 6 0.956 Netherlands 6 6 0.964 Lichtenstein 6 6 0.891 Australia 7 7 0.972 Netherlands 7 7 0.941 Belgium 7 7 0.925 Iceland 7 7 0.932 Switzerland 7 7 0.955 Sweden 7 7 0.963 Netherlands 7 7 0.890 France 8 8 0.971 Japan 8 8 0.940 Netherlands 8 8 0.925 Netherlands 8 8 0.931 Japan 8 8 0.953 France 8 8 0.961 Canada 8 8 0.888 Netherlands 9 9 0.970 New Zealand 9 9 0.939 Japan 9 9 0.924 Japan 9 9 0.928 Netherlands 9 9 0.953 Switzerland 9 9 0.960 Sweden 9 9 0.885 UK 10 10 0.964 Sweden 10 10 0.936 UK 10 10 0.918 Finland 10 10 0.925 France 10 10 0.952 Japan 10 10 0.960

World(top ten) World(top ten) World(top ten) World(top ten) World(top ten) World(top ten) World(top ten)

Source

Table 4.13

66 5. Situation and Trends of Environment and Livelihood 5.1 Infrastructure 5.1.1 Transportation 1) Land Transportation In 2009, Thailand had a road network of approximately 393,906.7 km, of which 51,625.9 km was under the highway network and 342,280.8 km under the rural road network leading to all four regions of the country. It is considered that the road network has covered all localities nationwide. In Bangkok, there are expressways of 198.4 km in length and another 80.8 km under construction expected to be completed by 2012. Two lines of electric rail mass transit system have been operational and another five lines are expected to be completed in the near future to help ease the traffic problems in the city. Besides, there is a railway system with a combined length of 4,428.8 km. 2) Waterway Transportation In 2009, Thailand had 7 principal harbours and 11 ports with an adequate potential for waterway transport of industrial products. However, some improvements in the infrastructure of the ports may be needed to cope with future economic expansion. 3) Air Transportation At present, Thailand has six international airports Suvarnabhumi, Bangkok, Chiang Mai, Hat Yai, Phuket and Chiang Rai. However Suvarnabhumi Airport needs to be expanded to cope with the much larger number of passengers in the future.

5.1.2 Telecommunications Thailandûs telecommunications have rapidly expanded, especially during the past de- cade. In 2009, there were 6,582,548 fixed-line telephone numbers and 63,610,376 mobile phones nationwide, a rate of 104.1 fixed-line phones per 1,000 population and 1,006.3 mobile phones per 1,000 population and the rate of computer possession was 96 sets per 1,000 population (Table 4.14). The access to the Internet has increased from 30 persons in 1991 to 10.96 million persons in 2008, a use rate of 17.3% or 18,169.2 users per 100,000 population. The number of Internet users in Bangkok is highest among all regions nationwide (Table 4.15). But in comparison with other countries, such as Singapore and Malaysia, Thailandûs telecommunication infrastructure and Internet uses are lower (Tables 4.14 and 4.16).

67 Table 4.14 Telecommunication infrastructure in some countries, 1996›2007

No. of fixed-line telephones No. of mobile phones No. of computers per 1,000 population per 1,000 population per 1,000 population Country 1996 1997 1999 2002 2007 1996 1997 1999 2002 2007 1996 1997 1999 2002 2007 Singapore 498.4 529.0 484.1 472 420 147.5 229 381.45 761.1 1,335 233 316 390.9 596 676 Malaysia 192.5 192.5 219.3 206 164 88.4 101.9 145.05 372.9 879 53 65 94.5 137 286 Thailand 78.6 85.5 101.9 99* 104.1** 27.8 34.5 138.6 346.8* 1,006.3** 22 28 40.4 43 96 Philippines 30.7 42.7 37.9 46 45 12.9 17.7 36.97 189.1 589 11 13 19.5 25 65 Indonesia 17.8 24.7 29.1 34 77 3.0 5.4 9.83 48.5 353 6 9 13.4 13 31 Sweden 684.1 685.4 694.5 750 604 281.8 358.1 590.08 900.3 1,137 286 353 510.4 687 880 U.S.A. 636.6 625.6 709.8 701 533 161.9 205.6 314.87 496.9 835 403 450 538.9 739 869 Norway 564.9 609.1 711.9 754 424 296.1 383.0 627.03 787.0 1,105 307 363 506.8 657 857 Source: IMD. The World Competitiveness Yearbook, 1996 and 2009. Notes:1.* Data for 2003. 2. ** Data for 2009. 3. Data on computer use per 1,000 population are data for 2008. Table 4.15 Internet access by administrative jurisdiction and region in Thailand, 2001, 2003, and 2006›2008

2001(1) 2003(2) 2006(2) 2007(2) 2008(2) Administrative No. of Use rate No. of Use rate No. of Use rate No. of Use rate No. of Use rate jurisdiction and Internet per Internet per Internet per Internet per Internet per region users 100,000 users 100,000 users 100,000 users 100,000 users 100,000 population population population population population Whole Kingdom 3,536,001 6,163.7 6,031,300 10,434.1 8,465,823 14,226.2 9,320,126 15,540.4 10,964,243 18,169.2 - Municipal areas 2,341,433 12,361.5 3,807,900 19,897.3 4,242,901 23,370.9 4,564,814 24,821.5 5,369,342 28,966.4 - Non-municipal areas1,194,568 3,108.7 2,223,400 5,750.2 4,222,921 10,211.6 4,755,312 11,435.7 5,594,901 13,382.1 Bangkok Metropolis 1,234,542 16,774.1 2,005,700 26,862.3 1,774,375 27,961.7 1,917,348 29,945.7 2,323,439 36,023.3 Central Plains 830,389 6,322.6 1,336,300 10,077.3 2,028,575 13,906.6 2,317,222 15,661.2 2,689,064 17,974.2 North 516,114 4,988.6 1,003,200 9,682.4 1,581,412 14,656.7 1,685,343 15,629.7 1,923,015 17,838.5 Northeast 559,193 2,937.4 1,070,100 5,586.5 2,103,780 10,599.5 2,382,704 11,937.8 2,778,257 13,859.1 South 395,763 5,283.3 616,000 8,147.4 977,680 12,316.2 1,017,509 12,667.1 1,250,469 15,422.5 Internet use rate (%) 5.7 9.5 13.5 14.8 17.3 Sources:- Survey on Householdûs Usage of Information Technology Equipment and Appliances, 2001 and 2003. National Statistical Office. - Survey on Information and Communication Technology (Households), Quarter 1, 2004. National Statistical Office. - Survey on Information and Communication Technology (Households), 2008. National Statistical Office. Notes: (1) Population aged 11 years and over. (2) Population aged 6 years and over.

68 Table 4.16 Comparison of the Internet usage in Asia-Pacific countries, 1998, 2002, 2005, and 2009

No. of Internet users (millions) Internet use rate (percent) Country 1998 2002 2005 2009 1998 2002 2005 2009 Australia 4.0 10.63 14.66 17.0 22.2 54.4 71.8 80.1 Singapore 0.55 2.31 2.42 3.4 18.3 51.9 53.9 72.4 Hong Kong 1.1 4.35 4.88 4.88 18.3 59.6 70.3 69.2 New Zealand 0.55 2.06 3.20 3.4 15.3 52.7 78.4 79.7 Taiwan 3.0 11.6* 13.21 15.1 14.3 51.8 59.9 65.9 Japan 14.0 56 86.3 95.9 10.8 44.1 67.7 75.5 Korea 2.0 25.6 33.9 37.5 4.6 53.8 69.4 77.3 Thailand 0.67 4.8 8.46 16.1 1.1 7.7 13.5 24.4 Malaysia 0.4 5.7* 11.02 16.9 2.0 25.1 41.2 65.7 Philippines 0.2 4.5 7.82 24.0 0.3 7.7 8.7 24.5 China 1.5 45.8 123.0 360.0 0.1 3.5 9.3 26.9 Indonesia 0.1 4.4 16.0 30.0 0.1 1.9 7.3 12.5 India 0.4 7.0* 60.6 81.0 < 0.1 0.6 4.6 7.0 Vietnam 0.15 0.4* 13.10 21.9 < 0.1 0.5 15.4 24.8

Sources:1.Internet Users Worldwide, 2001-2002. 2. The World Fact Book, 2006-2007. 3. Internet World Stats, 2009. No. of Internet users Notes:1.Internet use rate = X 100 2. * Data for 2001. Total population 3. Data for Thailand in 2009 were obtained from Internet World Stats, 2009.

Besides, Thailand has got its own Thaicom satellites, which make communication via cable TV and free TV systems more expansive. The expansion of communication networks in Thailand is related to global development and part of evolution in the çglobalizationé or borderless world era. In addition, advertisement business expansion through various media is annually worth tens of billions of baht. This business sector has strongly affected Thai peopleûs consumption behaviours. New sales patterns have been created, especially direct sales, through various media, which are more difficult to control than those through shopping outlets.

69 Peopleûs behaviours in accepting information have also shifted from radio to television as the main source. The 2008 media survey conducted by NSO revealed that there were as many as 57.0 million TV viewers (94.6%), compared with only 18.7million radio listeners (31.1%). Among urban people, a greater number of them were more interested in the information about economic, social, political and health conditions, while, previously viewing only entertainment programmes. In particular, new popular programmes such as live phone-in and discourse programmes result in the emergence of new communities using media as a means for interaction, for example, Jo So 100 community, TV game show communities, and various other radio programme communities. 5.1.3 Public Utilities 1) Electricity. In 2009, approximately 98.6% (70,186 villages) of all villages across the country had moderate and good levels of electricity supply. Only 944 villages (1.3%) had not yet had access to the electricity system (Table 4.17).

Table 4.17 Villages with electricity, 1992›2009

No. of Villages with Villages with electricity villages without electricity 1 2 available Good level Moderate level Year No. Percent information No. Percent No. Percent 1992 59,354 54,719 92.2 2,466 4.2 2,169 3.6 1994 59,059 55,590 94.1 1,675 2.8 1,794 3.0 1996 60,215 57,523 95.5 1,198 2.0 1,494 2.5 1999 63,230 56,483 89.3 5,678 9.0 1,069 1.7 2001 66,193 60,128 90.8 4,698 7.1 1,367 2.1 2003 68,496 60,613 88.5 7,096 10.4 787 1.1 2005 69,096 64,807 93.8 3,568 5.2 721 1.0 2007 69,730 66,867 95.9 1,868 2.7 995 1.4 2009 71,130 68,520 96.3 1,666 2.3 944 1.3

Source: Thai Rural Villages, 1992-2009, from Ko Cho Cho 2 Kho Database. Information Centre for Rural Development, Ministry of Interior. Notes: 1 Good level: more than half of households in the village have electricity. 2 Moderate level: less than half of households in the village have electricity.

2) Drinking Water. In 2009, 97.4% of households had adequate and safe drinking water (Figure 4.21) and 97.2% of them had adequate water for domestic use all year round.

70 Figure 4.21 Proportion of households with adequate and safe drinking water, 1960›2009

Percentage 120

97.4

97.4

96.9

96.0

95.47 95.51

95.34

95.49 100 94.6

93.21

92.4

92.25

80 74.42 65.96 60

40 23.06 20 13.56 8.52 0.1 1.63 0 Year

1960

1965 1980 1970

1985

1990

1995 1996 1997 1998 1999 2000 2001 2003 2005 2006 2007 2009

1975

Sources: Data for 1960›2000 were derived from the Department of Health, MoPH. Data for 2001, 2003, 2005 and 2007 were derived from Thai Rural Villages in 2001, 2003, 2005, 2007 and 2009. Information Centre for Rural Development, Ministry of Interior. Data for 2006 were derived from the 2006 Basic Minimum Needs Report, Information Centre for Renal Development, Ministry of Interior. Such changes in infrastructure have had an impact on Thai peopleûs health as follows: (1) More problems of traffic accidents and higher numbers of vehicles as a result of transporta- tion expansion with more roads and vehicles (see Chapter 5, section 5.2.6 on accident-related injuries). (2) Disparities in access to health information as the Thai communication infrastructure is a lot inferior to those in other countries; certain segments of the population may not have access to health informa- tion, particularly those living in rural areas, compared with those in urban areas. 5.2 Biodiversity Thailandûs biodiversity is abundant in terms of genetics, species and ecological systems with about 15,000 species of plants, 25,000 species of animals, and 7,800 species of bacteria, fungi and other microorganisms, in 15 ecosystems (National Resources and Environment Capital for Sustainable Development in the 10th National Development Plan, NESDB). So they have been exploited lavishly without effective management and control measures. As a result, natural resources and biodiversity have been deteriorated rapidly resulting in the extinction of as many as 14 animal species and the near-extinction of 684 animal/plant species, as well as in the deterioration of some ecosystems.

71 Thailand became the 188th member state of the Convention on Biological Diversity on 29 January 2004; so other member countries can now have access to the genetic resources of Thailand. Some countries have tried to take away some animal and plant species of Thailandûs nature for research purposes, which may lead to the registration of intellectual property right. Thus, the government has to develop strong measures for protecting the countryûs interests in the long run. In addition, a good management system has to be established to link with a foreign country that owns the technology and Thailand that owns natural resources and local wisdom so as to safeguard the nationûs benefits to the maximum extent possible. Besides, the consumption of health products has been on a rising trend including the use of medicinal plants for health care and medicine production. Thus, this is a good opportunity to raise the level of knowledge of health care using local wisdom and creating value-added herbal products. The government has to promote and support research and development on Thai herbal medicine to raise the quality up to the international standards. 5.3 The Environment 5.3.1 Global Warming Scientific evidence has confirmed that there is the problem of global warming resulting from the emission of greenhouse gas from the energy and transport sectors. According to the 2006 report from the World Bank, Thailand ranks 31st in emitting the large amount of green house gas (ranks 1st›5th are the U.S.A., China, Indonesia, Brazil and Russia, respectively) and ranks 4th among ASEAN members after Indonesia, Malaysia and Myanmar. A comparison of the amounts of greenhouse gas emitted between 1994 and 2003 showed that the amount for Thailand increased by 20% (Table 4.18).

Table 4.18 Amount of greenhouse gas emitted by various sectors in Thailand, 1994 and 2003

Amount of greenhouse gas emitted (Million tons) Sector 1994 2003 Change ( ± %) Energy 129.87 193.2 +48.7 Agriculture 77.39 82.78 +7.0 Waste 0.74 26.87 +353.1 Forest and land use 61.85 22.61 -63.4 Total 269.85 325.46 +20.6

Source: Committee on National Climate Change, 2007. Referred to in Thai Health Report 2008, Institute of Population and Social Research. Mahidol University.

72 For the impacts expected to occur if the temperatures rise, see Figure 4.22. Figure 4.22 Impacts expected to occur if the worldûs temperatures rise

Expected impacts at different levels of world temperature rise Changes in temperatures (compared with pre-industrial era) 0 ÌC1 ÌC2 ÌC3 ÌC4 ÌC5 ÌC Decrease in agricultural productivity in developing countries Food Increase in productivity in high Decrease in productivity in developed latitude areas countries Glaciers on moun- Decrease in water tains began to amounts in several areas Rising sea levels are a Water disapper; water such as the Mediterranian threat to several large scarcity in some areas and South America cities

Coral reefs damaged A large number of plants and animals face Eco system widely extinction

Disaster Occurrence of severe storms, forest fines, droughts, floods, and heat waves Widespread of vector-borne diseases; the threats of Diseases re-emerging and emerging diseases and heat waves became more severe

Source: Thai Health Report, 2008. Institute of Population and Social Research, Mahidol University.

Global warming has had an impact on the health system as follows: 1. Deaths of Thai people from disasters and floods over the past 20 years, causing an economic loss to the country, totaling 85,000 million baht. In 2006, there were floods in 47 provinces resulting in more than 100 deaths and 4.2 million people suffering (Report on Vision 2027: Towards the 11th National Development Plan, NESDB). 2. The outbreaks of communicable diseases including emerging and re-emerging diseases tend to be more severe. The warm weather causes the rapid rise in the number of vectors of communicable diseases, especially mosquitoes, flies and rats, and the wider spread of such diseases such as dengue haemorrhagic fever (DHF), whose incidence was rising in 2006›2008, with 89,626 cases in 2008. Moreover, in some mountain- ous areas, where there was no outbreak of DHF before, have found the spread of the disease with about 50 cases each day in Ban Saje, an Akha hill-tribe village in Mae Rai subdistrict, Mae Chan district, Chiang Rai province, the patients overcrowding the hospital (Thai Health Report, 2008)

73 3. Unhealthy environment, rising temperatures, droughts or heavy rainfalls have caused imbalanced environmental conditions. The drought also causes severe forest fires resulting in çsmogé dangerous to the respiratory system and causing eye initiation. For instance, the 1997›1998 fires in Indonesia caused thick smoke clouds as well as respiratory and eye diseases among a great number of people in southern Thailand. 5.3.2 Air Pollution According to the Air Quality Monitoring programme conducted in Bangkok and its vicin- ity as well as in other major cities, dust is still a major problem and the levels of carbon monoxide and ozone are occasionally higher than the maximum permissible levels, while the levels of other pollutants such as lead and sulfur dioxide are within the allowable limits. As the major cause of air pollution problem in Bangkok, dust or suspended particulate matter is particularly dispersed everywhere and near the roads; the problem seems to be more serious at places near the sources of pollution, i.e. motor vehicles and construction sites. In 2009, it was found that the 24-hr total average amounts of dust particles on the roadsides in Bangkok had been declining since 1997 due to decreased industrial and construction activities resulting from the economic crisis. During 1992›2009, the 24- hr average concentrations of particulate matter of less than 10 microns (PM10) on the roadsides of Bangkok were higher than the maximum permissible level at all monitoring stations (Figure 4.23), while the levels of carbon monoxide, sulfur dioxide and lead were found to be lower than the maximum allowable levels. Figure 4.23 24-hr average concentration of <10-micron particulate matter on roadsides in Bangkok, 1992›2009

Peak Average Lowest 450 416 400 387 349.8 350 341

300 286.6 265 242.7 250 224.8 224.8 207 251.3 244.4 216.0 205.4 200 208.9 183.0

(mcg./cu.m.) 150 174 PM10 permissible level: 120 mcg./cu.m. 114 100 80 79 84 89 81.6 80.1 79.9 24-hr average concentration of PM10 71 67.6 78.5 78.5 49 57.8 61.4 64.1 60.9 61.8 60.1 50 30 29 23 19 27 21.3 21.5 21.5 21 10 9.4 13.3 9.3 12.7 12.2 9.8 8.1 15.5 0 Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Pollution Control Department, Ministry of Natural Resources and Environment.

74 In other provincial cities, the Pollution Control Department conducted the air quality mea- surement in 25 stations covering 18 provinces nationwide in 2009 and found that the 24-hr average peaks of PM10 detected were higher than the maximum permissible level in almost all areas (maximum permissible concentration for 24-hr average PM10 is 120 mcg./cu.m.). The highest PM10 pollution was detected at 292.8 mcg./cu.m. in Lampang province, but the concentrations of nitrogen oxide, sulfur dioxide and carbon monox- ide were still within the maximum permissible levels. The deteriorating quality of air has negatively affected the peopleûs health as a result of inhaling PM10 dust. A study in six major cities in Thailand (Bangkok, Chiang Mai, Nakhon Sawan, Khon Kaen, Nakhon Ratchasima and Songkhla) reveals that annually there are 2,330 premature deaths and 9,626 cases of bronchitis, with a health-care cost of 28,009.6 million baht, or 2,000 baht/case/year; Bangkok having the highest proportion of health-care cost, 65.0% of all costs for the six cities. 5

5.3.3 Water Pollution At present, the quality of various waterways tends to be deteriorating, but the water is still usable for agricultural and industrial purposes, except for the lower stretches of the Chao Phraya and Tha Chin Rivers in the Central Plains, where the water is heavily polluted and the rivers can be used only for transportation purposes. A report on water quality surveillance on 49 waterways and 4 stagnant water reservoirs (Kwan Phayao, Boraphet, Nong Han and Songkhla Lakes) in 1992›2009 revealed that overall the water quality was better than before; the proportion of samples with good water quality rose from 6.25% in 1992 to 36.67% in 2002, but dropped to 31.0% in 2009; the proportion of those with satisfactory quality rose from 18.75% in 1992 to 54.0% in 2008, but dropped to 36.0% in 2009. The water from such sources can be used for human consumption after proper, regular or special treatment and disinfection in certain places (Table 4.19). For the Chao Phraya River, during 1992›2004, the water quality was at the satisfactory level, but after 2005 the proportion of samples with poor and very poor quality rose to 76.0% in 2009 (Table 4.19). However, the problems encountered were the high contents of coliform and faecal coliform bacteria exceeding the maximum permissible concentration, higher levels of pollution in terms of organic chemical substances, and lower levels of dissolved oxygen in relation to the allowable standards.

5 Quoted in Thailand Health Profile 2002 - 2004,pp. 109-110.

75 Table 4.19 Percentage of water samples with various water-quality levels from the Chao Phraya and other rivers, 1992›2009

Water quality of other rivers Water quality of Chao Phraya River Year Good Satisfactory Poor Very poor Good Satisfactory Poor Very poor

1992 6.25 18.75 75.00 0.00 0.00 5.88 17.65 76.47 1993 8.33 19.44 61.11 11.11 0.00 12.50 50.00 37.50 1994 4.35 32.61 60.87 2.17 3.65 8.03 33.58 54.74 1995 10.87 21.74 56.52 10.87 4.17 15.28 36.11 44.44 1996 9.43 30.19 56.60 3.77 0.00 15.28 31.94 52.78 1997 20.75 35.85 37.74 5.66 3.70 16.67 31.48 48.15 1998 30.19 49.06 15.09 5.66 19.44 26.39 27.78 26.39 1999 20.75 35.85 39.62 3.77 12.04 24.07 34.26 29.63 2000 27.78 38.89 27.78 5.56 15.63 31.25 31.25 21.88 2001 18.52 40.74 33.33 7.41 31.94 22.22 26.39 19.44 2002 36.67 20.00 40.00 3.33 8.33 31.94 27.78 31.94 2003 32.0 31.00 31.0 6.0 25.0 32.0 13.0 30.0 2004 23.0 51.0 21.0 5.0 6.0 17.0 6.8 10.0 2005 17.0 49.0 29.0 5.0 35.0 26.0 35.0 4.0 2006 21.0 53.0 23.0 3.0 3.0 26.0 48.0 23.0 2007 19.0 35.0 44.0 2.0 2.0 22.0 57.0 19.0 2008 22.0 54.0 24.0 0.0 7.0 24.0 49.0 20.0 2009 31.0 36.0 33.0 0.0 3.0 21.0 46.0 30.0

Source: Pollution Control Department, Ministry of Natural Resources and Environment.

Water pollution is detrimental to the publicûs health and results in high health-care costs. It was estimated that in 1999 the economic cost for the care of patients with diarrhoea, dysentery and typhoid was US$ 23 million or 0.02% GDP; US$ 7.59 million being the hospital-based medical care cost including US$ 4.96 million for outpatient care and US$ 2.64 million for inpatient care. 6

6 Quoted in Thailand Health Profile 2005 - 2007,pp. 79

76 5.3.4 Noise Pollution The most serious source of noise pollution is road traffic especially on major roads in Bangkok, its vicinity and other major cities with traffic congestions. A report on noise level monitoring in 1997›2009 of the Pollution Control Department revealed that, at 17 air quality and noise monitoring stations in 11 provinces, almost all stations had 24-hr average continuous equivalent noise levels (Leq)7 higher than the maximum permissible level (Figure 4.24). The rising noise pollution has caused hearing loss among the people. A study con- ducted by Andrew W. Smith8 reveals that the noise level exceeding 80 decibels is dangerous to hearing ability and Schuttz (1978)9 indicates that the noise exceeding 70 decibels will cause severe annoyance in 22% to 95% of the people.

Figure 4.24 Noise levels (Leq 24-hr) on roadsides in Bangkok, its vicinity and major provincial cities, 1997- 2009

Decibel A Bangkok and vicinity Provincial cities 100 95 90.5 90.389.8 90 88.7 88.2 88.1 86.8 86.3 84.8 85 82.3 83.7 83.6 83.3 81.4 80.5 81.7 80.6 82.1 80 79.7 79.3 78.477.3 77.6 76.6 75 Standard 70 dBA 70 65 62.8 60 55 54.5 50 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Pollution Control Department, Ministry of Natural Resources and Environment.

7 Noise level in Leq 24-hr is an average value of continuous noise or sound energy for a 24-hr period. 8 Quoted in Thailand Health Profile 1999 - 2000,pp. 113 - 114 9 Quoted in Thailand Health Profile 1999- 2000,pp. 113 - 114

77 5.3.5 Pollution from Hazardous Substances In 1994-2009, the amounts of chemical imports for industrial and agricultural uses increased from 4.9 million tons to 7.6 million tons and 3.0 million tons to 4.2 million tons, respectively (Figure 4.25). While good transportation, warehousing and use systems were lacking, there were frequent and serious chemical accidents, i.e. 119 incidents in 2007›2009, causing 990 injuries and 10 deaths. Moreover, the health impact of increased chemical use in the industrial and agricul- tural sectors includes pesticide poisoning among farmers and chemical poisoning among industrial workers (see Chapter 5, section 2.7, occupational and environmental diseases). In the future, it is likely that there will be more patients with chemical poisoning as the toxic substances will be accumulated in the bodies of affected people; their symptoms or illnesses will occur in the long run such as cancer and abnormalities in the central nervous, immunological and gastrointestinal systems. Figure 4.25 Amounts of chemical imports, 1994›2009

Million tons Chemical for industrial use Chemical for agricultural use 95 7.4 7.6 7.1 7.1 7.3 90 6.8 6.7 6.3 6.0 85 5.0 5.2 5.0 80 4.9 5.5 4.8 4.6 4.4 4.1 4.1 4.2 4.0 3.8 70 3.5 3.6 3.5 3.7 3.7 3.2 3.4 3.0 3.0 2.9 65

60

55

50 Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Information and Communication Technology Centre, Office of the Permanent Secretary, Ministry of Commerce, in cooperation with the Customs Department. Notes: Chemicals for agricultural use mean fertilizers and pesticides. Chemicals for industrial use mean inorganic and organic chemical products as well as other chemical products.

78 5.3.6 Pollution from Hazardous Wastes The amount of hazardous wastes in Thailand increased from 0.9 million tons in 1990 to 3.15 million tons in 2009; of this amount, 2.45 million tons (77.8%) were released from the industrial sector and 0.7 million tons (22.2%) from residential communities. The amount of such industrial wastes is on the rise, whereas the capacity for efficient treatment of such wastes according to the sanitation principles has not been in place. In 2009, only 75% of hazardous wastes were for properly disposed of, resulting in large amounts of such wastes being illegally dumped into the environment with detrimental effects to the public health. 5.4 Environmental Sanitation 5.4.1 Housing Sanitation The number of Thailandûs slum communities has risen from 1,587 in 1994 to 1,802 in 1997 and 2,453 in 2008, an increase of 13.5% and 36.1%, respectively. In 2008, there were 270,764 slum households, of which 44.8% (1,098 slums) were located in Bangkok, 18.9% (463 slums) in Bangkokûs vicinity, and 36.3% (892 slums) in provincial areas. The number of low-income communities in all has increased in Bangkok and its vicinity (Housing Information Division, National Housing Authority). Regarding rural households, according to the 2008 survey on basic minimum needs (BMN), more households have had a better environmental condition. The number of durable households has risen from 90.6% in 1993 to 98.9% in 2008. The number of households with hygienic conditions has risen from 69.4% in 1992 to 98.0% in 2008. The rapid increase in the number of slums has resulted in health-related environmental problems such as a lack of safe drinking water. Coupled with unhygienic behaviours, the incidence of diarrhoeal disease has been rising over the past 20 years, particularly among children under 5 years of age, from 3,031.3 per 100,000 population in 1984 to 10,000 per 100,000 population in 2009. 5.4.2 Safety in the Workplaces In 2009, 38.3 million Thais or 60.4% of the nationûs population were in the workforce and employed, including 14.0 million (36.6%) in the formal sector and 24.3 million (63.4%) in the non-formal sector. In the formal sector, most of the workers in business workplaces were employees with only elementary schooling. So they could not protect or take care of themselves from occupational illnesses. The occupational injuries had a tendency to rise from 2% 1976 to 4.7% in 1993; the rate remained steady in the period after 1994 and then dropped to only 1.7% in 2009. But the number of deaths due to occupational injuries (per 100,000 workers) dropped steadily from 44.9 in 1979 to 11.19 in 2003, but rose to 17.55 in 2005 and dropped to 6.83 in 2009 (Figure 4.26). The rate is considered to be very high, compared with those in developed/industrialized countries such as England with the rate of 1.3 per 100,000 workers and Finland with 4 per 100,000 workers (Chuchai Supawongse, Environmental Situation and Impact on Health in Thailand, 1996).

79 Figure 4.26 Rates of occupational deaths and injuries in the workplaces, 1974-2009

Death rate Injuriy rate Economic crisis 50 4.7 5 44.9 4.5 4.4 4.4 4.5

39.4 39.4 4.4 3.9 Injury rate per 100,000 workers 40 3.7 3.8 3.7 3.8 3.9 3.8 4

35.4 3.4 3.5 35 3.5 3.4 3.3 3.2 3.6 3.2 3.4 3.2 29.2 2.9 3.0 30 33.8 2.7 3 2.7 31.7 2.6 31.2 3.0 24.5 2.4

28.9 22.5 2.3

20.3 2.0

25.6

19.2

24.2

17.73

17.55

20 2.0 16.97 2

21.1

14.47 20.9 1.7

11.45

11.19 1.2 1.3 11.0

11.04

10.31

9.94

9.46

Death rate per 100,000 workers

8.44

10 6.98 1 6.83 0 0 Year

1974 1977

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007 2009

Source: Ministry of Labour.

For non-formal labour force, most of the workers are in the agricultural sector, self-employed, home-based workers, etc., who are not taken care of by the government as expected. Among home-based workers, the problems of unsafe working conditions increased from 8.8% in 2006 to 10.7% in 2009 and the incidence of environmental problems in the workplaces also increased from 12.9% in 2007 to 14.0% in 2009. Most of the unsafe conditions in the workplaces are chemical poisoning and hazardous machinery, while the problems of environmental conditions are mostly related to the working positions or ergonomics and inad- equate lighting (Reports on non-formal workers surveys, 2006, 2007 and 2009, National Statistical Office). Thus, although at present the government has expanded the universal health-care scheme to about 95% of the population, efforts should be rapidly made to ensure that the uncovered sector of the population has access to the state health services.

80 5.4.3 Food and Water Supply 1) Food Safety At present, peopleûs food consumption culture has shifted from eating home-cooked food to eating out and eating pre-cooked or semi-cooked or ready-to-eat food. Cooking food rapidly in large quantities may involve unhygienic practices and unsanitary conditions of food establishments. A survey on a sample of 4,344 pre-cooked/bagged foods at food-stalls and supermarkets revealed that as high as 35.0% of such foods had bacterial contamination and did not meet the food standards despite the efforts of MoPH and local agencies to improve such places according to the food establishment standards. The 2009 study on the situation of food establishments revealed that only 85.3% (121,963 out of 143,042) of the establishments met the çClean Food Good Tasteé criteria, and 77.4% (1,189 out of 1,536) of fresh markets met the healthy market standards. Besides, it has been found that more chemicals are used in cooking, some chemicals are without proper technical information and some are toxic chemicals as evidenced in the toxic chemical residues being found in some fresh vegetables and fruits and fresh food over the permissible levels. The 2003›2009 food safety project report revealed that before the implementation of the project a lot of chemical residues were found in the food, but after the campaign against the use of six chemicals in food, it was found that, among fresh food, the contamination levels have decreased. However, high levels are detected for meat- reddening substance and insecticides, especially in meats and agricultural products (Table 4.20). Table 4.20 Chemical contamination of fresh foods in fresh markets nationwide under the Food Safety Project, 2003›2009

Before project Project launch (2003) 2004 2009 implementation Food samples Food samples Food samples Chemical Food samples substance Contaminated Contaminated Contaminated Tested Contami- Tested No. % Tested No. % Tested No. % nated % 1. Meat-reddening 2,132 96.0 1,111 115 10.4 2,997 65 2.2 1,356 42 3.1 2. Bleaching agent 3,256 10.0 4,812 83 1.7 14,338 2 0.01 14,246 19 0.1 3. Fungicides 2,099 7.2 4,315 206 4.8 15,378 88 0.6 15,695 73 0.5 4. Borax 3,184 42.0 6,695 46 0.7 31,287 160 0.5 24,995 135 0.5 5. Formalin 2,471 10.0 3,800 46 1.2 13,743 206 1.5 9,974 232 2.3 6. Insecticides 2,268 20.3 8,437 508 6.0 82,049 2,580 3.1 54,140 1,760 3.2 Source: Food and Drug Administration, MoPH. However, despite the MoPHûs stringent monitoring and control measures, the problems of chemi- cal residues are still widespread even in fruits for domestic consumption and for export, 6.9% to 17.2% were found to be contaminated, with residues higher than the permissible levels (Table 4.21).

81 Table 4.21 Monitoring of chemical safety in fresh vegetables and fruits, 2007›2009

No. of Results Agency Type of food Chemical tested for samples exceeding Year of study tested MPL (%) responsible 1) General foods: Pesticides 1,521 9.4 DMSc 2007›2009 vegetables, fruits and meat products 2) Vegetables and Pesticides 295 6.9 DOA 2007›2009 fruits: 6 kinds for local consumption 3) Vegetables and Pesticides 49,150 17.2 DOA 2007›2009 fruits: 12 kinds for export Sources:- Food Quality and Safety Bureau, DMSc, MoPH. - Department of Agriculture (DOA), Ministry of Agriculture and Cooperatives. Notes: MPL = maximum permissible level

Such situation has a negative impact on consumerûs health due to consuming unsafe or unhygienic food resulting in a rising incidence of food poisoning from 4.35 per 100,000 population in 1976 to 162.98 per 100,000 population in 2009. With a high level of accumulated toxic chemicals in the body, there will be an increased risk of cancer, mutation and infant deformity.

2) Water Supply Safety Based on the Survey of Water Supply Situations of Thai People during 1986-2000, most Thais preferred rainwater for drinking, followed by artesian-well water and tap water. And in 2005, a similar preference was also found for rainwater but followed by bottled water, which will play a more dominant role in the future, and tap water. Almost half of urban residents preferred bottled water, followed by tap water, whereas half of rural residents preferred rainwater, followed by bottled water (Table 4.22).

82 Table 4.22 Percentage of drinking water sources of Thai people by residential area, 1986-2009 Source of 1986 2000 2005 2007 2008 2009 drinking Whole Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total water* country Bottled water NA 40.6 9.2 19.5 48.8 20.0 29.0 48.6 19.4 28.7 46.6 22.3 30.1 47.0 23.9 31.6 Tap water 15.8 36.4 16.8 23.2 36.0 15.3 21.7 25.1 36.7 15.6 39.1 15.0 22.7 39.9 15.9 23.9 Rainwater 39.2 16.1 51.0 39.6 10.7 49.6 37.4 10.5 49.3 37.0 10.3 48.7 36.4 9.5 47.0 34.6 Artesian wells / private wells 26.2 6.7 21.9 16.9 3.7 14.2 11.0 3.9 14.2 11.0 3.3 13.0 9.9 2.2 8.7 9.3 Artesian wells /} public wells Natural water 19.0 0.2 1.1 0.8 0.1 0.4 0.2 0.1 0.8 0.6 0 0.6 0.4 0 0.4 0.3 sources Sources:1.Data for 1986 were derived from Reports on the 3rd National Nutrition Survey. Department of Health, MoPH. 2. Data for 2000 were derived from the Population and Household Census. National Statistical Office. 3. Data for 2005 were derived from the report on Population Change Survey, 2005›2006. National Statistical Office. 4. Data for 2007›2009 were derived from the Survey on Economic and Social Conditions of House- holds, National Statistical Office. Note:*More than one answer can be made. With regard to the quality of drinking water in Thailand, the surveys conducted by the Depart- ment of Health, MoPH, during 1995›2009, revealed that most water samples of rainwater, deep/shallow well water, and tap water did not meet the drinking water standards, except for those of the Metropolitan Water- works Authority, about 70% of which met the standards. This is mainly because of contamination with bacteria and chemicals such as cadmium, iron, lead and manganese, including unacceptable physical quality, i.e. turbid- ity and colour levels being higher than maximum allowable standards (Table 4.23). Regarding the quality of bottled water, according to a survey conducted by the Food and Drug Administration and some Provincial Public Health Offices during 1995›2009, 72.4% of the water samples tested met the drinking water standards; no differences in terms of contamination were found among the water with and without FDA-licence logo. It was also found that only 59.4% of ice-cube samples tested met the standards (Table 4.23). Besides, the report on domestic water quality surveillance of the Department of Health on water at households and çdiamondé health›promoting schools in 2008›2009 revealed that as high as 14% to 22.4% of household water samples and 31.4% to 52.3% of school water samples did not meet the drinking water standards (Table 4.24). With this kind of problem, the people who use such unsafe/substandard water will be at high risk of gastrointestinal diseases such as diarrhoea, dysentery, etc.

83 meeting

Samples

standard

tested

Samples

meeting

Samples

standard

}}

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

meeting

Samples

standard

tested

Samples

(10.1) (12.6) (40.8) (43.2) (26.9)

meeting

Samples

standard

68 10 68 - 51 18 161 89 900 442 570 504 203 171 - - (51.6) (33.5)

tested

Samples

(84.4) (74.7) (68.6) (86.4)

(73.6) (50.4) (48.5) (89.1) (55.3) (76.7) 213 110 161 54

(37.5) (14.7) (35.3) (55.3) (49.1) (88.4) (84.2)

(51.2) (27.5) (46.8) (44.3) (35.3)

(48.8) (23.7) (23.2) (28.1) (40.4) (35.5) (85.9) (57.7) (20.9) (24.1) (13.1)

(41.5) (86.1) (4.2) (24.0) (40.4) (36.4) (28.7) (35.4) (19.8) (5.0) (34.9) (30.0) (27.5)

(28.1) (71.4) (90.9) (50.6) (51.9) (48.4) (52.2) (62.3) (68.4) (73.2) (74.4)

(66.2) (70.3) (88.0) (70.4) (61.8) (76.3) (67.1) (70.8) (90.1) (89.0) (86.2)

meeting

Samples

standard

1995 1996 1997 1998 1999 2000 2001 2003 2007 2008 2009

83

45 38 27 NA 75 56 118 81 81 70 ------

43 22 327 90 496 232 370 164 51 18 ------

65 27 438 377 355 15 258 62 277 112 280 102 - - 174 50 ------65 23 495 98 121 6 298 104 90 27 69 19 ------

32 9 42 30 187 170 401 203 335 174 285 138 299 156 273 170 155 106 157 115 164 122

NA NA 365 37 222 28 191 78 125 54 26 7 ------

129 95 547 276 1,470 713 1,568 1,397 532 294 120 92 - -

209 102 1,683 399 465 108 3,925 1,103 5,041 2,039 4,246 1,507 2,673 2,297 1,318 760 110 23 162 39 221 29

tested

1,462 968 407 286 3,225 2,837 4,496 3,167 3,766 2,329 1.033 788 3,551 2,383 2,996 2,121 232 209 218 194 420 362

Samples

Department of Health, MoPH.

Quality of water for domestic use in Thailand, 1995-2009

.

2. Food Control Division, FDA, MoPH The figures in ( ) are percentages. MWA=Metropolitan Waterworks Authority; PWA = Provincial Waterworks Authority.

:1

Water type

:

Tap water, MWA

Tap water, PWA Tap water, municipality waterworks Tap water sanitary district waterworks Tap water, village waterworks Shallow-well water Artesian-well water

Rainwater

Bottled water Ice cubes

Table 4.23

Source Note

84 Table 4.24 Monitoring of Quality of water for domestic use in urban and rural households and çdiamondé health promoting schools, 2008-2009

Water samples, 2008 Water samples, 2009 Type of water No. Met stsndards(%) No. Met stsndards(%) 1. Water for domestic use in 383 86 264 37 urban and rural households (22.4) (14.0) 2. Water for use atçdiamondé 360 113 132 69 health-promoting schools (31.4) (52.3)

Source: Department of Health, MoPH. Note: çDiamondé health-promoting school means a health-promoting school at the best level as measured by the health outcome and health behaviours of students.

5.4.4 Solid Waste and Sewage In 2009, there were an estimated 15.11 million tons of solid wastes nationwide, of which about 3.22 million tons (21.3%) were generated in Bangkok, 5.97 million tons (39.5%) in municipal areas, and 5.92 million tons (39.2%) in non-municipal/sanitary district areas. Between 1992 and 2009, the total amount of solid wastes increased on average by 2.0% each year, mostly in Bangkok and municipalities nationwide (Table 4.25). In general, solid waste disposal capacity is still limited; the Bangkok Metropolitan Administration (BMA) is able to collect almost all of its solid wastes, but municipalities and non-municipal areas can collect only half of their wastes. Such conditions have an impact on the quality of life of provincial residents as they are offended by the putrid smell of such wastes; and a lot of such residents have health problems.

85 Table 4.25 Amount of solid wastes, 1992-2009

Bangkok Municipal areas Sanitary districts Outside municipal/ Total Area including Pattaya City sanitary district areas Amount Change Amount Change Amount Change Amount Change Amount Change (million (percent) (million (percent) (million (percent) (million (percent) (million (percent) Year tons) tons) tons) tons) tons)

1992 2.19 - 1.16 - 1.62 - 5.81 - 10.78 - 1993 2.57 + 17.3 1.25 + 7.7 1.51 - 6.8 5.85 + 0.7 11.18 + 3.7 1994 2.56 - 0.4 2.05 + 64.0 1.53 + 1.3 5.91 + 1.0 12.05 + 7.8 1995 2.63 + 2.7 2.30 + 12.2 1.69 + 10.5 5.96 + 0.8 12.58 + 4.4 1996 2.95 + 12.2 2.43 + 5.6 1.78 + 5.3 5.97 + 0.2 13.13 + 4.4 1997 3.26 + 10.5 3.0 + 23.4 1.75 - 1.7 5.5 - 7.9 13.51 + 2.9 1998 3.10 - 4.9 2.71 - 9.7 1.74 - 0.6 6.04 + 9.8 13.59 + 0.6 1999 3.28 + 5.8 4.50 + 66.0 - - 6.04 - 13.82 + 1.7 2000 3.33 + 1.5 4.3 - 4.44 - - 6.3 + 4.3 13.93 + 0.8 2001 3.40 +2.1 4.34 +0.9 - - 6.36 +1.0 14.10 +1.2 2002 3.51 +3.2 4.37 +0.7 - - 6.43 +1.1 14.31 +1.5 2003 3.41 -2.8 4.42 +1.1 - - 6.50 +1.1 14.33 +0.1 2004 3.41 - 4.56 +3.2 - - 6.60 +1.5 14.57 +1.7 2005 3.04 -10.8 4.61 +1.1 - - 6.67 +1.1 14.32 -1.7 2006 3.06 +0.6 4.71 +2.2 - - 6.82 +2.2 14.59 +1.9 2007 3.11 +1.6 4.97 +5.5 - - 6.64 -2.6 14.72 +0.9 2008 3.20 +2.9 5.44 +9.4 - - 6.34 -4.5 14.98 +1.8 2009 3.22 +0.6 5.97 +9.7 - - 5.92 -6.6 15.11 +0.8

Source: Waste & Hazardous Substance Management Bureau, Pollution Control Department. Note: In 1999, all sanitary districts were upgraded as municipalities; since then only the figures for municipal areas appear. Regarding human waste or night soil from urban households, problems are found to be related to its unsanitary transportation and disposal. In 2009, 99.4% of rural households had sanitary latrines as shown in Figure 4.27. As the peopleûs lifestyles have changed, mostly going to work outside the home, the use of public toilets has become very important. According to the public toilet survey in Thailand in 2006›2009 in 11 target premises, less than half of the public toilets in such places did not met the standards (Table 4.26). Most of the problems found were related to the lack of cleanliness and safety. Regarding the toilet use behaviours only 47.1% had correct behaviours (Table 4.27).

86 Figure 4.27 Percentage of households with sanitary latrines, 1960-2009

Percentage 120

99.4

99.1

98.27 98.11

98.18

98.05

96.92

96.14 100 96.2

80 73.84 60

47.11

42.79

40 33.87

20 20.09

5.67 0 0.7 Year

1960 1965

1970

1975

1980

1985

1990

1995 1996 1997 1998 1999 2000

2005

2009

Sources:1.1960›2000 from the Department of Health, MoPH. 2. 2001 from the Provincial Health Status Survey, 2001. Bureau of Policy and Strategy, MoPH. 3. 2005 from the Report on Population Characteristics from the Population Change Survey, 2005- 2006. Bureau of Policy and Strategy, MoPH. 4. 2009 from the Survey on Householdsû Economic and Social Conditions, National Statistical Office.

Table 4.26 Public toilets survey in Thailand: Proportion of public toilets meeting the standards,2006›2009 Toilets meeting the standards (%) Target premises 2006 2007 2008 2009 (N = 6,149) (N =64,328 ) (N = 51,025 ) (N = 38,909) Religious places 20.6 9.36 6.91 11.75 Public parks 0.6 24.79 40.26 60.06 Petrol stations 12.8 21.75 32.33 44.07 Fresh markets 3.1 25.54 39.90 48.6 Bus terminals 0.5 14.16 44.21 41.4 Government offices 4.0 21.91 39.07 47.28 Hospitals 3.2 48.91 65.73 83.11 Schools 24.4 15.29 38.38 48.6 Tourist sites 2.4 21.88 51.34 62.91 Restaurants 28.3 22.68 26.24 36.15 Roadside toilets 0 12.35 46.81 67.02 Average 9.08 20.16 30.85 40.37 Source: Bureau of Environmental Health, Department of Health, MoPH.

87 Table 4.27 Latrine use behaviours of Thai people, 2006

Description Correct use (percent) Incorrect use (percent) 1. Flushing the toilet 94.9 5.1 2. Disposal of toilet paper 78.3 21.7 3. Handwashing 47.1 52.9 4. Sitting on the toilet 83.0 17.0 Correct behaviours in 4 aspects 47.1 52.9 Source: Department of Health, MoPH. 6. Political and Administrative Situations and Trends 6.1 Political System Even though the Constitution of the Kingdom of Thailand, B.E. 2550 (2007) has been in force since late 2007, the results of the general elections cannot resolve the political conflicts as certain groups of people in society have different opinions on the governmentûs righteousness in the administration of the country. This actually caused the widespread of political conflicts and social divide in 2008›2009 in all regions of the country even at the family and community levels. Despite the governmentûs effort to create national reconciliation, the problem has not been resolved, resulting in Thailandûs image of political stability dropping from a score of 59.1 in 2002 to 12.9 in 2008, from the 4th rank among ASEAN countries to the 8th rank for the period (Table 4.28). This is because there have been cases of human rights violation and the use of forces in ending the problem rather than using a peaceful method under the democratic system. Table 4.28 Political stability scores of ASEAN countries, 2002›2008

Country 2002 2003 2004 2005 2006 2007 2008 Rank Score Rank Score Rank Score Rank Score Rank Score Rank Score Rank Score Brunei 2 63.2 1 87.0 1 95.7 1 90.9 2 93.3 1 92.8 2 93.3 Singapore 1 95.7 2 84.6 2 89.9 2 89.4 1 94.2 2 91.8 1 96.2 Vietnam 5 57.2 4 52.4 4 55.3 4 59.1 3 60.6 3 56.3 3 56.5 Malaysia 3 60.1 3 56.7 3 57.2 3 62.5 4 56.7 4 52.4 4 50.2 Laos 6 36.1 7 17.8 7 27.4 5 37.0 5 46.2 5 40.4 5 43.5 Cambodia 8 24.5 6 25.0 6 30.3 6 30.8 6 31.3 6 26.9 6 34.4 Thailand 4 59.1 5 47.1 5 31.7 7 28.4 8 19.7 7 17.3 8 12.9 Indonesia 10 8.7 10 3.8 10 7.2 10 12.0 9 13.5 8 15.9 7 15.8 Myanmar 9 13.0 9 13.0 8 18.8 8 20.2 7 21.6 9 13.0 10 9.1 Philippines 7 26.0 8 14.4 9 12.5 9 17.8 10 12.0 10 11.5 9 10.5 Source: Worldwide Governance Indicators for 1996-2008.

88 Table 4.27 Latrine use behaviours of Thai people, 2006

Description Correct use (percent) Incorrect use (percent) 1. Flushing the toilet 94.9 5.1 2. Disposal of toilet paper 78.3 21.7 3. Handwashing 47.1 52.9 4. Sitting on the toilet 83.0 17.0 Correct behaviours in 4 aspects 47.1 52.9 Source: Department of Health, MoPH. 6. Political and Administrative Situations and Trends 6.1 Political System Even though the Constitution of the Kingdom of Thailand, B.E. 2550 (2007) has been in force since late 2007, the results of the general elections cannot resolve the political conflicts as certain groups of people in society have different opinions on the governmentûs righteousness in the administration of the country. This actually caused the widespread of political conflicts and social divide in 2008›2009 in all regions of the country even at the family and community levels. Despite the governmentûs effort to create national reconciliation, the problem has not been resolved, resulting in Thailandûs image of political stability dropping from a score of 59.1 in 2002 to 12.9 in 2008, from the 4th rank among ASEAN countries to the 8th rank for the period (Table 4.28). This is because there have been cases of human rights violation and the use of forces in ending the problem rather than using a peaceful method under the democratic system. Table 4.28 Political stability scores of ASEAN countries, 2002›2008

Country 2002 2003 2004 2005 2006 2007 2008 Rank Score Rank Score Rank Score Rank Score Rank Score Rank Score Rank Score Brunei 2 63.2 1 87.0 1 95.7 1 90.9 2 93.3 1 92.8 2 93.3 Singapore 1 95.7 2 84.6 2 89.9 2 89.4 1 94.2 2 91.8 1 96.2 Vietnam 5 57.2 4 52.4 4 55.3 4 59.1 3 60.6 3 56.3 3 56.5 Malaysia 3 60.1 3 56.7 3 57.2 3 62.5 4 56.7 4 52.4 4 50.2 Laos 6 36.1 7 17.8 7 27.4 5 37.0 5 46.2 5 40.4 5 43.5 Cambodia 8 24.5 6 25.0 6 30.3 6 30.8 6 31.3 6 26.9 6 34.4 Thailand 4 59.1 5 47.1 5 31.7 7 28.4 8 19.7 7 17.3 8 12.9 Indonesia 10 8.7 10 3.8 10 7.2 10 12.0 9 13.5 8 15.9 7 15.8 Myanmar 9 13.0 9 13.0 8 18.8 8 20.2 7 21.6 9 13.0 10 9.1 Philippines 7 26.0 8 14.4 9 12.5 9 17.8 10 12.0 10 11.5 9 10.5 Source: Worldwide Governance Indicators for 1996-2008.

88 Such changes have an impact on the national administration resulting in the lowliness in implementing different policies, the loss of opportunity for economic development, and the decline in peopleûs quality of life and livelihood in society with higher levels of stress and suspicion causing decreased happiness and poor physical and mental health of Thai people.

Table 4.29 Gross Domestic Happiness (GDH) index of Thai people in various aspects, December 2009 › January 2010

Average GDH index Order Group of factors Dec 2009 Jan 2010 1 Relationship of family members 8.96 8.01 2 Physical health 7.72 7.61 3 Mental health 7.96 7.58 4 Occupation and responsibility 7.58 7.15 5 Current Thai culture and tradition 6.91 6.99 6 Environment, roads, electricity, soil, air and water 7.03 6.92 7 Access to medical care 7.53 6.78 8 Relationship of community numbers 7.58 6.67 9 Familiesû economic and social conditions 7.09 5.87 10 Social justice and injustice received 7.07 5.19 11 Overall political situation 5.58 4.06 Thaisû GDH for Dec. 2009 and Jan. 2011 7.26 6.52

Source: GDH for Thai people in Jan 2010, Community Happiness Centre, 2010 Note: Full score is 10.

89 6.2 Public Administration System 6.2.1 Public Sector Development It has been found that the personnel cost in the public sector has been rising resulting in very little budget remaining for national development and the civil service system being incapable of responding to the needs of the people as well as being inefficient, slow, and corrupt. Such a situation led to the 2001 major public sector reform; the restructuring of ministries, sub-ministries and departments was under- taken so as to have good governance and a modern public sector administration system according to the Royal Decree on Criteria and Methods for Good Governance, B.E. 2546 (2003), which aims to enhance the capacity of the public sector. As a result, the capacity and performance of the civil service system has been found to be higher plan before; and 80.2% of the people are satisfied with the services provided by various state agencies. The details of development achievements in various sectors are shown in Table 4.30. Besides, many state agencies have successfully improved their services systems and received international recognition. For instance, the Revenue Department has received the eASIA Award for public sectorûs electronic transaction and Yasothon Hospital got into the final round of the United Nations Public Service Awards for 2008 of the U.N. Economic and Social Council (ECOSOC) and received a certificate of appreciation as an agency that provided public services in a professional manner.

Table 4.30 Achievements of public sector development Major goal Indicator Results of operation 1. Development of 1. Service recipients: 80% of the people, on average, are 80.25% public service quality satisfied with improved public services 2. Steps and time in providing services to the public 50.31% reduced by more than 50% on average by 2007 2. Adjustment of role, Role and mission mission and size as 1. No. of non-core functions is reduced by not less than 73% appropriate 80% by 2007 2. Not less than 90% of public agencies have implemented 100% çMeasure 3/1é of the State Administration Act (No.5) of 2002 or the 2003 Royal Decree on Good Governance 3. Not less than 100 laws that are unnecessary or More than 100 laws obstructing national development will be amended or deregulated by 2007 State budget - Maintain the proportion of state budget in relation to 17.80% GDP at not to exceed 18% on average for the period 2003-2007

90 Table 4.30 Achievements of public sector development

Major goal Indicator Results of operation Public sector workforce - Reduce the number of government officials by at least 9.72% 10% by 2007 and/or enhance the capacity of workforce at the same level 3. Enhancement of 1. Each agency has got at least one certificate for its Certified by all performance quality/standard by 2007, especially in reducing steps agencies competency and for service provision standards to the 2. At least 80% of state officials have their competencies 80% international levels enhanced as per specified criteria on average by 2007 3. At least 90% of state agencies have their service Operational in systems improved or operational using the all agencies e-government system by 2007 4. Response to public 1. On average 80% of the people have confidence and 80% administration in the faith in the transparency and fairness in the public democratic system administration (especially regarding public services) by 2007 2. At least 80% of state agencies have measures or Operational in activities that are open to public participation by 2007 all agencies 3. The number of conflicts or complaints between the Not less than 81% administration and the people does not increase by of both parties more than 20% each year on average for the period 2003-2007 (emphasizing the readiness of both parties to jointly resolve the conflict)

Source: Strategic Plan for Thai Public Sector Development (2008›2012), Office of the Public Sector Development Commission.

The transform of the public administration system according to the modern administration principles has caused all state health facilities to accelerate the improvement of public service quality in a more efficient manner.

91 6.2.2 Efficiency of the Public Administration System in the Thai Business Sector Develop- ment: A Comparison with Other Countries Low efficiency in the public sector results in a higher operating cost in the private sector. A study conducted by Saowanee Thairungroj and colleagues revealed that business operators had to spend a lot of time when dealing with public agencies. On average they spent 14% of their time each year, small-size businesses10 spending more than medium- and large-scale businesses.10 For this reason, they had to pay bribes to state officials to expedite transactions, resulting in a higher cost in business operations. However, after the 2001 public sector reform, the situation is getting better; a study on international competition conducted by the International Institute for Management Development (IMD) for the period 2000-2006 revealed that the efficiency score of the Thai public sector in the development of the business sector increased from 2.86 in 2000 to more than 3.5 in 2006 or from rank 31st in 2000 to rank 21st in 2006, during the administration of an elected government under the 1997 constitution, and after the 2006 military coup the score dropped slightly to 2.90 or rank 20th in 2009 (Figure 4.28). Nevertheless, the efficiency level in Thailand is lower than those in developed countries or certain ASEAN countries, i.e. Singapore and Malaysia (Table 4.31). Figure 4.28 Ability and ranking of Thai public sectorûs competitiveness for business sector development, 1997›2009 Score 4.5 4 3.93 3.86 3.64 3.5 3.49 3.14 3.11 3 2.91 2.86 2.90 2.58 2.5 2 1.5 1 0.5 0 Year 1997 1999 2000 2002 2004 2005 2006 2007 2008 2009

1997 1999 2000 2002 2004 2005 2006 2007 2008 2009 Rank of the Thai public 28 24 31 24 19 16 21 34 21 20 sectorûs competitiveness for business sector development Source: IMD. The World Competitiveness Yearbook, 1997-2009. 10 Saowanee Thairungroj et al. The Business Environment and Attitudes of Busines Operators towards Public Sector Services. Faculty of Economicis, University of the Thai Chamber of Commerce, 1999.

92 Score

rank

2009

in-group

rank

Actual

Country

Group and

Score

2004

rank

in-group

rank

Actual

Country

Group and

Score

rank

2002

in-group

rank

Actual

Country

Group and

Score

rank

1999

in-group

rank

Actual

Country

Group and

Score

rank

1997

in-group

rank

Actual

Efficiency of the state service system in the business sector development in various countries, 1997-2009

IMD. The World Competitiveness Yearbook, 1997-2009

:

Country

Group and

ASEAN ASEAN ASEAN ASEAN ASEAN Singapore 1 1 6.88 Singapore 1 1 7.45 Singapore 1 1 7.46 Singapore 4 1 5.95 Singapore 2 1 5.83 Malaysia 15 2 4.69 Malaysia 16 2 4.20 Malaysia 13 2 4.59 Malaysia 10 2 4.82 Malaysia 15 3 3.37 Thailand 28 4 2.91 Thailand 24 3 3.14 Thailand 24 3 3.49 Thailand 19 3 3.93 Thailand 20 2 2.90 Philippines 27 3 2.96 Philippines 34 4 2.32 Philippines 41 5 2.00 Philippines 49 4 1.86 Philippines 46 4 1.30 Indonesia 32 5 2.67 Indonesia 39 5 1.80 Indonesia 32 4 2.83 Indonesia 56 5 1.50 Indonesia 34 5 2.09 Brunei - - - Brunei - - - Brunei - - - Brunei - - - Brunei - - - Vietnam - - - Vietnam - - - Vietnam - - - Vietnam - - - Vietnam - - - Myanmar - - - Myanmar - - - Myanmar - - - Myanmar - - - Myanmar - - - Cambodia - - - Cambodia - - - Cambodia - - - Cambodia - - - Cambodia - - - Laos - - - Laos - - - Laos - - - Laos - - - Laos - - - World World World World World (top ten) (top ten) (top ten) (top ten) (top ten) Singapore 1 1 6.88 Singapore 1 1 7.45 Singapore 1 1 7.46 Denmark 1 1 6.41 Denmark 1 1 6.12 Hong Kong 2 2 6.63 Finland 2 2 7.03 Finland 2 2 6.83 Iceland 2 2 6.40 Singapore 2 2 5.83 Finland 3 3 6.49 Hong Kong 3 3 6.28 Iceland 3 3 6.09 Finland 3 3 6.09 Finland 3 3 5.83 Denmark 4 4 6.09 Denmark 4 4 5.87 Luxembourg 4 4 5.95 Singapore 4 4 5.95 Hong Kong 4 4 5.17 New Zealand 5 5 6.08 Switzerland 5 5 5.54 Denmark 5 5 5.77 Hong Kong 5 5 5.45 Sweden 5 5 5.05 Iceland 6 6 5.89 Luxembourg 6 6 5.33 Switzerland 6 6 5.71 Australia 6 6 5.11 Switzerland 6 6 4.77 Ireland 7 7 5.80 Iceland 7 7 5.19 Sweden 7 7 5.70 Canada 7 7 4.89 Australia 7 7 4.65 Norway 8 8 5.67 Ireland 8 8 5.16 Ireland 8 8 5.32 Sweden 8 8 4.85 Norway 8 8 4.4 Netherlands 9 9 5.41 Netherlands 9 9 4.98 Hong Kong 9 9 5.21 Estonia 9 9 4.84 Ireland 9 9 4.36 Switzerland 10 10 5.38 Australia 10 10 4.97 Netherlands 10 10 5.06 Malaysia 10 10 4.82 Canada 10 10 4.09

Table 4.31

Source

93 6.2.3 Transparency and Corruption in Public Sector Agencies As the government has monopolized public services, it is hard to examine such systems, resulting in wastages. Most state officials have low salaries with a lot of debts and thus they tend to commit malpractice that leads to illegally taking kickbacks, which is a problem of transparency and corruption in the public service system. The inspection systems of the State Audit Office and the National Anti-Corruption Commission are not strong enough to cope with such problems. Surveys conducted by the Transparency International in 1980›2005 revealed that Thailand is getting better in terms of transparency and corruption, its corruption perceptions index has risen from 2.42 during the period 1980›1985 to 3.8 in 2005, but dropped to 3.4 in 2009, ranking 84th among 180 countries under survey (Figure 4.29). Such a ranking was, however, rather low in terms of transparency, with a high level of corruption, compared with developed countries and certain ASEAN countries, i.e. Singapore and Malaysia (Table 4.32).

Figure 4.29 Corruption perceptions index, Thailand, 1980-2009

Index 4 3.8 3.6 3.5 3.4 3.5 3.33 3.2 3.2 3.2 3.2 3.3 3.3 3.3 3.06 3.0 3 2.79 2.5 2.42 2 1.85 1.5 1 0.5 0 Year

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

1980-1985 1988-1992

Source: Transparency International, 1998-2009.

94 Score

In-

rank

2009

group

rank

Actual

s range from 1 to 10, ç0é

country

Group and

Score

In-

rank

2006

group

rank

Actual

country

Group and

Score

In-

rank

2004

group

rank

Actual

country

Group and

Score

In-

rank

2002

group

10 10 8.7 Netherlands 10 10 8.7 Netherlands 10 10 8.7 Iceland 8 8 8.7

rank

Actual

country

United Kingdom

Group and

Score

In-

rank

2000

group

10 10 8.7

rank

Actual

country

Group and

United Kingdom

Score

In-

rank

1998

group

Corruption Perceptions Index is computed based on the perceptions of businesses, risk analysts and the general public; score meaning highly corrupt and ç10é meaning çvery cleané.

rank

.

Actual

Corruption perceptions index in various countries, 1998›2009

2. At least three surveys were used to calculate each countryûs CPI.

: Transparency International and Dr. Johann Graf Lambsdarff Gottingen University, Germany, 1998-2009

:1

country

ASEAN ASEAN ASEAN ASEAN ASEAN Singapore 7 1 9.1 Singapore 6 1 9.1 Singapore 5 1 9.3 Singapore 5 1 9.3 Singapore 5 1 9.4 Singapore 3 1 9.2 Malaysia 29 2 5.3 Malaysia 36 2 4.8 Malaysia 33 2 4.9 Malaysia 39 2 5.0 Malaysia 44 2 5.0 Malaysia 56 2 4.5 Thailand 61 4 3.0 Thailand 60 3 3.2 Thailand 64 3 3.2 Thailand 64 3 3.3 Thailand 65 3 3.6 Thailand 84 3 3.4 Philippines 55 3 3.3 Philippines 69 4 2.8 Philippines 77 4 2.6 Philippines 102 4 2.6 Philippines 126 5 2.5 Philippines 139 6 2.4 Indonesia 80 6 2.0 Indonesia 85 6 1.7 Indonesia 96 6 1.9 Indonesia 133 6 2.0 Indonesia 134 6 2.4 Indonesia 111 4 2.8 Brunei - - - Brunei - - - Brunei - - - Brunei - - - Brunei - - - Brunei - - - Vietnam 74 5 2.5 Vietnam 76 5 2.5 Vietnam 85 5 2.4 Vietnam 102 4 2.6 Vietnam 118 5 2.6 Vietnam 120 5 2.7

Group and

Source Notes

Myanmar - - - Myanmar - - - Myanmar - - - Myanmar 142 7 1.7 Myanmar 162 8 1.9 Myanmar 178 8 1.4 Cambodia - - - Cambodia - - - Cambodia - - - Cambodia - - - Cambodia 152 7 2.1 Cambodia 158 7 2.0 Laos - - - Laos - - - Laos - - - Laos - - - Laos 114 4 2.6 Laos - - - World World World World World World (top ten) (top ten) (top ten) (top ten) (top ten) (top ten) Denmark 1 1 10.0 Finland 1 1 10.0 Finland 1 1 9.7 Finland 1 1 9.7 Finland 1 1 9.6 New Zealand 1 1 9.4 Finland 2 2 9.6 Denmark 2 2 9.8 Denmark 2 2 9.5 New Zealand 2 2 9.6 Iceland 2 2 9.6 Denmark 2 2 9.3 Sweden 3 3 9.5 New Zealand 3 3 9.4 New Zealand 2 2 9.5 Denmark 3 3 9.5 New Zealand 3 3 9.6 Singapore 3 3 9.2 New Zealand 4 4 9.4 Sweden 3 3 9.4 Iceland 4 4 9.4 Iceland 3 3 9.5 Denmark 4 4 9.5 Sweden 3 3 9.2 Iceland 5 5 9.3 Canada 5 5 9.2 Singapore 5 5 9.3 Singapore 5 5 9.3 Singapore 5 5 9.4 Switzerland 5 5 9.0 Canada 6 6 9.2 Iceland 6 6 9.1 Sweden 5 5 9.3 Sweden 6 6 9.2 Sweden 6 6 9.2 Finland 6 6 8.9 Singapore 7 7 9.1 Norway 6 6 9.1 Canada 7 7 9.0 Switzerland 7 7 9.1 Switzerland 7 7 9.1 Netherlands 6 6 8.9 Netherlands 8 8 9.0 Singapore 6 6 9.1 Luxembourg 7 7 9.0 Norway 8 8 8.9 Norway 8 8 8.8 Australia 8 8 8.7 Norway 8 8 9.0 Netherlands 9 9 8.9 Netherlands 7 7 9.0 Australia 9 9 8.8 Australia 9 9 8.7 Canada 8 8 8.7 Switzerland 10 10 8.9

Table 4.32

95 6.3 Decentralization According to the Planning and Steps of Decentralization to Local Administration Organiza- tions Act of B.E. 2542 (1999), only 180 out of 244 missions have been transferred to local government organizations (LGOs). Such missions are those related to the promotion of quality of life including education and public health. The transfer process is undertaken rather slowly as there are a number of practical problems such as voluntarism to transfer, unreadiness of personnel to transfer, the kinds of personnel to be transferred do not meet LGOûs needs, and the concept for supervising the public health system as a single one for the entire province, resulting in arguments against such a transfer. Regarding the financial decentralization, the LGOsû revenues have increased from 159 billion baht in 2001 to 414 billion baht in 2009, or the proportion of LGOsû revenue in relation to the government revenue has risen from 11.1% to 26.1% for the same period. 7. Situations and Trends of Technology 7.1 Technology Development Advances in technology have been rapidly made resulting in innovations being developed and having an impact on health development as modern technologies have been used freely in the treatment and prevention of diseases, namely: 7.1.1 Information and communication technology (ICT). For health programmes, ICT has been used for medical and health consultation including diagnosis and medical treatment with telemedicine and diagnostic imaging technology. 7.1.2 Genetics and biotechnology. Rapid developments have been made in this area such as digital-genomics convergence that integrates computer technology into biology. This might be a new dimen- sion of curative care, moving from treatment towards prevention: adding disease-prevention elements to food, soap or cosmetics, rather than taking medication orally for treatment of illness; organ transplantation (such as for bone marrow); stem-cell treatment for patients with heart disease and leukemia; using recombinant DNA, polymerase chain reaction (PCR) and genomics for producing a new vaccine and medicine; and farming of genetically modified plants. 7.1.3 Material technology. New materials have been produced in response to needs in a more efficient manner. In the field of public health, the technology has been used in producing medical materials and equipment such as artificial bones, legs and feet for more efficient medical care of patients which also helps improve their quality of life. 7.1.4 Nanotechnology. A more active role has been played by this kind of technology which is believed to be used in producing a molecular machine comprising atoms to be inserted into the human body for destroying cancerous cells or eliminating blood vessel-clogging lipids without surgery, or in producing a small particle for carrying medication to the diseased part of the body without affecting other parts.

96 6.3 Decentralization According to the Planning and Steps of Decentralization to Local Administration Organiza- tions Act of B.E. 2542 (1999), only 180 out of 244 missions have been transferred to local government organizations (LGOs). Such missions are those related to the promotion of quality of life including education and public health. The transfer process is undertaken rather slowly as there are a number of practical problems such as voluntarism to transfer, unreadiness of personnel to transfer, the kinds of personnel to be transferred do not meet LGOûs needs, and the concept for supervising the public health system as a single one for the entire province, resulting in arguments against such a transfer. Regarding the financial decentralization, the LGOsû revenues have increased from 159 billion baht in 2001 to 414 billion baht in 2009, or the proportion of LGOsû revenue in relation to the government revenue has risen from 11.1% to 26.1% for the same period. 7. Situations and Trends of Technology 7.1 Technology Development Advances in technology have been rapidly made resulting in innovations being developed and having an impact on health development as modern technologies have been used freely in the treatment and prevention of diseases, namely: 7.1.1 Information and communication technology (ICT). For health programmes, ICT has been used for medical and health consultation including diagnosis and medical treatment with telemedicine and diagnostic imaging technology. 7.1.2 Genetics and biotechnology. Rapid developments have been made in this area such as digital-genomics convergence that integrates computer technology into biology. This might be a new dimen- sion of curative care, moving from treatment towards prevention: adding disease-prevention elements to food, soap or cosmetics, rather than taking medication orally for treatment of illness; organ transplantation (such as for bone marrow); stem-cell treatment for patients with heart disease and leukemia; using recombinant DNA, polymerase chain reaction (PCR) and genomics for producing a new vaccine and medicine; and farming of genetically modified plants. 7.1.3 Material technology. New materials have been produced in response to needs in a more efficient manner. In the field of public health, the technology has been used in producing medical materials and equipment such as artificial bones, legs and feet for more efficient medical care of patients which also helps improve their quality of life. 7.1.4 Nanotechnology. A more active role has been played by this kind of technology which is believed to be used in producing a molecular machine comprising atoms to be inserted into the human body for destroying cancerous cells or eliminating blood vessel-clogging lipids without surgery, or in producing a small particle for carrying medication to the diseased part of the body without affecting other parts.

96 Such technological changes have resulted in Thailand freely importing medical and health-care technologies with no limitation or any mechanism for screening or inspecting the appropriateness of imported high-cost technologies. Moreover, policy-makers lack evidence-based information for making decisions on various technologies resulting in a lack of suitable selection process. And there is no law related to the monitoring and control of the appropriate use of medical and health technologies, causing a rapid rise in health-care spending, particularly for curative care for hospitalized patients. It was found that the costs of medical supplies/equipment imports rose from 2,493.2 million baht in 1991 to 22,654.3 million baht in 2009. 7.2 Utilization Efficiency, Diffusion and Equality, and Access to Technology The weakness of the public sector in controlling the use of high-cost technologies in a cost- effective manner results in doctors prescribing diagnoses and treatments without due consideration for their worthiness which negatively affects professional ethics and clientsû confidence. Moreover, an investment is needed for personnel development and monitoring of the adverse effects of the utilization of high-cost technologies. Unequal distribution of medical devices has also been noted, mostly clustered in major cities and more in the private sector, not the public sector (see Chapter 6, section 3 on health technologies). This has affected the access to high-cost health technologies of the poor and uninsured. 8. Health Behaviours Risk factors of Thai people have an impact on their lives and are a national problem affecting the countryûs economic and social security. It is noteworthy that in all groups of countries, risk factors related to behaviour clearly create a high burden of disease. In developing countries with high mortality rates, the top risk factor is malnutrition; while more advanced developing countries (high income) face other risk behaviours of alcohol and tobacco use, and over-nutrition (Table 4.33).

97 Such technological changes have resulted in Thailand freely importing medical and health-care technologies with no limitation or any mechanism for screening or inspecting the appropriateness of imported high-cost technologies. Moreover, policy-makers lack evidence-based information for making decisions on various technologies resulting in a lack of suitable selection process. And there is no law related to the monitoring and control of the appropriate use of medical and health technologies, causing a rapid rise in health-care spending, particularly for curative care for hospitalized patients. It was found that the costs of medical supplies/equipment imports rose from 2,493.2 million baht in 1991 to 22,654.3 million baht in 2009. 7.2 Utilization Efficiency, Diffusion and Equality, and Access to Technology The weakness of the public sector in controlling the use of high-cost technologies in a cost- effective manner results in doctors prescribing diagnoses and treatments without due consideration for their worthiness which negatively affects professional ethics and clientsû confidence. Moreover, an investment is needed for personnel development and monitoring of the adverse effects of the utilization of high-cost technologies. Unequal distribution of medical devices has also been noted, mostly clustered in major cities and more in the private sector, not the public sector (see Chapter 6, section 3 on health technologies). This has affected the access to high-cost health technologies of the poor and uninsured. 8. Health Behaviours Risk factors of Thai people have an impact on their lives and are a national problem affecting the countryûs economic and social security. It is noteworthy that in all groups of countries, risk factors related to behaviour clearly create a high burden of disease. In developing countries with high mortality rates, the top risk factor is malnutrition; while more advanced developing countries (high income) face other risk behaviours of alcohol and tobacco use, and over-nutrition (Table 4.33).

97 Table 4.33 Top ten risk factors: percentage of disability-adjusted life years (DALYs) in three groups of countries by income level, 2004 Order Low-income countries Percent Middle-income countries Percent High-income countries Percent 1 Childhood underweight 9.9 Alcohol use 7.6 Tobacco use 10.7 2 Unsafe water sanitation 6.3 High blood pressure 5.4 Alcohol use 6.7 and hygiene 3 Unsafe sex 6.2 Tobacco use 5.4 Overweight and obesity 6.5 4 Suboptimal breastfeeding 4.1 Overweight and obesity 3.6 High blood pressure 6.1 5 Indoor smoke from solid 4.0 High blood sugar 3.4 High blood sugar 4.9 fuels 6 Vitamin A deficiency 2.4 Unsafe sex 3.0 Physical inactivity 4.1 7 High blood pressure 2.2 Physical inactivity 2.7 High cholesterol 3.4 8 Alcohol use 2.1 High cholesterol 2.5 Illicit drug use 2.1 9 High blood sugar 1.9 Occupational risks 2.3 Occupational risks 1.5 10 Zinc deficiency 1.7 Unsafe water sanitation 2.0 Low fruit and vegetable 1.3 and hygiene intake Top 10 risk factors 40.8 37.9 47.3 Source: Global Health Risks: Mortality and burden of disease attributable to selected major risks, World Health Organization, 2009 A study on major burdens of diseases of Thai people conducted in 1999 and 2004 by the Interna- tional Health Policy Programme (IHPP), using 15 leading risk factors for males and females, revealed that alcohol use and unsafe sex were the cause of highest burden of disease among males, while unsafe sex and high body mass index (BMI) were the cause of highest burden of disease among females. However, when consider- ing some risk factors, such as low vegetable and fruit intake, high BMI, high cholesterol and high blood pressure, it is noted that they are all related to food consumption behaviour resulting in a high burden of disease. A comparison of burden of disease for 1999 and 2004 shows that high BMI, high cholesterol, and low vegetable and fruit intake result in high levels of DALYs as all of such risk factors are associated with cardiovascular disease (Figure 4.29).

98 Figure 4.30 Patterns of burden of disease among Thai people, 1999 and 2004

0.2 Malnutrition-Thailand 0.2 Malnutrition-International 0.30.6 2004 Non-use of safety belt 0.30.4 0.6 1999 Unsafe water 0.5 1.3 Air pollution 0.9 1.1 Physical inactivity 1.3 3.4 Drug abuse 0.9 1.4 Low vegetable & fruit intake 1.6 2.1 High cholesterol 2.2 3.7 High BMI 3.7 4.7 High blood pressure 5.5 4.3 Non-helmet use 4.5 5.5 Tobacco use 5.7 Alcohol use 4.9 8.0 13.1 Unsafe sex 9.3 DALYs (x100,000) 0123456789101112131415

Source: Working Group on Burden of Disease and Risk Factors in Thailand, IHPP, 2006.

8.1 Food Consumption 8.1.1 Pattern of Food Consumption among Thai People The food consumption behaviors of Thai people have changed according to changing lifestyles and differences in urban and rural residences. Surveys conducted by the National Statistical Office reveal that most Thais consume 3 meals a day; the trend is rising in all regions (Figure 4.31). For the food groups that are consumed by more than 80% of the people are vegetables/fruit, meat/meat products, and high-fat foods, followed by carbonated/sweetened drinks, while fast foods and dietary supplements are less consumed (Figure 4.32).

99 Figure 4.31 Proportion of population aged 6 years and above consuming 3 major meals by region, 2005 and 2009

2005 2009 Percentage 100 94.5 95.1 90.1 91.3 88.6 91.9 85.2 87.7 84.3 81.5 77.4 80 73.6

60

40

20

0 Region Bangkok Central North North-east South Total

Sources:1.Report on Thai Peopleûs Health Behaviour Survey, 2005 (Food Consumption Behaviour), National Statistical Office. 2. Report on Health, Welfare and Food Consumption of Thai People Survey, 2009, National Statis- tical Office. Figure 4.32 Proportion of population aged 6 years and above and food consumption behaviour by food group consumed per week, 2005 and 2009

Food group consumed per week 71.7 Carbonated & sweetened drinks 68.7 15.3 Fast food 14.2 2005 10.1 Dietary supplements 9.2 48.9 2009 Snacks 51.0 86.3 High-fat foods 90.0 98.9 Fresh vegetables and fruit 98.9 97.4 Meat & meat products 98.3 Percentage 020406080100

Sources:1.Report on Thai Peopleûs Health Behaviour Survey, 2005 (Food Consumption Behaviour), National Statistical Office. 2. Report on Health, Welfare and Food Consumption of Thai People Survey, 2009, National Statistical Office. 100 8.1.2 Groups and Types of Food Consumed 1) Vegetable and fruit consumption The data from NSOûs survey on food consumption behaviours show only frequency of consumption. But when considering the amount of food consumed per day, especially vegetables and fruit, based on the WHO criteria (vegetable and fruit intake of at least 600 grams/person/day), the third health examination survey on Thai people in 2003-2004 showed that both male and female Thais aged 15 years and over consumed a low amount of vegetables and fruit; males consumed about 268 grams/day, while females consumed about 283 grams/day. By age group, Thais aged 80 years and over consumed the least, about 200 grams/day (Table 4.34). Besides, the fourth health examination survey of Thai people, 2008-2009, based on the adequacy according the recommended daily intake (RDI), revealed that Thais aged 15 years and over, on average, consumed 1.7 servings of vegetables, compared with RDI of 3 servings, and only 23.8% had 3 or more portions of vegetables per day (Figure 4.33). Regarding fruit consumption, on average, Thais consumed only 1.5 portions/day which was lower than the RDI of 2 servings, only 28.2% had 2 or more of fruit per day (Figure 4.34). And it was found that Thais aged 15 year and over consumed only 3 servings of vegetables and fruit on average which was lower than the RDI of 5 servings per day overall, 17.7% of Thais (16.9% for males and 18.5% of females) consumed adequate amount of vegetables and fruit as recommended (5 or more serving). The proportion of people taking adequate amount of vegetables and fruit decreased in older age groups. For those taking 5 or more servings of vegetables and fruit, less than 10% of the 70 and over age group had such an amount. According to the third and fourth health examination surveys (2004 and 2009, respectively), the proportion of Thais eating adequate amounts of vegetables and fruit (5 portions or more) was higher in the fourth survey, the percentage being 20% for males and 24% for females, while in the fourth survey, the percentage dropped to 16.9% and 18.5% respectively. Moreover, the 2007 trimesterly social opinion survey on obesity and Thai society, conducted by NESDB, revealed that only one-third of Thais aged 15›74 years eat one meal of vegetables and fruit per day, more females taking than males (Table 4.35).

101 Figure 4.33 Percentage of Thais aged 15 year and over consuming vegetables each day by age group, 2008›2009

< 1 servings/day 1 - < 2 servings/day 2 - < 3 servings/day > = 3 servings/day Percentage 100 14.5 12.2 21.5 26.0 25.8 20.8 23.8 80 11.2 8.3 12.9 12.0 15.2 13.1 26.7 13.5 60 28.3 28.1 30.1 29.3 29.1 40 28.7 46.0 52.9 20 37.4 30.1 31.1 37.9 33.7 0 Age group(yrs) 15 - 29 30 - 44 45 - 5960 - 69 70 - 79 80 + Total

Source: Report on the Fourth National Health Examination Survey, 2008›2009, Office of the Thai Peopleûs Health Survey, HSRI, MoPH.

Figure 4.34 Percentage of Thais aged 15 years and over consuming fruit each day by age group, 2008›2009

1 - < 1 servings/day 2 - < 2 servings/day > = 2 servings/day Percentage 100 22.6 21.6 31.5 28.0 27.8 27.0 28.2 80 19.1 18.1 22.5 19.5 60 25.6 23.6 23.0

40 58.3 60.3 48.4 49.8 53.5 48.8 20 42.9 0 Age group 15 - 29 30 - 44 45 - 5960 - 69 70 - 79 80 + Total (yrs)

Source: Report on the Fourth National Health Examination Survey, 2008›2009, Office of the Thai Peopleûs Health Survey, HSRI, MoPH.

102 Table 4.34 Amount of vegetables and fruit consumed by each of Thais aged 15 years and over by age and sex Average amount of vegetables/fruit consumed (grams/day) Age (years) Males Females 15›29 285 300 30›44 272 293 45›59 261 283 60›69 238 245 70›79 216 215 80 and over 203 193 Total 268 283

Source: Report on the third National Health Examination Survey, 2003›2004, MoPH.

Table 4.35 Proportion of Thais consuming vegetables and fruit each week Thais consuming vegetables/fruit Frequency of Males Females Total consumption No. Percent No. Percent No. Percent Fewer than 1 meal/week 87 3.6 87 3.2 174 3.4 Fewer than 1 meal/day 381 15.8 343 12.6 724 14.1 1 meal/day 848 35.1 896 33.0 1,744 34.0 2 meals/day 684 28.3 849 31.3 1,533 29.9 3 meals/day 417 17.2 539 19.9 956 18.6 Total 2,417 100.0 2,714 100.0 5,131 100.0

Source: Report on Trimesterly Social Opinion Survey on Obesity and Thai Society, 2007, NESDB.

2) Consumption of carbohydrates and sugar Thais have a tendency to consume more and more sugar and carbohydrate foods as evidenced in the fact that, over the past 2 decades the rate of sugar consumption increased nearly threefold from 12.7 kg/person/year in 1983 to 31.2 kg/person/year in 2009; whereas the Dietary Guidelines for Thaisû Good Health specify that sugar consumption should not exceed 14.6 kg/person/year (Bureau of Nutrition, Department of Health) (Figure 4.35). And it was found that the production of candies is on the rise (Table 4.36) corresponding to a survey conducted by Child Watch in 2006-2007 which revealed that almost one-fifth of children and youth liked to eat sweet foods (Table 4.37).

103 Figure 4.35 Quantity of sugar intake in Thailand, 1983-2009 Kilograms/person/year 40

36.4

35 33.2

31.9

31.2

30.5

30.5

29.6

29.3

29.1

28.5

27.9 30 27.2

26.7

26.5

25.8

25 23.0

21.7

20.3

18.9

20 17.8

15.9

14.8

14.6

12.9

12.9 15 12.8 12.7 10 5 0 Year

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Office of the Sugar Cane and Sugar Commission. Table 4.36 Amount of sugar used in industries, 2008›2009 Unit: sack (100 kg) Increase/decrease Type of industries 2008 2009 Amount Percent • Drinks 3,639,320.11 3,817,897.73 + 178,577.62 + 4.91 • Bakery (including liquor and beer 231,903.00 149,684.30 - 82,218.70 - 35.45 plants) • Foods (canned food and fish sauce) 1,950,505.20 1,880,350.49 - 70,154.71 - 3.60 • Milk products 1,505,286.34 1,653,290.60 + 148,004.26 + 9.83 • Candies 219,764.87 612,726.16 + 392,961.29 + 178.81 • Pharmaceuticals and others 89,347.50 206,620.55 + 117,273.05 + 131.25 Total 7,636,127.02 8,320,569.83 + 684,442.81 + 8.96

Source: Office of the Sugar Cane and Sugar Commission.

104 Table 4.37 Percentage of people who like to consume sweet foods

Age group People who like sweet foods (%) 6›14 years 18.3 15›24 years 9.9 25›59 years 7.2 60 years and over 5.8

Source: Child Watch 2006›2007 Project, Ramajitti Institute.

3) Consumption of snacks and carbonated drinks Thai peopleûs consumption of snacks and carbonated drinks tends to be rising with the convenience in purchasing and the rise in their types and varieties. The survey on child and youth situation, conducted in 2004›2009, revealed that the proportions of primary school children regularly eating snacks and carbonated drinks increased from 26.7% and 20.3% in 2004›2005 to 40.6% and 31.4% in 2008›2009, respec- tively (Figure 4.36). The increased consumption is a result of more diversity in brands and varieties as well the influence of consumption-inducing advertisements. The data from Media Spending Company showed that the total value of food advertisements in Thailand is on the rise, particularly for carbonated drinks and snacks, whose proportion rose to one-third of the food advertisement value (Table 4.38). Besides, according to the snacks consumption survey, conducted in four provinces of Chiang Mai, Khon Kaen, Songkhla and Bangkok in 2004, showed that advertisements via various media had the highest influence in deciding to buying snacks among youth. Thus, it can be concluded that there is an association between the stimulation of consumption and the advertisement of such foods and drinks.

105 Figure 4.36 Proportion of primary school children regularly consuming snacks and carbonated drinks, 2004›2009

Percentage 40 47.0 2004 - 2005 38.1 40.6 40 2005 - 2006 27.1 31.9 31.4 30 26.7 24.8 2006 - 2007 20.322.8 20 2007 - 2008 2008 - 2009 10 0 Type Snacks Carbonated drinks

Source: Report on Child and Youth Situation, 2004›2009, Child Watch Project, 2010.

Table 4.38 Advertisement values of carbonated drinks and snacks, 2006›2009 Unit: thousand baht Item 2006 2007 2008 2009 Carbonated drinks 2,107,214 2,242,832 2,062,776 2,403,077 Snacks 2,707,511 2,508,990 2,442,873 2,430,742 • Biscuits 1,622,136 1,535,150 1,506,151 1,640,632 • Candies 712,953 680,538 652,262 441,443 • Chocolates/wafers 372,422 293,302 284,460 348,667 Advertisement values of drinks/snacks 4,814,725 4,751,822 4,505,649 4,833,819 Advertisement values of foods 16,716,291 16,432,446 16,448,422 17,761,223 Proportion in relation to all food 28.8 28.9 27.4 27.2 advertisements (%)

Source: Media Spending Company.

106 4) Consumption Of faSt food Globalization has caused consumerism and imitation of western lifestyles, one of which is eating fast food that has become a peopleûs way of life.11 A Cheewajit poll conducted on Bangkok residents in 2006 revealed that one-third of them regularly ate fast food. That was consistent with the 2005-2006 survey conducted by Child Watch which found that about one-third of children and youth regularly consumed fast food; the proportion would be higher on weekends (Table 4.39). The 2005 and 2009 surveys on food consump- tion behaviours conducted by the National Statistical Office also found that teenagers had a higher frequency in consuming fast food than other age groups (Table 4.40).

Table 4.39 Percentage of children and youth regularly consuming fast food

Percent consuming at least 1 day/week Educational level Weekdays Weekends Primary school 36.9 48.4 Lower-secondary school 36.1 43.8 Higher-secondary school 34.0 40.2 Vocational school 32.1 34.2 Higher education 35.6 36.8

Source: Child Watch 2005-2006 Project, Ramajitti Institute.

Table 4.40 Percentage of people consuming fast food by consumption frequency, 2005 and 2009 Age group consuming fast food (%) Frequency Total 6-14 yrs. 15-24 yrs. 25-59 yrs. 60+ yrs. 2005 2009 2005 2009 2005 2009 2005 2009 2005 2009 1-2 days/wk. 12.3 11.8 17.1 18.9 20.0 19.3 10.0 9.6 3.1 3.0 3-4 days/wk. 2.0 1.6 3.5 2.9 3.2 2.7 1.3 1.1 0.7 0.3 5-6 days/wk. 0.5 0.6 0.8 1.2 0.9 1.0 0.4 0.4 0.1 0.1 Every day 0.5 0.3 0.8 0.5 0.7 0.3 0.4 0.3 0.2 0.1 Sources:1.Report on Thai Peopleûs Health-Care Behaviours Survey, 2005 (Food Consumption), National Statistical Office. 2. Report on Peopleûs Health, Welfare and Food Consumption Survey, 2009, National Statistical Office.

11 Rangsan Thanapornpan. Globalization and Thai Food. In: Sungsidh Piriyarangsan and Pasuk Phongpaichit(ed.).Globalization and Thai Society and Economy, 1995.

107 Besides, it has been found that a more hectic lifestyle for both urban and rural residents has caused them to consume more ready-to-cook or semi-cooked food. In terms of spending on food, Bangkok residents spend 50% of their food expenditure on pre-cooked food, while only 20% of rural residents do so.12

8.1.3 Consequences of Consuming Health-Affecting Foods Consuming food rich in fat content and calorie results in an increased risk for cardio- vascular diseases. According to the trimesterly social opinion and attitude survey focusing on obesity in Thai society in 2007, conducted by NESDB, Thais aged 15›74 years consumed 2›5 meals of foods related to risk factors for obesity per week. Such foods mostly included snacks and fried foods (5 meals/wk.), sweets, foods with coconut cream, beef/pork steak, grilled fatly pork, and fast foods such as fried chicken, burger, pizza, rice and stewed pork leg, respectively (Table 4.41). That means one-fourth of the major meals consumed are the cause of high risk for obesity. Besides, a survey on health behaviours in preventing hypertension, conducted by the Department of Health Service Support on people aged 35 years and over in 8 provinces in all 4 regions of the country in April 2008, revealed that most of the respondents consumed fried foods (96.2%), foods and desserts with coconut cream (918%), and salty foods (91.8%) (Table 4.42). So there are risk factors for ill health including five diseases, namely hypertension, diabetes, heart disease, cardiovascular disease and cancer. It was also found that the prevalence of obesity is on the rise, particularly among the 20-29, 30›39 and 60+ age groups (Figure 4.37). And a study on risk factors for cardiovascular diseases among Thais aged 35›59 years revealed rising trends in high cholesterol, blood sugar, overweight and obesity (Table 4.43).

12 Patthanee Vinijjakul and Wongsawat Kosolwat. Food and Nutrition Review and Revision of Strategic Plan for Health Research in Thailand, 2003.

108 Figure 4.37 Prevalence rate of obesity in Thailand by age group, 1986, 1995, and 2003

3rd National Nutrion 4th National Nutrion Survey 5th National Nutrion Survey Survey (1986) (1995) (2003) Percentage 45 40.2 40 38.1 35.0 35 32.1 33.2 29.8 30 28.6 23.8 25 21.7 20.4 19.4 19.1 20 15 12.1 10 5 2.9 0 0 Age (Years) 20 - 29 30 - 39 40 - 49 50 - 59 60 +

Source: Department of Health, MoPH. Note: Obesity in population aged >20 years: BMI ≥ 25 kilograms/square metre.

Table 4.41 Frequency in consuming obesity-causing foods among Thais by sex

Frequency (average), meals/week Type of food Males Females Total • Snacks 5 5 5 • Fried foods 5 5 5 • Desserts 3 3 3 • Food containing coconut cream 3 3 3 • Steak, fatty grilled beef/pork 2 2 2 • Fast foods such as fried-chicken, burger, pizza 2 2 2 • Rice with stewed pork leg 2 2 2 Total 5 4 5 Source: Report on Trimesterly Social Opinion and Attitude Survey Focusing on Obesity and Thai Society, 2007, NESDB.

109 Table 4.42 Percentage of Thais aged 35 years and over with different food consumption behaviours

Type of behavior Thais with such behaviour (%) • Consuming fried foods such as fried beef, fried chicken, fried fish, fried 96.2 eggs, fried bananas • Eating food containing coconut cream 91.8 • Eating salty foods such as salted beef, salted fish, salted eggs, pickled 91.8 mustard, pickled garlic • Adding sugar in foods 86.1 • Eating rice with stewed pork knuckle/leg, chicken rice, fried mussels, 85.1 Thai fried noodles • Adding fish sauce or soy sauce in food prior to eating it 82.5 • Eating extremely sweet desserts such as egg drop sweet (thong-yod), 75.8 sweet egg-serpentine (foi-thong), and wax gourd in syrup Source: Report on Surveillance of Behaviours for Prevention of Hypertension, Department of Health Service Support. Table 4.43 Changes and prevalence of cardiovascular disease risk factors among Thais aged 35-59 years 1st health 2nd health Inter-ASIA 3rd health 4th health Risk factor survey survey (2000›2001) survey survey (1991›1992) (1996›1997) (2003›2004) (2008›2009) Cholesterol (mg/dl) 189 198 201 207 204 Blood sugar (mg/dl) 87 92 99 100 89 Body mass index (BMI) (kg/m2) 22.8 23.8 24.4 24.6 23.8 Overweight (%) 20 25 30 38 34.7 Obesity (%) 5 8 9 10 Female = 6.0 Male = 11.6

Sources:1.Piyamit Srithara et al. Cardiovascular Research Group in Review and Revision of Strategic Plan for Health Research in Thailand, 2003. 2. Report on the Third National Health Examination Survey, Thailand (2003›2004), HSRI, MoPH. 3. Report on the Fourth National Health Examination Survey, Thailand (2008›2009), National Health Examination Survey Office, HSRI, MoPH. Note: For 2008›2009, survey on population aged 15 years and over.

110 Snack consumption tends to be rising among Thai children under 5 and primary schoolchil- dren, resulting in a high dental health prevalence. During 2000-2007, 80.6% of 5-year-old children entering the schooling system had on average 5.4 decayed, missing and filled teeth (DMFT) per child, (Tables 4.44 and 4.45). And during 1995-2008, the DoHûs dental health surveys revealed that only 40% of 12-year-old children in various provinces had dental caries.13

Table 4.44 Percentage of people with dental caries by age group, according to National Dental Surveys, 1984, 1989, 1994, 2000›2001, and 2006›2007

People with dental caries (%) Age group (years) 1984 1989 1994 2000-2001 2006-2007 3* - 66.5 61.7 65.7 61.4 5----80.6 6* 71.6 83.1 85.1 87.4 - 6** 74.4 82.8 85.3 87.5 - 6 30.3 19.2 11.1 - - 12 45.8 49.2 53.9 57.3 56.9 15 - - - - 66.3 18 63.1 63.3 63.7 62.1 - 35›44 80.2 76.8 85.7 85.6 89.6 60 and over 95.2 93.9 95.0 95.6 96.1

Sources:1.Reports on the 2nd, 3rd, 4th, 5th, National Dental Health Surveys. Department of Health, MoPH 2. Report on the 6th Oral Health Survey at the Country Level, 2006›2007, Department of Health, MoPH. Notes:* Baby or deciduous teeth ** Mixed (permanent and baby teeth) Other age groups › only permanent teeth.

13 Dental Health Division, Department of Health. Reports on Provincial Dental Health Surveys, 2005-2008,2008.

111 Table 4.45 Average DMFT in various age groups according to National Dental Surveys, 1984, 1989, 1994, 2000-2001, and 2006›2007

Average DMFT (teeth/person) Age group (years) 1984 1989 1994 2000›2001 2006›2007 3* - 4.0 3.4 3.6 3.2 5----5.4 6* 4.9 5.6 5.7 6.0 - 6** 0.5 0.3 0.3 - - 12 1.5 1.5 1.6 1.6 1.6 15 - - - - 2.2 18 3.0 2.7 2.4 2.1 - 35›44 5.4 5.4 6.5 6.1 6.7 60 and over 16.3 16.2 15.8 14.4 15.8 Sources:1.Reports on the 2nd, 3rd, 4th, 5th, National Dental Health Surveys. Department of Health, MoPH 2. Report on the 6th Oral Health Survey at the Country Level, 2006›2007, Department of Health, MoPH. Notes:* Baby or deciduous teeth ** Mixed (permanent and baby teeth) Other age groups › only permanent teeth.

8.2 Drug Consumption In 2008, drug consumption of Thai people accounted for approximately 151,578 million baht in wholesale prices or 272,841 million baht in retail prices, or 46.4% of the overall national health expenditure (see Chapter 6, item 3, health technologies). This proportion is rather high, compared with only 10% to 20% in developed countries (Figure 4.38). During the period 1988›2008, the rising rates of drug consumption exceeded the increasing rates of national health spending and economic growth. In general, an analysis of drug consumption patterns of Thai people revealed that about two- thirds of the consumption was done according to the decision or advice of professionals, such as doctors, pharmacists and other health personnel; the remainder was done as suggested by relatives, friends, or advertise- ments. Nevertheless, medication use according to the advice of health professionals has been rising (Table 4.46).

112 Figure 4.38 Proportion of drug to health expenditures in Thailand and other countries

Percentage 60 46.7 50 40 30 18.1 18.9 16.3 16.3 20 12.0 14.3 10 0 Country U.S.A. Canada Japan England France Australia Thailand

Source: OECD Health Data 2008. Note: From OECD are data on OTC drug dispensary and outpatients, but for Thailand the data cover outpatient, inpatient and OTC drug use.

113 7

}

(%)

2009

7

(%)

}

2008

7

(%)

}

2007

8

(%)

}

2006

9

(%)

2005

}

9

(%)

}

2004

9

(%)

}

2003

21 11 21 1 1

8

(%)

}

2002

8

(%)

}

2001

7

(%)

2000

}

7

(%)

1999

}

(%)

1998

(%)

1997

(%)

1996

(%)

1995

22222 53333332

40 34 34 34 34 32 32 30 30 26 26 26 24 22 22 20 43 46 52 52 52 58 58 60 60 64 64 64 66 70 70 72

10 15 9 9 9

(%)

1994

Drug distribution in Thailand: percentage of drug values distributed through drug outlets (as percentage of total drug value)

IMS Company Thailand.

Type

:

Drugstores Public and private hospitals Private clinics GPO Others

Table 4.46

Source

114 No matter through whom the people get medication, it is evident that irrational use and over-use of drugs, are found at all levels, partly due to advertising influence (Figure 4.39), while very little effort has been made to disseminate drug information to the public through various media including newspaper, radio, television, and magazine from drug business operators. Besides, the 3rd and 4th National Health Examination Surveys in Thailand for 2003/04 and 2008/09, respectively, revealed that the daily use of pain killers among Thai males and females was declining, but the use of tranquilizers and sleeping pills was rising in both sexes, the older the more of such drugs were used, while the use of anti-obesity drugs was more prevalent in female adolescents (15›29 years) with the use rate of 4.9% (Table 4.47); the sources of anti-obesity drugs were drug stores (27.8%), hospitals (27.0%); shops (19.4%), direct sales persons (11.4%) and relatives/acquaintances (9.5%).

Figure 4.39 Billings of drug, food and cosmetic advertisements, 1989-2009

Drug ads. Food ads. Cosmetics ads. Million baht

20,000 19,021

17,158

16,716 18,000 16,637

16,500

16,000 14,615

13,708 14,000 17,761

12,505

16,448

16,432 12,000 15,932

10,055

13,723 10,000 9,627

12,544

8,004

7,653

7,635

8,000 11,141

6,566

10,290 6,000 5,722

4,470

3,792

7,290

6,555 3,073 3,381

2,915

4,000 2,677 3,315

5,590 1,423 2,281 2,835 2,423 2,496 2,444

4,805 2,000 1,2201,4641,821 1,127 4,791 1,335 1,769 1,026 714 842 1,012 2,402 2,346 2,498 2,552 0 1,013 1,053 1,197 1,503 Year 375 511 619 650

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Media Spending Company. Notes:1.Food means an alcoholic beverage, milk, energy drink, snack, soft drink, candy, seasoning, instant noodle, coffee, food, cooking oil, canned food, dairy product, chocolate and cigarette, liquid food and any other food item. 2. Cosmetic means shampoo, soap, general cosmetic, body powder and skin moisturizing cream.

115 Table 4.47 Percentage of people regularly taking medication by age, sex and type of medicine People on medication (%) Age (years) Painkillers Tranquilizers and sedatives Anti-obesity 2003 2008›2009 2003 2008›2009 2003 2008›2009 Males 15 › 29 1.4 0.6 0.4 1.7 0.2 0.1 30 › 44 3.6 1.1 0.8 1.4 0.1 0.3 45 › 59 5.2 2.6 0.7 2.0 0.2 0.4 60 › 69 7.9 3.2 1.3 3.1 0.0 0.4 70 › 79 8.0 3.2 1.8 4.2 0.1 0.3 80+ 8.4 3.2 2.7 6.5 0.2 0.2 All ages 3.8 1.8 0.7 2.0 0.1 0.3 Females 15 › 29 2.2 1.2 0.1 1.1 0.3 4.9 30 › 44 3.8 2.2 0.5 3.4 0.1 1.9 45 › 59 6.5 3.2 2.1 5.7 0.1 1.1 60 › 69 10.0 4.9 2.9 8.3 0.2 0.2 70 › 79 12.7 5.1 2.7 8.4 0.1 0.1 80+ 10.6 4.3 2.2 8.5 0.0 0.2 All ages 4.9 2.3 1.0 4.5 0.2 1.9 Sources:1.Report on the Third National Health Examination Survey, Thailand (2003›2004). Ministry of Public Health 2. Report on the Fourth National Health Examination Survey, Thailand (2008›2009), Thai Health Examination Survey Office, HSRI, MoPH.

8.3 Cigarette Smoking As a result of the intensive tobacco consumption control with two laws since 1992 and tax measures, the prices of cigarettes have increased almost four-fold over the past 15 years; and the smoking rate among Thais has dropped from 30.1% in 1976 to 20.7% in 2009 even though the number of smokers remains stable or does not increase. Obviously, cigarette sales have constantly dropped from 2,328 million packets in 1994 to 1,790 million packets in 2009, while the cigarette tax revenue has risen from 15,345 million baht in 1993 to 44,167 million baht in 2009, a nearly three-fold increase (Table 4.48). However, despite the drop in the use rate of locally produced cigarettes, the use of imported cigarettes has increased from 3.0% in 1994 to 24% in 2009 (Table 4.50). All this success has been a good example for other countries worldwide.

116 Besides, the 2009 Global Adult Tobacco Survey (GATS) revealed that there were 14.3 million current users of tobacco (smoke and smokeless), or 27.2% of the population (46.4% male and 9.1% female) (Table 4.51). Among the users, 6 of 10 smokers had thought about quitting and 5 of 10 tobacco users (including current users and those who had just quit for less than 12 months) used to quit using it during the past 12-month period (Table 4.52). Besides, it was found that 3.3 million people (27.2%) received second-hand smoke in the workplace and 20.5 million people (39.1%) received second-hand smoke in the home (Table 4.53).

Table 4.48 Excise tax rate, cigarette sales, taxes collected and number of smokers, 1989›2009

Year Tax rate Sales volume Cigarette tax collected No. of smokers Cigarette price, (%) (million packets) (million baht) (million) baht per packet 1989 35-55 1,843 14,664 1990 55 1,941 15,461 15 1991 55 1,942 15,898 11.3 1992 55 2,035 15,438 1993 55 2,135 15,345 10.4 15 1994 60 2,328 20,002 18 1995 62 2,171 20,736 21 1996 68 2,463 24,092 11.2 24 1997 68 2,415 29,755 10.2 28 1998 70 1,951 28,691 1999 70 1,810 26,708 10.2 28 2000 71.5 1,826 28,110 32 2001 75 1,727 29,627 10.5 36 2002 75 1,716 31,247 2003 75 1,904 33,582 7.7 38 2004 75 2,110 36,326 11.3 2005 75 2,187 39,690 38 2006 79 1,793 35,646 11.0 42 2007 80 1,958 41,528 10.8 45 2008 80 1,837 40,489 45 2009 85 1,790 44,167 10.9 58

Sources:1.Excise Department, Ministry of Finance. 2. Action on Smoking and Health Foundation.

117 Table 4.49 Number and proportion of smokers, 1976-2009

Year Population No. of smokers (millions) Proportion of smokers (%) (millions) Total Males Females Total Males Females 1976 28.7(1) 8.6 7.7 0.9 30.1 54.7 6.1 1981 35.1(1) 9.8 9.0 0.8 27.8 51.2 4.4 1986 38.0(2) 10.4 9.6 0.8 27.4 50.4 4.2 1988 40.5(2) 10.1 9.4 0.7 25.0 46.7 3.5 1991 43.3(2) 11.4 10.6 0.8 26.3 49.0 3.8 38.3(3) 11.3 10.5 0.8 29.7 55.3 4.3 1993 45.7(2) 10.4 9.8 0.6 22.8 43.2 2.5 40.7(3) 10.4 9.8 0.6 25.5 48.5 2.8 1996 48.0(2) 11.2 10.6 0.6 23.4 44.6 2.5 1999 49.9(2) 10.2 9.6 0.6 20.5 38.9 2.4 2001 51.2(2) 10.5 10.0 0.5 20.6 39.3 2.2 2003 35.8(2) 7.7 7.1 0.6 21.6 44.1 2.9 2004 49.4(3) 11.3 10.7 0.6 21.1 40.1 2.4 2006 54.5(2) 11.0 10.3 0.7 20.3 38.8 2.6 2007 51.2(3) 10.8 10.3 0.5 21.2 41.7 1.9 2009 52.7(3) 10.9 10.4 0.5 20.7 40.4 2.0

Sources:1 Health and Welfare Surveys. National Statistical Office. 2. Preliminary Results of Survey on Populationûs Tobacco and Liquor Consumption, 2001. National Statistical Office. 3. Populationûs Smoking and Drinking Behaviours Surveys, 2004 and 2007, National Statistical Office. Notes: (1) Population aged 10 and over. (2) Population aged 11 and over. (3) Population aged 15 and over.

118 Figure 4.40 Average number of cigarettes smoked per day by a regular smoker aged 11 years and over by gender, 2001, 2003, 2004, 2006 and 2007

2001 2003 2004 2006 2007 Cigarettes/day 14

12 10.6 10.4 10.3 10.7 10.4 9.7 9.9 10 9.0 9.0 8.8 8.3 8 7.4 7.0

6

4

2

0 Gender Total Male Female

Sources:1.Preliminary Results of Populationûs Smoking and Drinking Behaviours Survey, 2001. National Statistical Office. 2. Health and Welfare Surveys, 2003 and 2006. National Statistical Office. 3. Reports on Populationûs Smoking and Drinking Behaviours Surveys, 2004 and 2007. National Statistical Office. Note: For 2004 and 2007, survey on population aged 15 years and over; no analysis by sex.

119 Table 4.50 Market shares of locally produced and imported cigarettes, 1991›2009

Market share (%) Fiscal year For cigarettes produced by For imported cigarettes the Thailand Tobacco Monopoly 1991 99.4 0.6 1992 97.4 2.5 1993 97.2 2.8 1994 97.0 3.0 1995 96.7 3.2 1996 96.8 3.1 1997 95.9 4.1 1998 91.5 8.4 1999 86.4 13.5 2000 86.7 13.3 2001 85.0 15.0 2002 84.7 15.3 2003 85.9 14.1 2004 80.1 19.9 2005 77.7 22.3 2006 73.2 26.8 2007 77.4 22.6 2008 76.0 24.0 2009 76.0 24.0

Source: Excise Department, Ministry of Finance.

120 Table 4.51 Percentage of tobacco product users (in adults ≥15 years old), 2009 Tobacco product users Total (%) Males (%) Females Smoked product users Current smokers 23.7 45.6 3.1 Daily smokers 20.3 39.2 2.4 Current smokers › manufactured cigarettes 15.0 29.6 1.1 Daily smokers › manufactured cigarettes 11.3 22.4 0.8 Current smokers › hand-rolled cigarettes 14.1 27.0 1.8 Daily smokers › hand-rolled cigarettes 12.4 24.0 1.4 Former daily smokers1 (of total population) 8.9 16.7 1.4 Former daily smokers1 (% of current daily and occasional smokers) 28.8 28.4 34.4 Smokeless tobacco users Current smokeless tobacco users 3.9 1.3 6.3 Daily smokeless users 3.4 0.9 5.8 Former daily smokeless users2 (of total population) 0.6 0.4 0.7 Former daily smokeless users2 ( of daily and occasional users) 13.8 27.8 11.0 Total smoked and smokeless tobacco Current users 27.2 46.4 9.1 Source: Global Adult Tobacco Survey, 2009 (Thailand). Notes: 1 Those who do not currently use smoked tobacco product. 2 Those who do not currently use smokeless tobacco product.

Table 4.52 Percentage of tobacco users with cessation experience (in adults ≥15 years old) Tobacco use cessation Total (%) Males (%) Females (%) Current smokers who ever made a quit attempt 60.0 60.5 52.9 Smokers who ever made a quit attempt1* 49.8 49.9 47.4 Smokers who were advised to quit by a health-care provider1,2* 51.9 52.3 48.7 Current smokeless tobacco users who thought of quitting 24.0 37.4 21.3 Current smokeless tobacco users who made a quit attempt3* 21.5 31.6 19.5 Smokeless tobacco users advised to quit by a health-care 18.7 14.1 19.4 provider2,3* Source: Global Adult Tobacco Survey, 2009 (Thailand). Notes: 1 Includes current and former tobacco smokers who have been abstinent for less than 12 months. 2 Among current and recent former smokers who visited a health-care provider during the past 12 months. 3 Includes current and former smokeless tobacco users who have been abstinent for less than 12 months. * During the past 12 months.

121 Table 4.53 Percentage of adults exposed to second-hand smoke (SHS)

Thais aged 15 years and over Total (%) Males (%) Females (%) Workers exposed to SHS in index workplaces 1* 27.2 34.9 18.9 Adults exposed to SHS at home2 39.1 43.4 35.1 Adults exposed to SHS in public transport1* 6.3 5.1 7.5 Adults exposed to SHS in restaurants* 9.0 10.8 7.2 Adults exposed to SHS in outside markets* 53.5 54.4 52.7

Source: Global Adult Tobacco Survey, 2009 (Thailand). Notes: 1 Among those who work outside of home and usually work within a building or equally within and outside the building. 2 Includes smoking in the homes that occurs daily, weekly, or less than monthly. * During the past 30 days.

8.4 Alcoholic Beverage Consumption Alcohol abuse is number one cause of burden of disease among males and number nine among females in Thailand. Thai people tend to consume more alcoholic beverages; during the past decade, alcohol use rose from 37.9 litres/person/year in 1997 to 45.7 litres/person/year in 2008, a 1.2-fold increase. By type of alcohol used, it was found that liquor consumption seemed to be stable while beer consumption was on the rise (Table 4.54). As evidenced in the market share structure for 1997›2008, beer had the largest market share (52.4›69.0%), followed by clear liquor (19.4›27.3%) and mixed liquor for the period 1997›2001, after which it was imported liquor until 2008 (Table 4.55). As a result of the 1992 free trade policy of the government, many more beer brewery plants have been operational, coupled with beerûs lower prices, the sales volumes and consumption of beer have been higher than those for liquor. However, in 2008, the Thaisû consumption of all kinds of alcohol dropped probably due to the countryûs economic recession together with other measures undertaken by the government and communities such as alcohol tax increase, the enactment of the 2008 Alcoholic Beverage Control Act, and anti-alcohol drinking campaigns.

122 All

types

Im-

liquor

ported

Local

liquor

Excise tax (million baht)

types

Beer Wine All

(litres/person/yr.)

Dis-

tilled

Alcohol consumption per capita

liquor

and over

Population

aged 15 years

beverages

of alcoholic

(million litres)

Total, all types

litres)

Total,

liquor

(million

distilled

Im-

liquor

ported

Amount pro-

(million litres)

enous

duced/imported

Beer Wine Indig-

liquor

Special

Spe-

cially

liquor

mixed

Amount sold (million litres)

liqour

Mixed

Alcohol consumption and excise tax levied on local and imported alcoholic beverages, Thailand, 1997›2008

Excise Department, Ministry of Finance. Alcoholic beverages mean all types of liquor, beer and wine.

Clear

liquor

:

:

1997 449.7 204.1 72.6 10.2 863.9 3.9 NA 45.2 781.8 1,649.6 43,537,586 18.0 19.8 0.09 37.9 4.7 2,915.6 41,983.6 1998 389.9 315.1 52.4 16.9 950.3 4.3 0.08 17.6 791.9 1,746.6 44,235.024 17.9 21.5 0.10 39.5 330.3 2,098.7 43,391.6 1999 419.7 116.7 44.4 17.8 1,032.2 7.2 0.30 24.5 623.1 1,662.8 44,755,436 13.9 23.1 0.17 37.2 440.0 2,365.0 47,749.8 2000 395.3 167.1 19.3 27.2 1,092.2 15.4 0.76 34.7 643.6 1,752.0 45,163,700 14.3 24.2 0.36 38.8 118.5 3,033.7 34,670.5 2001 404.8 130.3 31.1 83.5 1,158.7 11.0 2.29 54.6 704.3 1,876.3 45,726,748 15.4 25.3 0.29 41.0 24.3 4,728.4 38,852.5 2002 421.6 99.1 34.0 84.2 1,195.6 21.3 3.97 101.1 740.0 1,960.9 46,323,539 16.0 25.8 0.55 42.3 27.2 5,675.8 53,890.4 2003 495.5 39.3 19.9 71.3 1,506.7 22.6 3.55 138.7 764.7 2,297.6 46,788,017 16.3 32.2 0.56 49.1 35.9 7,437.4 62,618.2 2004 489.6 21.7 19.0 69.2 1,531.7 32.6 5.61 161.8 761.3 2,331.2 47,152,370 16.1 32.5 0.81 49.4 34.6 7,864.1 68,868.4 2005 507.1 24.2 17.6 78.6 1,468.7 3.3 0.34 176.7 804.2 2,276.5 47,731,109 16.8 30.8 0.08 44.7 41.2 8,587.2 74,029.7 2006 527.1 39.9 18.9 55.2 1,621.1 1.7 0.42 159.9 801.0 2,424.2 48,290,398 16.6 33.6 0.04 50.2 40.3 7,770.0 72,871.5 2007 480.1 75.3 9.9 48.0 1,711.0 1.6 0.11 152.3 765.6 2,478.3 48,615,243 15.7 35.2 0.03 51.0 43.2 7,401.6 84,863.3 2008 441.2 112.7 8.5 44.6 1,477.1 1.5 0.17 156.2 763.2 2,242.0 49,075,757 15.6 30.1 0.03 45.7 39.5 7,589.0 90,186.1

Year

Table 4.54

Note

Source

123 Table 4.55 Structure of market shares of alcoholic beverages, 1997›2008

Market share (%) Year Beer Clear Imported Mixed Special Specially Wine Indigenous liquor liquor liquor liquor mixed liquor liquor 1997 52.4 27.3 2.7 12.4 0.6 4.4 0.2 NA 1998 54.4 22.3 1.0 20.1 1.0 3.0 0.2 0.0 1999 62.1 25.2 1.5 7.0 1.1 2.7 0.4 0.0 2000 62.3 22.6 2.0 9.5 1.3 1.1 0.9 0.0 2001 61.7 21.6 2.9 6.9 4.5 1.7 0.6 0.1 2002 61.0 21.4 5.2 5.1 4.3 1.7 1.1 0.2 2003 65.5 21.6 6.0 1.7 3.1 0.9 1.0 0.2 2004 65.7 21.0 6.9 0.9 3.1 0.8 1.4 0.2 2005 64.5 22.2 7.8 1.1 3.5 0.8 0.1 0.0 2006 66.8 21.7 6.7 1.6 2.3 0.8 0.1 0.0 2007 69.0 19.4 6.1 3.0 1.9 0.4 01 0.0 2008 65.9 19.7 7.0 5.0 2.0 0.4 0.1 0.0 Source: Excise Department, Ministry of Finance.

A survey conducted by the NSO revealed a similar result, i.e. the proportion of alcoholic beverage drinkers increased from 31.5% in 1991 to 35.3% in 2004, but dropped slightly to 32.0% in 2009 (Table 4.56). It is noteworthy that during the 12-year period (1996›2007), the proportion of female drinkers rose in all age groups, particularly teenagers (15›19 years) (Table 4.57). Regarding drinking frequency among drinkers, it was found that about half of them drank occasionally, but the proportion of regular drinkers (every day) was rising from 8.6% in 1996 to 13.0% in 2006 and dropped to 11.7% in 2009. It was noted that, the number of those who drank only once or twice a month almost doubled in 2007 (Table 4.58). The reasons for drinking were to socialize with friends and just to try it; some drank due to the influence of continual advertisements as evident in the rising trends in advertisement billings, especially during the period 2000›2006, being higher than 2,000 million baht per year on average. But after the alcohol advertisement ban, according to the 2008 Alcoholic Beverage Control Act, the advertisement bills were declining (Table 4.59).

124 Table 4.56 Number and proportion of alcoholic beverage drinkers, 1991›2009 Population No. of drinkers (millions) Proportion of drinkers (%) Year (millions) Total Males Females Total Males Females 1991 39.5 12.4 10.5 1.8 31.5 53.7 9.5 1996 43.4 13.7 11.9 1.7 31.6 55.4 8.1 2001 46.9 15.3 13.0 2.3 32.6 55.9 9.8 2003 35.8 12.7 9.8 2.8 35.5 60.8 14.5 2004 49.4 16.1 13.6 2.5 35.3 59.3 11.7 2006 54.5 15.9 13.3 2.6 29.2 50.3 9.1 2007 51.1 14.9 12.6 2.3 29.3 51.0 8.8 2009 52.7 16.8 13.9 2.9 32.0 54.4 10.8 Sources:1.Reports on Health and Welfare Surveys, 1991, 1996, 2001, 2003, 2006, and 2009. National Statistical Office. 2. Reports on Smoking and Drinking Surveys, 2004 and 2007. National Statistical Office. Note: In the 2003 Health and Welfare Survey, the interview was undertaken only when the interviewee was present; thus, the total population surveyed was smaller than the overall population of the country.

Table 4.57 Alcohol drinking rate among population aged 11 and over by age and sex, 1991›2009

Age group 1991 1996 2001 2003 2004 2006 2007 2009 (years) Males FemalesMales FemalesMales FemalesMales FemalesMales FemalesMales FemalesMales FemalesMales Females 11-14 - - 0.2 0.05 - - 0.5 0.4 0.5 0.3 0.9 0.4 0.7 0.1 - - 15-19 21.7 2.1 20.8 1.0 19.9 1.9 33.5 5.6 25.5 3.3 24.2 2.9 23.2 1.8 41.0 6.7 20-24 59.5 5.4 56.0 5.7 55.8 7.2 70.4 11.8 59.7 10.1 58.1 8.2 55.3 6.0 } } 25-29 66.7 9.2 67.6 6.9 68.1 10.2 75.7 16.8 72.8 13.1 64.2 9.8 59.8 8.3 30-34 68.6 11.9 67.7 9.5 67.0 12.3 76.5 20.0 72.9 13.5 66.1 12.0 60.7 10.1 35-39 66.2 15.3 69.0 12.2 69.2 14.2 73.3 19.2 73.6 17.6 64.8 14.3 63.7 12.1 62.8 13.4 40-49 65.1 15.6 65.8 12.9 67.5 14.2 73.0 21.7 73.7 17.4 64.6 13.2 61.0 13.4 50-59 56.1 14.2 59.9 10.1 58.7 11.5 64.5 14.4 70.2 13.5 56.3 10.0 50.5 10.2 } } 60 and over 38.0 8.5 36.8 6.3 37.0 5.7 41.9 8.6 62.7 10.4 33.2 5.9 29.4 4.6 34.2 4.9 Total 53.7 9.5 50.1 7.4 55.9 9.8 60.8 14.5 59.3 11.7 50.3 9.1 51.0 8.8 54.4 10.8 Source:A reanalysis of the Health and Welfare Survey Database. National Statistical Office.

125 Table 4.58 Percentage of drinking population by frequency of drinking, 1996, 2001, 2003, 2004, 2006, 2007 and 2009

Drinking frequency19961 20012 20031 20042 20062 20071 20091

Every day 8.6 7.9 9.4 9.5 13.0 8.9 11.7 Quite frequent (3-4 times/wk.) 10.7 9.9 10.7 10.2 11.2 8.9 12.3 Some day (1-2 times/wk.) 17.4 17.2 17.7 18.6 21.1 14.5 20.2 1-2 times/month 16.4 15.3 12.2 16.3 13.2 26.0 19.3 Occasionally 46.2 49.4 50.0 45.5 41.5 41.7 36.3 Unknown 0.6 0.3 - - - - 0.2

Sources:1.Reports on Health and Welfare Surveys, 1996, 2003, 2006 and 2009. National Statistical Office. 2. Reports on Populationûs Smoking and Drinking Behaviours Surveys, 2001 and 2007. National Statistical Office. Notes: 1 Population aged 15 years and over. 2 Population aged 11 years and over.

126 Table 4.59 Alcohol advertisement billings, 1989›2009

Year Advertisement billings (million baht) Increase (%) 1989 255 - 1990 347 +36.1 1991 460 +32.6 1992 514 +11.7 1993 705 +37.2 1994 772 +9.5 1995 1,318 +70.7 1996 2,169 +64.6 1997 1,859 -14.3 1998 1,264 -32.0 1999 1,812 +43.4 2000 2,522 +39.2 2001 1,910 -24.3 2002 2,180 +14.1 2003 2,025 -7.1 2004 2,007 -0.9 2005 2,302 +14.7 2006 2,000 -13.1 2007 1,440 -2.8 2008 1,429 -0.8 2009 1,294 -9.4

Source: Media Spending Company.

Besides, the implementation of free trade agreement has resulted in the tax decrease for imported alcohol from other ASEAN countries from 60% to only 5%, a 12-fold decline; and as a result, the market share of the alcohol imports rose from 99.25 million baht in 2002 to 787.39 million baht in 2003, a 693.3% increase (Table 4.60). In 2010, the import tax for alcoholic beverages from other ASEAN countries was 0%, i.e. there has been no import, tax imposed on alcohol from such countries since then.

127 Table 4.60 Values of imported liquor by source of origin

Import value, million baht Source 2001 2002 2003 2004 2005 2006 2007 2008 ASEAN countries 102.80 99.25 787.39 1,016.34 821.03 872.29 642.96 551.71 Australia 162.67 180.31 59.61 2.55 3.48 2.23 27.73 7.51 European Union 3,389.21 3,844.22 4,312.94 3,980.85 4,485.75 4,718.79 4,173.99 5,305.70 USA 123.19 85.38 205.53 169.99 178.46 258.83 129.66 173.60 Others 310.10 373.61 121.22 123.05 138.70 155.25 101.69 213.33 Total, worldwide 4,087.98 4,582.77 5,486.69 5,292.78 5,627.41 6,007.39 5,076.03 6,251.85

Source: Information Technology and Communication Centre, Office of the Permanent Secretary, Ministry of Commerce, in cooperation with the Customs Department.

The economic cost due to alcohol drinking for Thais was as high as 150.7 billion baht in 2006, which included direct costs (health-care cost, 5,263.3 million baht; loss of properties due to land transport accidents, 779.4 million baht; and law enforcement and litigation cost, 247.6 million baht) and indirect costs (decreased productivity due to premature death, 98.9 billion baht and decreased productivity due to lower efficiency, 45.5 billion baht). The total economic cost was 1.92% of GDP (Table 4.61). It should be noted that the economic cost due to alcohol use was higher than the excise tax revenue collected by the government. Thus, the government needs to have measures to deal with the negative impact of alcohol drinking on society, to reduce alcohol consumption, and to appropriately strike a balance between the state revenue and social welfare spending.

128 Table 4.61 Social and economic costs of alcohol consumption in Thailand, 2006

Cost Million baht 1. Direct cost Health-care cost 5,263.3 - Outpatient care cost 2,294.5 - Inpatient care cost 2,968.8 Law enforcement cost 247.6 - Court cost 154.5 - Police cost 93.1 Cost of property damage due to traffic accident 779.4 2. Indirect cost Cost of productivity loss - Cost of productivity loss due to premature death 98,922.5 - Cost of productivity loss due to reduced productivity 45,464.6 Total cost (million baht) 150,677.4 Total cost as % of GDP 1.92 Total cost per capita (baht) 2,398.21 Source: The economic costs of alcohol consumption in Thailand, under the Health Intervention and Tech- nology Assessment Programme, Ministry of Public Health; Department of Pharmacy, Faculty of Pharmacy, Mahidol University; and the Centre for Alcohol Studies, 2007.

8.5 Physical Activity The 2007 survey conducted by the National Statistical Office revealed that approximately 29.6% of Thai people regularly exercised14 (Figure 4.41). However, when considering the trend in regular exercise for 1987-2007, it was found that Thais had a fluctuating rate of exercise, ranging from 20% to 30% on average (Table 4.62), males exercising more than females (Figure 4.41) and about one-third of the people exercising were 15-24 years of age; the prevalence of teenagers exercising had a declining trend while those in the working age (25›59 years) tended to take more exercise (Figure 4.42).

14 Exercise or physical activity means any movement of the body or part of body for health promotion, entertainment, and socialization, using simple activities or simple rules, such as walking, running, rope-jumping, body-stretching, and weight-lifting (except for exercise while working or body movement in daily life activities).

129 Figure 4.41 Percentage of Thai people who regularly exercised, 1987›2007

Total Males Females Percentage 50

40 36.6 35.7 31.8 32.8 32.7 30.7 29.6 29.1 29.6 27.2 26.7 30 25.7 24.8 23.7 25.4 21.3 19.7 20 15.6

10

0 Year 19871992 2000 2002 2004 2007

Sources:1.Reports on Surveys of People Aged 6 Years and Above Playing or Watching Sports, 1987, 1992, 1997 and 2002. National Statistical Office. 2. Reports on Exercise Behaviour of People Aged 11 Years and Above Surveys, 2004 and 2007. National Statistical Office. Table 4.62 Percentage of Thai people who regularly exercised, 1987›2007

People regularly exercising Year Percent Change (%) 1987 21.3 - 1992 25.7 +20.7 1997 30.7 +19.5 2001 24.2 -21.2 2002 29.6 +22.3 2003 29.0 -2.0 2004 29.1 +0.3 2007 29.6 +1.7

Sources:1.Reports on Surveys of People Aged 6 Years and Above Playing or Watching Sports, 1987, 1992, 1997 and 2002. National Statistical Office. 2. Report on Health and welfare Survey, 2001, National Statistical Office. 3. Reports on Exercise Behaviour of People Aged 11 Years and Above Surveys, 2003, 2004 and 2007. National Statistical Office.

130 Figure 4.41 Percentage of Thai people who regularly exercised by age group, 1987-2007

6 - 14 years 15 - 24 years 25 - 59 years 60 years and over Percentage 100 0.6 1.1 2.7 3.3 11.4 14.3 6.6 8.7 12.0 20 80 31.9 30.7 33.8 43 40.3 60 34.4

40 30.8 29.3 56.1 53.9 56.9 20 42.3 17.5 18.4 0 Year 19871992 1997 2002 2004 2007

Sources:1.Reports on Surveys of People Aged 6 Years and Above Playing or Watching Sports, 1987, 1992, 1997 and 2002. National Statistical Office. 2. Report on Surveys of Exercise Behaviour of People Aged 11 Years and Above, 2004 and 2007. National Statistical Office.

When considering peopleûs exercise behaviours, based on the exercise for health criteria, it was found that more than 60% of Thais (aged 11 years and over) exercised more than 3 days per week and more than half of them spent about the same time period of 21›30 minutes and 31›60 minutes taking exercise (31.0% and 29.3%, respectively); 14.2% exercised more than 60 minutes, and only 3.9% exercised for less than 10 minutes. It is noteworthy that, in 2004, the proportions of people exercising for 31›60 minutes and more than 60 minutes were as high as 33.6% and 23.3% respectively, probably resulting from the influence of exercise campaigns (Figures 4.43 and 4.44). Regarding their continuity of exercise, most of them had exercised continually for more than 7 months, rising from 67.5% in 2004 to 83.4% in 2007 (Figure 4.45).

131 Figure 4.43 Percentage of Thais aged 11 years and over exercising by frequency per week, 2003, 2004 and 2007

2003 2004 2007 Percentage 50

38.2 40 34.6 30.2 31.3 31.2 30 28.2 24.2 21.0 21.6 20 14.3 13.2 12.0 10 Frequency 0 Less than 3 days3 - 5 days 6 - 7 days Irregularly per week Source: Reports on Exercise Behaviour Surveys among People Aged 11 Years and Over, 2003, 2004 and 2007, National Statistical Office. Figure 4.44 Percentage of Thai aged 11 years and over exercising by exercising period, 2003, 2004 and 2007

2003 2004 2007 Percentage 40 35 33.6 31.0 29.3 30 29.2 25.3 24.7 23.3 25 22.6 21.6 20 16.9 14.2 15 14.2 10 6.5 5 3.6 3.9 Time period 0 (minutes per < 10 min10 - 20 min 21 - 30 min 31 - 60 min > 60 min session) Source: Reports on Exercise Behaviour Surveys among People Aged 11 Years and Over, 2003, 2004 and 2007, National Statistical Office.

132 Figure 4.45 Percentage of Thai people regularly exercising by period of time of continuous exercise, 2004 and 2007 Percentage 100 90 83.4 80 67.5 70 60 2004 50 2007 40 30 18.1 11.0 20 9.0 6.9 10 3.4 0.7 Period of 0 continuous 7 + months1 - 3 months 4 - 6 months < 1 months exercise Source: Reports on Exercise Behaviour Surveys among People Aged 11 Years and Over, 2004 and 2007. National Statistical Office. The types of exercise most favored are jogging and aerobics while other sports and walking are less popular (Table 4.63); where they want to play or exercise depends on the type of exercise and the venueûs readiness and convenience. However, it was found that sports playgrounds of educational institutions are mostly used for exercising, followed by empty spaces in a community and residential compounds.

Table 4.63 Percentage of people that exercised by type of exercise, 2001, 2004, and 2007

Type2001 (%) 2004 (%) 2007 (%) Playing sports 55 51 48 Jogging 16 18 18 Aerobics 4 14 8 Walking 16 12 19 Others 8 5 7

Source: Reports on Exercise Behaviour Surveys among People Aged 11 Years and Over, 2004 and 2007. National Statistical Office.

133 With regard to the reasons for exercising, most of them (76.9%) wanted to be healthy, followed by being persuaded by friends (8.5%).

Figure 4.46 Percentage of Thai aged 11 years and over exercising by reason, 2007 Percentage 100 90 76.9 80 70 60 50 40 30 20 8.5 6.6 3.1 2.6 2.3 10 0 Reason for exercising To be healthyPersuaded by To relieve To relieve To lose weight Others friends health problem stress Source: Report on Exercise Behaviours Survey in Thais Aged 11 years and over, 2007, National Statistical Office. Effects of Peopleûs Exercise and Their Health Status An analysis of the association between peopleûs exercise and their health status (morbidity and hospitalization) revealed that, among Thais aged 11 years and over who did not exercise, 16.3% were ill during the past month and 6.4% were hospitalized (Table 4.64). Table 4.64 Thais aged 11 years and over classified by illness, hospitalization and exercise behaviours, 2007

Thais aged 11+ years Exercising Total Ill Hospitalized Number Percent Number Percent Number Percent (thousands) (thousands) (thousands) Total 55,031.0 100.0 Exercising 16,318.9 29.7 2,897.4 17.7 861.6 5.3 Non exercising 38,712.1 70.3 6,301.3 16.3 2,478.6 6.4

Source: Modified from the Report on Health and Welfare Survey, 2007, National Statistic Office.

134 The analysis of the association between exercise and morbidity revealed that those who had exercised for 3 months or more would be less likely to get sick or hospitalized during the past month than those who exercised for a shorter period of time (less than 1 month). It was found that, among the people who exercised for 3+ months, the proportions of those who were ill and hospitalized were only 17.4% and 5.2%, respectively; whereas those who exercised for less than 1 month had higher proportions at 24.1% and 8.2%, respectively (Table 4.65). Table 4.65 Thais aged 11 years and over who exercised and their incidence of morbidity and hospitalization, 2007 Thais aged 11+ years who exercised Duration of exercise Total (thousands) Ill (%) Hospitalized (%) Total 16,318.9 17.7 5.3 1 month and less 424.7 24.1 8.2 2+ months 435.0 22.7 6.2 3+ months 15,459.1 17.4 5.2 Source: Report on Health and Welfare Survey, 2007, National Statistic Office.

8.6 Substance Abuse The trends in substance or drug abuse for 2009 were still on the rise. The estimated number of substance abusers in 2008 was 605,095, compared with that for 2007 of 575,312 (Figure 4.47).

Figure 4.47 Estimated numbers of substance abusers in Thailand, 2001, 2003, 2007 and 2008 Numbers 2,500,000 1,942,100 2,000,000

1,500,000

1,000,000 575,312 605,095 455,500 500,000

0 Year 20012003 2007 2008 Source: Office of the Narcotics Control Board.

135 Regarding the types of substances, most of the abusers use marijuana, kra-tom (Mitragyra speciosa) and methamphetamine (ya ba). In 2007, the number of former ya ba users was as high as 788,900 (Table 4.66), indicating that the use of ya ba is widespread.

Table 4.66 Number of substance abusers in Thailand by type of substance and use duration, 2001, 2003 and 2007

No. of abusers in thousands (percent) Substance 2001 2003 2007 Ever used Ever used Ever used Ever used Ever used Ever used Ever used Ever used Ever used in 1 year in 30 days in 1 year in 30 days in 1 year in 30 days Any substance 7,312.2(16.4) 1,942.1 (4.3) 998.7 (2.2) 3,155.5 (6.9) 455.5 (1.0) 257.8 (0.6) 2,521.5 (5.4) 575.3 (1.2) 335.8 (0.7) Methamphetamines 3,491.6(7.8) 1,092.5 (2.4) 490.3 (1.1) 1,094.0 (2.4) 83.8 (0.2) 34.1 (0.1) 788.9 (1.7) 66.3 (0.1) 22.8 (0.1) (ya ba) E or ecstasy drug 360.1 (0.8) 46.5 (0.1) 17.7 (0.0) 119.7 (0.3) 13.3 (0.0) 7.4 (0.0) 124.3 (0.3) 15.2 (0.0) 3.3 (0.0) K or ketamine drug 40.7 (0.1) 7.2 (0.0) 1.2 (0.0) 23.4 (0.1) 1.0 (0.0) 0.04 (0.0) 30.3 (0.1) - - Cocaine 52.8 (0.1) 4.9 (0.0) 1.1 (0.0) 29.4 (0.1) 7.4 (0.0) 1.0 (0.0) 28.3 (0.1) - - Marijuana 5,425.3(12.1) 667.2 (1.5) 210.0 (0.5) 2,019.1 (4.4) 83.4 (0.2) 18.7 (0.0) 1,506.3 (3.2) 57.5 (0.1) 13.5 (0.0) Kratom (Mytragyna spp.)2,105.8 (4.7) 643.8 (1.4) 364.2 (0.8) 1,160.0 (2.6) 344.7 (0.8) 221.6 (0.5) 1,078.1 (2.3) 378.2 (0.8) 264.5 (0.6) Opiates 907.0 (2.0) 38.6 (0.1) 12.3 (0.0) 323.7 (0.7) 0.6 (0.0) 0.3 (0.0) 228.9 (0.5) 3.0 (0.0) - Heroion 274.2 (0.6) 22.7 (0.1) 9.4 (0.0) 192.6 (0.4) 1.4 (0.0) - 151.0 (0.3) 3.9 (0.0) - Thinner/glue/ 933.9 (2.1) 199.7 (0.4) 101.2 (0.2) 447.9 (1.1) 21.2 (0.1) 13.2 (0.0) NA NA NA benzene Sources:- Reports on Estimates of Substance Abusers in Thailand, 2001 and 2003, Office of the Narcotics Control Board. - Situation of Substance Abuse in 2007, Office of the Narcotics Control Board.

During the period 2008›2009, the numbers of drug-related crime suspects arrested and drug rehabilitation clients or patients in creased from 150,160 to 233,378 and 94,584 to 118,700, respectively (Figure 4.48). Among the drug abusers, most of them are in the 15-24 age group, 70% of whom are new abusers, mostly involving methamphetamine, followed by marijuana and inhalants (Figure 4.49).

136 Figure 4.48 Number of arrested drug-related crime suspects and drug clients, 2003›2009

suspects clients Number 350,000 319,962 300,000 233,378 250,000 200,000 150,160 150,000 109,278 117,071 92,134 100,000 62,660 79,309 118,700 94,584 50,000 62,056 42,929 49,038 55,789 0 Year 20032004 2005 2006 2007 2008 2009

Source: Report on Narcotics Situation for Planning Purposes, Fy 2010. Office of the Narcotics Control Board.

137 Figure 4.49 Proportions of new and old drug-related crime suspects, 2006›2009

new cases Old cases Percentage Percentage 100 100 31.5 29.3 28.8 31.4 15.4 15.5 14.6 16.4 80 80 9.6 9.6 8.9 9.6 60 13.9 14.4 15 16.3 60 40 68.5 70.7 71.2 68.6 23.3 23.7 23.9 23.4 20 40 25.5 24.6 24.2 22.6 0 20 2006 2007 2008 2009 12 11.9 13 11.5 0 2006 2007 2008 2009 new cases Old cases Percentage 25 - 29 yrs 30 - 34 yrs 100 90 36.2 38.2 25.0 23.4 30.5 20 - 24 yrs > 39 yrs 80 70 15 - 19 yrs > 39 - 39 yrs 60 50 40 63.8 61.8 75.0 76.6 69.5 30 20 10 0 BMS. Central Norteast South North

Source: Report on Narcotics Situation for Planning Purposes, FY 2010. Office of the Narcotics Control Board.

When considering the number of drug rehab clients during the period 2001›2009, it was found that the proportion of new cases increased considerably from 43.2% in 2001 to 77.4% in 2009. In particular, when the government issued the war on drug policy in 2003, strict measures were taken to have substance addicts undergo rehabilitation, resulting the rise in the proportion of new rehab clients to as high as 88.7% (Figure 4.50).

138 Figure 4.50 Proportions of drug rehab clients at drug rehabilitation facilities in Thailand, 2001›2009

Old cases New cases Percentage 100 11.3 90 25.7 22.8 22.0 22.2 20.8 22.6 80 56.8 47.8 70 60 50 88.7 40 74.3 77.2 78.0 77.8 79.2 77.4 30 52.2 20 43.2 10 0 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Health Administration, Office of the Permanent Secretary, MoPH. With regard to the type of narcotic users by the first-time clients attending rehabilitation facilities, no difference was noted compared with the previous period; the most commonly used narcotic was methamphet- amine or ya ba (79›84%), followed by marijuana (7›10%), and inhalants (4›5%). The proportion of ya ba clinets was on the rise (Table 4.67). Table 4.67 Proportions of drug rehab clients by type of drug used, 2006›2008 Drug rehab clients (%) Drug2006 2007 2008 Methamphetamine (ya ba) 78.9 80.2 84.5 Heroin 1.2 0.9 0.5 Marijuana 10.2 9.9 6.9 Inhalants 5.0 4.3 4.1 Club drugs 0.9 1.1 1.0 Kratom 1.3 1.4 1.1 Dpiates 1.6 1.4 1.5 Others 0.9 0.8 0.4 Source: Report on Narcotics Situation for Planning Purposes, FY 2010. Office of the Narcotics Control Board.

139 Among the first-time rehab clients, the major group among all the clients, previously they were in the 20›24, 15›19, and 25›29 age groups, respectively. But since 2008, larger numbers of them have been found in the 15›19, 20›24 and 25›29 age groups (Figure 4.51).

Figure 4.51 Proportions of first-time drug rehab clients by age group, 2006›2009

2006 2008

Percentage 2007 2009 30 27.2 26.9 26.4 26.7 25 25.4 25.5 21.5 24.1 25.3 21.3 20 20.8 20.6 13.5 15 12.4

11.9 8.5 10 11.5 6.7 7.0 6.5 6.5 6.4 5 5.8 5.8

0 0 Age (Years) < 15 yrs 15 - 19 yrs 20 - 24 yrs 25 - 29 yrs 30 - 34 yrs 35 - 39 yrs > 39 yrs

Source: Report on Narcotics Situation for Planning Purposes, FY 2010. Office of the Narcotics Control Board.

However, with regard to the occupations of drug rehab clients, most first-time clients were employees, unemployed persons and farmers. During the past three years, they were mainly employees (40%), followed by unemployed persons (23%) and farmers (10%), while students accounted for only 7›8% of the clients and the proportion tends to be gradually rising (Figure 4.52).

140 Figure 4.52 Proportions of drug rehab clients by occupation, 2009

Percentage 40.0 40

30 23.0 20 10.0 10 8.0

0 Occupation Employees Unemployed Farmers Students

Source: Report on Narcotics Situation for Planning Purposes, FY 2010. Office of the Narcotics Control Board. The analysis of drug rehabilitation costs in 10 agencies revealed that, on average, the cost per capita was 15,597 baht for 2007. So, based on a total of 62,056 clients, the total cost would be nearly 1 billion baht and would be steadily rising proportional to the number of clients of 94,584 for 2008 and 118,700 for 2009, or an increase by 34.4% and 20.3% respectively (Table 4.68). Table 4.68 Costs of drug rehabilitation by agency in fiscal year 2007

No. Rehabilitation facility Cost (baht/yr) No. of clients 1 Ban Metta Juvenile Detention Centre 11,138,855 430 2 Probation Office for Dusit District Court 7,431,553 1,018 3 Khlong Phai Community Rehabilitation 10,758,301 400 4 Nakhon Ratchasina Rajanagarindra Psychiatric Hospital 25,914,461 1,063 5 Central Detention Centre, Pathum Thani 4,350,697 4,061 6 Drug Rehabilitation Centre, Lat LumKaeo 28,764,103 360 7 Thanyarak Institute 181,136,030 8,668 8 Children and Youth Training Centre, Ayutthaya 12,032,093 360 9 Drug Rehabilitation Centre, Air Force Wing 46 6,676,737 180 10 Ratchaburi Regional Hospital ,714,682 2,112 Total 290,917,513 18,652 Average rehab cost per person 15,597 baht Source: Report on the Cost-Effective Analysis of Drug Rehabilitation System, Health Economics Centre, Faculty of Economics, (June 2009).

141 8.7 Driving Behaviours 8.7.1 Use of Safety Belt while Driving A survey on safety-belt use among all driver categories reveals that, even though the law has required since 1996 that all drivers and passengers use safety belts at all times, the safety-belt use rate remained at around 30% for the period 1996›2006 (Table 4.69). 8.7.2 Use of Helmet while Riding a Motorcycle Despite the enforcement of the helmet use law since 1996, the actual helmet use rate among Thai people has got no rising trends, i.e. not exceeding 20% for constant use and only around 50% occasional use (Table 4.70).

Table 4.69 Proportion (%) of drivers aged 14 years and over using safety belts by type of use

Use of safety belt 1991(1) 1996(1) 1997(2) 2000(3) 2001(1) 2003(1) 2004(4) 2006(1)

Vehicles with safety belts - Constant use 4.3 35.8 35.7 25.9 27.1 23.5 30.4 31.3 - Occasional use 11.7 28.0 29.6 32.2 44.2 39.7 16.9 45.2 - Non-use 12.6 6.3 34.7 13.9 12.1 32.2 11.5 21.9 Vehicles without 64.6 29.9 - - 4.4 2.4 - 1.6 safety belts

Sources: (1) Data for 1991, 1996, 2001, 2003 and 2006 were derived from Health and Welfare Surveys. National Statistical Office. (2) Data for 1997 were derived from Prapapen Suwan et al. Study on Behaviours and Environmental Conditions for Health Promotion among Youths, Housewives and Factory Workers, 1997. Faculty of Public Health, Mahidol University. (3) Data for 2000 were derived from the Survey of Health Behaviour of Working-age Population (15- 59 years). Health Education Division, Department of Health Service Support. (4) Data for 2004 were derived from the Smoking and Drinking Behaviour Survey, 2004. National Statistical Office. Note: Data for 2001 were derived from a survey on safety-belt use of drivers and passengers aged 15 and over in front seats.

142 Table 4.70 Proportion (%) of motorcyclists aged 14 years and over using helmets while driving

Use of helmets 1991(1) 1996(1) 2000(2) 2001(1) 2003(1) 2004(3) 2006(1)

- Constant use 7.2 29.0 32.0 16.1 16.0 34.4 18.6 - Occasional use 21.7 55.4 44.2 64.3 49.5 31.0 59.7 - Non-use 11.0 6.0 15.8 10.3 32.8 15.9 21.7 - No helmet 59.8 9.3 - 9.1 - - -

Sources: (1) Data for 1991, 1996, 2001, 2003 and 2006 were derived from Health and Welfare Surveys. National Statistical Office. (2) Data for 2000 were derived from the Survey of Health Behaviours of Working-age Population (15-59 years). Health Education Division. Department of Health Service Support. (3) Data for 2004 were derived from the Smoking and Drinking Behaviour Survey, 2004. National Statistical Office. Note: Data for 2001 were derived from a survey on helmet use among motorcyclists andpassengers aged 15 and over.

Alcohol drinking and drunk driving are a major factor causing road traffic accidents/injures. Even though Thailand has launched campaigns against drunk driving, having law prohibiting driving for any person with a blood alcohol concentration exceeding the specified limit, there has been no downward trend for drunk driving; the proportion being 40›50% during the period 2001›2006 and males being twice more likely to do so than females (Figure 4.53).

Figure 4.53 Proportion of drunk drivers by sex, 2001, 2002 and 2006

Percentage 2001 2002 2006 80

53.5 60 48.2 41.1 44.1 40.5 36.6 40 24.7 21.2 15.2 20

0 Sex Total Females Males Source: Reports on Health and Welfare Surveys, 2001, 2003 and 2006. National Statistical Office.

143 8.8 Sexual Behaviours Unsafe sex is the primary health risk in spreading sexually transmitted infections (STIs), especially HIV/AIDS. Thanks to intensive campaigns, people are more aware of self-protection when having sex with a female commercial sex worker (CSW). This brings about a higher condom use rate in CSWs from 25% in 1989 to 96.0% in 2009 (Figure 4.54). However, it has been recently discovered that people are more likely to have sex with other women who are not CSWs. In particular, youths tend to have first sex at a younger age and practise unsafe sex. According to Thailandûs surveillance of HIV/AIDS risk behaviours over the past 15 years (1995-2009), the proportions of military recruits and male industrial workers having sex with CSWs and other women were declining except for a slightly rising rate in 2003 and a rising trend of military recruits having sex with other women (Figures 4.55 and 4.56). However, the constant condom use rate among military recruits having sex with CSWs was higher than with other women they superficially knew (Figures 4.57 and 4.58). Regarding female industrial workers and pregnant women attending an antenatal clinic (ANC), there was a reduction in sexual relation with other males (Figures 4.59 and 4.60), and the rate of constant condom use when having sex with other males was increasing except for 2003 when the rate decreased markedly (Figures 4.60 and 4.61). For male teenagers, it was revealed that there was an increase in sexual relations with various groups of females including, girlfriends, lovers, close friends, CSWs and others (Figure 4.62). They were more likely to use a condom when having sex with CSWs than with other kinds of sex partners (Figure 4.63). But a survey conducted by the ABAC Social Innovation Research Centre of Assumption University (2007) on pre-mature sex among youths (aged 12›24) in Bangkok and its vicinity reveals that one- third (30.9%) of respondents have ever had sex before, a higher proportion in males (37.0%) than in females (24.8%). The 2006 survey conducted by the Centre among a similar age group revealed that two-thirds (45.0%) of them had ever had sex (Table 4.71). Among those with sexual experience, the partners they had first sex with were similar for both surveys, i.e. with lovers (83.1% and 85%, respectively), followed by students at the same or different institution (Table 4.72), and citing similar sex-stimulating situations such as love (68.8% and 66.9% respectively), followed by intimacy and desire to experiment (Table 4.73). The aforementioned situations have indicated that Thai youths are in a delicate situation with regard to sexual relation, many of them having had pre-mature sex. Thus, if there are no suitable preventive measures, they are at risk of contracting HIV and sexually transmitted infactions, resulting in other social problems.

144 Figure 4.54 Condom use rate among female commercial sex workers, 1989-2009

Percentage 120

98.7

98.9

97.6

98

98

97.6

97.3

97

97.1

96.9

96.6

96.0

96.1

95

94

93

100 92

90

84

80 73

65

60 56

50 40 25 20 0 Year

June.89 June.90 June.91 June.92 June.93 June.94 June.95 June.96 June.97 June.98 June.99 June.00 June.01 June.02 June.03 June.04 June.05 June.06 June.07 June.08 June.09 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Figure 4.55 Proportion of military recruitsû sex partners in the past year according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009

CSWs

Percentage Other females 60 55.7 52.8 52.0 49.6 50 48.8 47.9 45.0 44.2 46.0 41.6 43.9 37.8 38.7 40 35.7 29.4 28.9 30 25.9 27.2 24.9 24.0 23.0 24.0 22.1 22.7 22.8 21.8 19.5 20 16.8 18.8

10

0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995›2009).

145 Figure 4.56 Proportion of male industrial workersû sex partners in the past year according to survey on HIV/ AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 CSWs Other females Percentage Males 50 45.2 39.5 40 37.6 30.628.4 29.4 29.5 27.3 29.7 30 25.4 25.7 25.4 27.2 25.0 21.6 22.1 21.8 23.1 25.6 18.5 20 17.3 17.8 15.6 15.1 14.6 14.7 13.3 14.4 15.1 13.5 10 6.8 6.1 2.9 3.0 2.5 3.3 2.3 3.6 4.2 3.3 3.9 4.7 3.8 3.5 0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995›2009). Figure 4.57 Rate of constant condom use during sexual encounters in the past year of military recruits according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009

CSWs Percentage Other females 50 88.6 40 66.6 67.0 69.9 69.2 60.1 63.4 60.1 59.5 63.1 30 54.7 56.7 56.1 55.6 50.4 48.6 40.9 36.6 39.7 40.9 20 32.6 30.9 35.3 35.7 23.9 25.5 25.0 20.1 19.9 20.9 10

0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Bureau of Epidemiology, Department of Disease Control. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995-2009).

146 Figure 4.58 Rate of constant condom use during sexual encounters in the past year of male industrial workers according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009 CSWs Other females Percentage Males 80 75.8 66.7 69.7 60.5 63.4 62.4 63.4 61.9 61.5 60.5 60 54.6 53.5 56.3 57.3 56.1 53.1 47.1 52.7 43.9 38.3 38.6 49.3 52.2 40 32.1 35.9 33.4 45.0 46.2 28.8 32.6 41.7 40.0 36.4 33.9 26.2 30.0 33.3 30.0 33.3 31.7 20 26.3 25.8 27.9 13.4 0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology Division, Department of Disease Control. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995›2009). Figure 4.59 Proportion of female industrial workers having sexual encounters with other males in the past year according to survey on HIV/AIDS risk behaviours in Thailand, 1st›15th rounds, 1995›2009

Percentage 50

40 38.6

30 24.5 20 16.8 10 11.5 6.6 6.3 6.0 6.4 6.6 7.3 5.3 3.0 4.9 4.6 0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995›2009).

147 Figure 4.60 Proportion of pregnant women attending ANC having sex with other males and constant condom use rate according to survey on HIV/AIDS risk behaviour in Thailand, 1st›8th rounds, 1995› 2002 Having had sex Percentage Constant condom use 25

20 19.2 16.7 15 13.8

10 7.4 8.5 5.0 5 3.1 2.7 3.2 3.7 2.8 3.5 1.5 0.9 0.9 0 Year 1995 1996 1997 1998 1999 2000 2001 2002 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note:1.The Bureau of Epidemiology deployed the new data analysis method for the 1st›8th rounds of survey (1995›2002). 2. There has been no survey in ANC clients since 2003. Figure 4.61 Rate of constant condom use during sexual encounters with other males in the past year of female industrial workers according to survey HIV/AIDS risk behavior, 1st›15th rounds, 1995› 2009 Percentage 30 26.3 24.6 25 19.3 20 17.5 21.1 20.0 14.7 15

10 8.8 9.0 9.1 6.5 5.8 6.6 9.4 5

0 Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note: The Bureau of Epidemiology deployed the new data analysis method for the 1st›15th rounds of survey (1995›2009).

148 Figure 4.62 Proportion of male secondary school students (Mathayomsueksa 5 or grade 11) having sex in the past year according to surveys on HIV/AIDS risk behaviours in Thailand, 2nd›15th rounds, 1996›2009 CSWs Girl friends, lovers, close friends Other femals Percentage Males 18 16.6 16 15.2 14.3 14 13.2 13.7 12 10.9 12.0 10 8.6 8.9 8.8 8 7.2 8.0 5.9 6 5.2 4.7 4.4 4.6 4.3 4.2 4.6 4.9 3.6 4.0 3.8 3.0 4 2.8 3.5 3.0 2.5 2.2 1.9 2.4 2.2 2.6 2.3 1.9 2.2 2.0 2.8 2 2.1 1.8 2.1 1.6 1.9 2.2 1.5 2.1 2.1 1.9 0 1.3 1.6 1.3 Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note: The Bureau of Epidemiology deployed the new data analysis method for the 2nd›15th rounds of survey (1996-2009). Figure 4.63 Rate of constant condom use during sexual encounters in the past year of male secondary school students (Mathayomsueksa 5 or grade 11) according to survey on HIV/AIDS risk behaviours in Thailand, 2nd›15th rounds, 1996›2009 CSWs Other femals

Percentage Girl friends, lovers, close friends Males 80 73.9 73.9 70 66.7 66.7 65.2 66.3 60 56.3 54.5 51.9 50.0 50.0 50.0 52.8 60.6 63.9 50 43.1 44.9 41.7 37.5 37.5 38.9 50.0 40.0 40 30.8 33.3 30.0 38.3 28.2 30 25.0 25.0 25.7 27.8 25.0 27.3 22.2 22.4 19.0 21.9 19.7 17.5 25.7 20 22.7 25.0 16.4 13.1 16.4 16.7 10 14.3 3.9 15.4 9.4 0 Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Bureau of Epidemiology, Department of Disease Control. Note: The Bureau of Epidemiology deployed the new data analysis method for the 2nd›15th rounds of survey (1996›2009). 149 Table 4.71 Percentage of youths having had sexual experience, 2006›2007

Sex experience Aged 12›24 yrs (2007) Aged 15›24 yrs (2006)

Having ever had sex 30.9 45.0 Having never had sex 69.1 55.0

Source: ABAC Social Innovation Research Centre, Assumption University.

Table 4.72 Percentage of youthsû first sex partners, 2006›2007. First sex partners Aged 12›24 yrs (2007) Aged 15›24 yrs (2006) Lovers 83.1 85.0 Friends at the same or 11.3 11.0 different institutions Friends met via the Internet - 0.8 Sex workers 1.5 0.6 Others 4.1 2.6 Source: ABAC Social Innovation Research Centre, Assumption University.

Table 4.73 Percentage of situations leading to youthsû first sex, 2006›2007

Situation Aged 12›24 yrs (2007) Aged 15›24 yrs (2006) Feeling of love/like 68.8 66.9 Intimacy with the opposite sex 33.3 34.2 Desire to experiment 28.5 28.8 Alcohol drinking 10.9 9.9 Watching obscene media 6.1 7.1 Friendûs persuasion 3.8 4.9 Others (being forced/deceived, 5.3 6.8 drug taking)

Source: ABAC Social Innovation Research Centre, Assumption University.

150 8.8 Self-Healthcare and Healthcare Seeking Behaviour Peopleûs healthcare seeking behaviours have been changing. Overall, the proportion of people seeking care at state health facilities rose from 15.5% in 1970 to 33.7% in 1996, while the rate of self- medication decreased from 51.4% in 1970 to 37.9% in 1996; and the rate of healthcare seeking at private clinics and hospitals slightly fell from 22.7% in 1970 to 18.7% in 1996. Nonetheless, after the universal coverage of health-care scheme was launched, there has been a change in the health service delivery system; the proportion of people seeking treatment at state-run health facilities has risen from 33.7% in 1996 to 53.9% in 2009, while the self-medication rate has dropped from 37.9% to 23.4% for the same period (Table 4.74). Table 4.74 Pattern of healthcare seeking behaviours among Thai people when ill (percent)

Care or health facility 1970 1979 1985 1991 1996 1996 2001 2003 2004 2006 2007 2009 attended when ill IPSR IPSR IPSR HWS PHS HWS HWS HWS HWS HWS HWS HWS Both rural and urban areas Nothing 2.7 4.2 15.9 0.5 6.9 5.4 5.9 5.3 5.1 4.4 7.7 Traditional care or others 7.7 6.3 2.4 5.7 4.2 2.8 2.5 2.9 4.4 3.3 1.2 0.7 Self-medication 51.4 42.3 28.6 38.3 17.1 37.9 24.2 21.5 20.9 25.0 25.4 23.4 Health centres/primary 4.4 16.8 14.7 14.8 34.5 20.8 17.4 23.9 24.6 16.2 15.4 18.9 care units Public hospitals 11.1 10.0 32.5 12.9 19.4 12.9 34.8 33.1 30.2 30.0 26.4 35.0 Private clinics/hospitals 22.7 20.4 21.8 12.4 24.2 18.7 15.0 19.4 22.7 26.4 25.3 14.3 Rural areas Nothing 15.6 0.4 6.7 5.8 6.0 5.0 4.6 4.1 7.8 Traditional care or others 5.8 6.2 2.5 2.6 3.0 4.4 3.5 1.4 0.6 Self-medication 38.6 11.6 38.4 22.1 19.9 18.7 23.8 23.0 22.0 Health centres/primary 17.0 49.6 24.6 22.3 29.5 30.8 20.0 19.6 22.7 care units Public hospitals 12.8 20.0 13.8 35.2 34.4 31.0 31.3 26.5 34.3 Private clinics/hospitals 10.2 12.3 14.0 11.4 15.4 19.5 23.4 23.4 12.5 Urban areas Nothing 17.9 0.7 7.5 4.4 5.4 6.1 6.4 5.1 7.3 Traditional care or others 4.7 1.3 4.3 2.1 2.6 4.7 2.5 0.8 0.9 Self-medication 36.9 25.2 36.0 29.4 25.6 27.0 28.4 31.4 27.4 Health centres/primary 2.7 12.8 3.5 5.5 9.6 7.1 5.7 4.8 9.1 care units Public hospitals 13.1 18.5 8.9 33.9 30.2 28.3 26.5 25.9 36.8 Private clinics/hospitals 24.7 41.6 39.8 24.0 29.8 32.0 34.4 30.2 18.9

Sources:1.IPSR : Institute for Population and Social Research, Mahidol University, 1988. 2. HWS : The Health and Welfare Survey, NSO, 1991, 1996, 2001, 2003, 2004, 2006, 2007, and 2009. 3. PHS: Provincial Health Survey, BHPP 1996. Notes:1.Different definition of illness in different sources 2. More than one answer could be mentioned.

151 152 CHAPTER 4 Situations and Trends of Health Determinants

As health becomes more complex due to its association with numerous factors, Thailandûs health situations and trends require a wider range of analyses and syntheses of changes in individual and environmen- tal factors of all dimensions that determine health problems as well as the health services system (Figure 4.1).

Figure 4.1 Linkage and dynamics of factors related to health

Education Genetics Economy Population/Family and Behaviours Migration Values/Beliefs and Culture Beliefs Polittics/ IndividualHealth Environment Administration Environment Infrastructure Spirituality Technology

Health Equality/Coverage Services Quality/Efficiency System Type and level of services Public/Private

Dynamics

33 Chapter 5 Health Status and Health Problems of Thai People

1. Overall Health Status Indicators Over the past three decades, the overall health status of Thai people has a promising trend of improvement as evidenced by the following indicators: 1.1 Life Expectancy at Birth In 2008, the life expectancy at birth of Thai people was 70 years. Though higher than that of the people in other developing countries and of the world population, life expectancy of Thais is still lower than that for several other ASEAN countries (Table 5.1). However, during the period 1964›2010, Thaisû life expectancy at birth substantially increased from 55.9 years to 70.6 years for males and from 62.0 years to 77.5 years for females. In 2030, it is expected that the life expectancy of Thai citizens will reach 76.0 years for males and 82.7 years for females (Table 5.2). The World Health Report 2009 also revealed that, Thailandûs healthy life expectancy (HALE) was 62 years: 59 for males and 65 for females, which were lower than those for Singapore, Brunei and Malaysia (Table 5.1).

153 Table 5.1 Life expectancy at birth (in years) of Thai people in comparison with those for other countries

Life expectancy at birth Healthy life Healthy life (4) (7) Group and country expectancy (2002) expectancy (2009) 1998(1) 2002(2) 2004(3) 2006(5) 2007(6) 2008(8) Total Male Female Total Male Female WHO / SEAR Sri lanka 73.3 72.5 74.3 72 74.0 69 61.6 59.2 64.0 63 61 65 Thailand 68.9 69.1 70.3 72 68.7 70 60.1 57.7 62.4 62 59 65 Indonesia 65.6 66.6 67.2 68 70.5 67 58.1 57.4 58.9 60 60 61 Maldives 65.0 67.2 67.0 72 71.1 74 57.8 59.0 56.6 64 64 64 India 62.9 63.7 63.6 63 63.4 64 53.5 53.3 53.6 56 56 57 Bhutan 61.2 63.0 63.4 64 65.7 63 52.9 52.9 52.9 55 54 56 Myanmar 60.6 57.2 60.5 60 61.2 54 51.7 49.9 53.5 50 48 52 Bangladesh 58.6 61.1 63.3 63 65.7 65 54.3 55.3 53.3 56 56 55 Nepal 57.8 59.6 62.1 62 66.3 63 51.8 52.5 51.1 55 55 55 ASEAN Singapore 77.3 78.0 78.9 80 80.2 81 70.1 68.8 71.3 73 71 75 Brunei 75.7 76.2 76.6 77 77.0 76 65.3 65.1 65.5 66 66 67 Malaysia 72.2 73.0 73.4 72 74.1 73 63.2 61.6 64.8 64 62 66 Thailand 68.9 69.1 71.4 72 68.7 70 60.1 57.7 62.4 62 59 65 Philippines 68.6 69.8 70.7 68 71.6 70 59.3 57.1 61.5 62 59 64 Vietnam 67.8 69.0 70.8 72 74.3 73 61.3 59.8 62.9 64 62 66 Indonesia 65.6 66.6 67.2 68 70.5 67 58.1 57.4 58.9 60 60 61 Myanmar 60.6 57.2 60.5 60 61.2 54 51.7 49.9 53.5 50 48 52 Laos 53.7 54.3 55.1 60 64.6 62 47.0 47.1 47.0 54 53 54 Cambodia 53.5 57.4 56.5 62 60.6 62 47.5 45.6 49.5 53 51 55 High human development index (HDI) Japan 80.0 81.5 82.2 83 82.7 53.0 75.0 72.3 77.7 76 73 78 Canada 79.1 79.3 80.2 81 80.6 81.0 72.0 70.1 74.0 73 71 75 Iceland 79.1 79.9 80.9 81 81.7 82 72.8 72.1 73.6 74 71 75 Sweden 78.7 80.0 80.3 81 80.8 81 73.3 71.9 74.8 74 72 75 Switzerland 78.7 79.1 80.7 82 81.7 82 73.2 71.1 75.3 75 73 76 World 66.9 66.9 67.3 67 67.5 68 - - - 59 58 61 Very high HDI 77.0 77.4 78.0 80 80.1 80 ------Medium HDI 66.9 97.2 67.3 69 66.9 67 ------

Source: (1) UNDP, Human Development Report 2000. (2) UNDP, Human Development Report 2004. (3) UNDP, Human Development Report 2006. (4) WHO, World Health Report 2003. (5) WHO, World Health Report 2008. (6) UNDP, Human Development Report 2009. (7) WHO, World Health Statistics 2010. (8) UNDP, Human Development Report 2010. Note: HDI = human development index.

154 Table 5.2 Life expectancy at birth (in years) of Thai people

Year Males Females Female-male difference 1964 - 1965(1) 55.9 62.0 6.1 1974 - 1976(1) 58.0 63.8 5.8 1985 - 1986(1) 63.8 68.9 5.1 1989(1) 65.6 70.9 5.3 1991(1) 67.7 72.4 4.7 1995 - 1996(1) 69.9 74.9 5.0 2005 - 2006(1) 69.9 77.6 7.7 2005 - 2010(2) 70.6 77.5 6.9 2010 - 2015(2) 71.9 78.8 6.9 2015 - 2020(2) 77.3 80.1 6.8 2020 - 2025(2) 74.6 81.4 6.8 2025 - 2030(2) 76.0 82.7 6.7

Sources: (1) Reports on Population Change Surveys, 1964›1965, 1974›1976, 1985-›1986, 1989, 1991, 1995, 1996 and 2005›2006. National Statistical Office. (2) Population Projection for Thailand, 2000›2030. Office of the National Economic and Social Development Board, 2007.

1.2 Maternal Mortality The maternal mortality ratio (MMR) in Thailand has declined from 374.3 per 100,000 live births in 1962 to 10.7 per 100,000 live births in 2009 (Figure 5.1). However, MMR estimates from several surveys are higher than the reported figure. For example, the 1995›1996 RAMOS1 survey on mortality among women of reproductive age revealed a MMR of 44.1, while the Safe Motherhood Project2 reported the MMR at 16.3 and the 2003 study of Yongjua Laosiritaworn3 reported a MMR of 52.2 for the same period; and Worawan Chandoevwit and colleaques4 (2007) reported a MMR of 41.6 for 2006.

1 Survey on Mortality among Women of Reproductive Age Using the Reproductive Age Mortality Survey Method. Bureau of Health Promotion, Department of Health, MoPH. 2 Bureau of Health Promotion, Department of Health. Report on Maternal Mortality in Thailand. Safe Motherhood Project, 1995-1996. 3 Yongjua Laosiritaworn. Situation and Report on Maternal Mortality Resulting from Pregnancy and Childbirth in Thailand, 1995-1996, 2003. 4. Worawan Chandoevwit et al. Using Multiple Data for Calculating the Maternal Mortality Ratio in Thailand, TDRI, 2007.

155 Figure 5.1 Maternal mortality ratio, Thailand, 1962›2009

400

374.3 360.2 350

317.3

311.6 300 298.2

282.1

226.6

260.9 250

226.1

222.4

209.5

200 184.5

171.5

171.7

150 149.0

130.3

128.9

MMR per 100,000 live births

102.9 100 98.5

81.2

69.6

63.5

48.0

42.0

37.2

50 34.7

27.1

24.8

22.7

19.4

15.6

14.7

14.2

13.7

12.9

12.5

13.2

13.0

12.04

12.2

10.7

9.8 12.2 11.3

10.8

10.6

10.7

7.02 0 Year

1966

1962 1964 2006 2008 2009 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Sources: Civil Registration Database, Ministry of Interior, and Bureau of Policy and Strategy, Office of the Perma- nent Secretary, MoPH. 1.3 Infant Mortality In Thailand, the infant mortality rate (IMR, per 1,000 live births) constantly declined from 84.3 in 1964 to 40.7 in 1985›1986 and to 11.3 in 2005›2006 (Figure 5.2). However, although the IMR for Thailand is lower than the global average, it is still higher than that for some other countries in the same region such as Singapore and Malaysia (Table 5.3).

156 Table 5.3 Infant mortality rate and child mortality rate for Thailand in comparison with those for other countries, 1980, 2001, 2003, 2004, 2006, 2007 and 2008

IMR Per 1,000 live birth CMR per 1,000 live birth Group and country 1980 2001 2003 2004 2006 2007 2008 1980 2001 2003 2004 2006 2007 2008

WHO / SEAR North Korea 32 42 42 42 42 - 42 43 55 55 55 55 - 65 Sri lanka 34 17 13 12 11 17 13 48 19 15 14 13 21 15 Thailand 49 24 23 18 7 6 13 58 28 26 21 8 7 14 Indonesia 90 33 31 30 26 25 31 125 45 41 38 34 31 41 Myanmar 109 77 76 76 74 79 71 134 109 107 106 104 113 98 India 115 67 63 62 57 54 52 173 93 87 85 76 72 69 Nepal 132 66 61 59 46 43 41 195 91 82 76 59 55 51 Bangladesh 132 51 46 56 52 47 43 205 77 69 77 62 61 54 ASEAN Singapore 12 3 3 3 3 2 2 13 4 5 3 3 3 3 Malaysia 30 8 7 10 10 10 6 42 8 7 12 12 11 6 Thailand 49 24 23 18 7 6 13 58 28 26 21 8 7 14 Philippines 52 29 27 26 24 23 26 81 38 36 34 32 28 32 Vietnam 57 30 19 17 15 13 12 70 38 23 23 17 15 14 Indonesia 90 33 31 30 26 25 31 125 45 41 38 34 31 41 Myanmar 109 77 76 76 74 79 71 134 109 107 106 104 113 98 Laos 127 87 82 65 59 56 48 200 100 91 83 75 70 61 High income Sweden 7 3 3 3 3 2 2 8 3 4 4 4 3 3 Japan 8 3 3 3 3 3 3 10 5 5 4 4 4 4 Switzerland 9 5 4 5 4 4 4 11 6 6 5 5 5 5 Canada 10 5 5 5 5 5 6 13 7 7 6 6 6 6 Iceland 11 6 5 5 4 3 3 14 6 7 6 4 4 4 World 80 56 57 54 49 46 44 121 81 86 79 71 67 63 High income 13 5 5 6 6 6 5 15 7 7 7 7 7 6 Middle income 57 31 30 30 27 19 38 80 38 37 37 35 22 49 Low income 116 80 80 79 73 80 79 171 121 123 122 110 126 83

Sources:1.World Bank, World Development Indicators, 1999, 2000/2001, 2003, 2004, 2005, 2006. 2. WHO, World Health Statistics, 2008. 3. WHO, World Health Statistics, 2009. 4. UNDP, Human Development Report 2010.

157 Figure 5.2 Infant mortality rate for Thailand, 1964 › 2006

90 84.3 80 70 60 51.8 50 40.7 38.8 40 34.5 30 26.1

IMR per 1,000 live births 20 11.3 10 0 Year 1964 1974 1985-1986 1995-1996 2005-2006

1989 1991

Source: Calculated by the Institute of Population and Social Research, Mahidol University, based on the data from the Population Changes Survey. National Statistical Office.

1.4 Child Mortality Rate The child mortality rate (CMR among children aged under 5 years per 1,000 live births) dropped slightly from 12.8 in 1990 to 9.5 in 2009. It is noteworthy that, during the first stage of the economic crisis, the rate rose to 16.7 in 1998 and has had a tendency to drop further since 1999 (Figure 5.3). However, even though the Thai CMR is lower than the global average, it is still higher than that for other countries in this region such as Singapore and Malaysia (Table 5.3). It is also noted that the rate reported by the Registration Administration Bureau of the Ministry of Interior tends to be lower than reality, whereas the rate of 15.7 was derived from the 2006 population change survey.

158 Figure 5.3 Child mortality rate in Thailand, 1990›2009

Economic crisis 20

15 16.7 14.5 12.8 12.8 11.9 12.3 12.0 11.7 11.6 11.4 11.6 11.7 11.3 10.8 10.4 10.0 9.9 10 9.5

5

Child mortality rate per 1,000 live births 0 Year

1990

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. Note: In 1996›1997, there was some adjustment in the data processing system of the Registration Admin- istration Bureau of the Ministry of Interior and, as a result, there was no child death data processing for those years, possibly resulting in the higher CMR for 1998.

1.5 Causes of Death The causes of death analysis for 2005›2008 under the Setting Priorities using Information on Cost-Effectiveness Spice 2004-›2009 Project, using verbal autopsy from of the database of the Bureau of Policy and Strategy, MoPH, and the review of data from hospitalsû medical records, reveals that the number one cause of death was cerebrovascular disease, almost equal numbers of deaths for males and females at 23,741 and 21,546, respectively. Among males, the next 5 causes of death (in descending order) were road traffic accidents (20,458 deaths), AIDS (19,953 deaths), ischemic heart disease (16,164 deaths), chronic obstructive pulmonary disease (14,396 deaths) and cirrhosis (12,628 deaths), while in females, the causes were diabetes (15,254 deaths), ischemic health disease (14,300 deaths), AIDS (10,868 deaths), chronic kidney failure (7,627 deaths) and pneumonia (6,483 deaths). It is noteworthy that AIDS is still a health problem for males, whose number of deaths was almost twice that for females. Besides, road traffic accident remains a severe health problem among males. For cancers, they were among the top 12 leading causes of death for males (liver and lung cancers) and females (cervical and liver cancers) (Table 5.4).

159 Table 5.4 Number and percentage of deaths among Thai people, estimated for the top 12 causes, by sex, 2005

Males Females Cause of death Cause of death No. Percent No. Percent Cerebrovascular disease 23,741 9.4 Cerebrovascular disease 21,546 11.3 Road traffic accidents 20,458 8.1 Diabetes 15,254 8.0 AIDS 19,953 7.9 Ischemic heart disease 14,300 7.5 Ischemic heart disease 16,164 6.4 Undefined cause 13,728 7.2 Pulmonary disease 14,396 5.7 AIDS 10,868 5.7 Cirrhosis 12,628 5.0 Chronic kidney failure 7,627 4.0 Liver cancer 11,365 4.5 Pneumonia 6,483 3.4 Undefined cause 9,598 3.8 Cervical cancer 5,720 3.0 Lung cancer 9,345 3.7 Liver cancer 5,339 2.8 Diabetes 8,082 3.2 Hypertension 5,339 2.8 Pneumonia 7,072 2.8 Chronic obstructive 4,957 2.6 pulmonary disease Suicide 6,819 2.7 Other heart diseases 4,767 2.5 Other diseases 92,944 36.8 Other diseases 74,743 39.2 Total 252,566 100 Total 190,670 100

By age group and sex, the causes of death are as shown in the table below:

Age group Major causes of death (years) Males Females 0 - 14 Perinatal asphyxia /birth trauma /road traffic accidents /accidental drowning 15 - 49 HIV/AIDS, road traffic accidents HIV/AIDS, road traffic accidents 50 - 74 Cerebrovascular diseases, ischemic heart disease Diabetes, cerebrovascular diseases, 75 + Cerebrovascular diseases, chronic obstructive Cerebrovascular diseases, ischemic pulmonary disease heart disease Source: Cause of Death Quality Development Project, Thailand, 2005-2008. 1.6 Causes of Illness Surveys on peopleûs illnesses conducted by the National Statistical Office between 1991 and 2007 revealed that the most prevalent illness was diseases of the respiratory tract, followed by musculoskeletal diseases and gastrointestional diseases. However, when considering the trends in illnesses, it was found that the prevalence of cardiovascular diseases, endocrine system diseases, allergies and neuropsychiatric diseases were on the rise (Table 5.5).

160 Table 5.5 Percentage of people with illnesses by major group of diseases, 1991›2007

Group of diseases 1991 1996 2001 2003 2004 2005 2006 2007 Respiratory tract diseases 38.1 45.7 39.6 40.2 44.8 45.0 44.3 40.9 Musculoskeletal diseases 15.7 13.2 14.0 14.9 11.8 12.2 11.4 11.4 Gastrointestinal diseases 15.4 11.3 10.0 10.3 9.1 9.3 9.4 9.4 Cardiovascular diseases 3.0 6.6 6.6 6.3 5.2 5.9 6.3 4.1 Endocrine system diseases 1.4 3.3 4.7 4.4 3.1 4.4 4.1 5.1 Oral ear, throat, nose, eye 4.7 3.2 3.6 2.6 3.3 3.2 2.7 2.2 and dental diseases Infectious diseases 2.2 2.1 1.8 1.3 2.1 1.7 0.9 1.0 Urinary tract diseases 1.4 1.8 1.3 1.3 1.1 0.9 1.0 1.2 Allergies 0.7 1.5 1.8 2.1 1.8 1.9 2.3 2.2 Neuropsychiatric diseases 0.8 1.3 1.5 1.7 1.6 1.9 2.1 1.8 Skin diseases 3.2 1.2 1.5 1.1 1.0 1.2 1.4 1.8 Female genital diseases 1.4 0.8 0.9 0.9 0.8 0.8 0.7 0.9

Source: Reports on Health and Welfare Surveys, 1991, 1996, 2001, 2003, 2004, 2005 2006 and 2007. National Statistical Office.

1.7 Disabilities A survey conducted by the National Statistical Office revealed that the proportion of people with disabilities was rising from 0.5% in 1974 to 1.7% in 2002 and rose to 2.9% in 2007 (Table 5.6). However, other surveys have reported higher prevalence, compared with that reported by NSO. For example, the 1991- 1992 health examination survey on the Thai population revealed a 6.3% disability prevalence (excluding mental/intellectual disabilities); and if all kinds of disabilities are taken into account, the overall prevalence of disabilities will be 8.1% of the total population. Besides, Suwit Wibulpolprasert and colleagues (1997) projected that the prevalence of people with disabilities had increased at a rate higher than that of the population growth. The physical and movement disabilities were most commonly found, which is associated with the socio-economic changes and the countryûs epidemiological transition.5 Regarding the characteristics of disability, for 2007, the top 5 disabilities and crippling conditions were impaired vision in both eyes, impaired vision in one eye, hearing impairment in both ears, paresis, and atrophied/inflexible limbs, which are similar to those reported in 2002, except for hearing impairment in both ears and paresis which slightly declined (Figure 5.4).

5 Suwit Wibulpolprasert et al. Medical Rehabilitation Service System for the Disabled, 1997.

161 Figure 5.4 Proportion of people with disabilities (first five major types), 2002 and 2007

Type of disability Impaired vision, 6.8 one eye 10.4 2002 Atrophied/inflexible 7.6 limbs 8.0 2007 10.2 Paresis 9.1 Hearing impairment, 10.3 both ears 9.5 Impaired vision, 21.9 both eyes 22.3 Percentage 0 5 10 15 20 25

Sources:1.Report on Disabilities and Crippling Conditions Survey, 2002. National Statistical Office. 2. Disability Survey, 2007. National Statistical Office.

Besides, a survey on peopleûs difficulties or health problems of at least 6 months in 2007 found that the top 5 difficulties among the disabled persons were walking up one flight of stairs (to another floor, seeing, walking 50 metres on a flat surface, squatting, and body pain with a prevalence of 42.2%, 40.7%, 40.6%, 37.6% and 28.2%, respectively (Table 5.5).

162 Figure 5.5 Percentage of disabled people aged 7 years and over with top 5 difficulties by type of difficulties and degree of difficulty, 2007 Disabled persons aged 7 yrs and Some A lot of Unable to over with difficulties or health difficulty difficulty do it at all Percentage problems = 1,833,297 (100%) 50 42.2 40.7 40.6 40 37.6 15.5 14.0 30 15.5 28.2 No. difficulty with help of 25.4 device/drug 16.6 20 14.8 Some difficulty 15.1 11.1 12.8 10 11.9 A lot of difficulty 9.9 12.5 10.2 0 2.5 1.3 Unable to do it at all Walking one seeing Walking 50 Squatting Body pain flight of stairs metres on flat surface Source: Disability Survey, 2007, National Statistical Office. Notes:1.Responses can be made to more than one type. 2. For the top 5 health sufferings/problems, less than 0.1% of the disabled persons. Table 5.6 Number and percentage of Thai people with disabilities, 1974›2007 People with disabilities Year of survey Population Number Percentage of total population (thousands) (thousands) 1974 39,796.9 209.0 0.5 1976 42,066.9 245.0 0.6 1977 44,211.5 296.2 0.7 1978 45,344.2 324.6 0.7 1981 47,621.4 367.5 0.8 1986 51,960.0 385.9 0.7 1991 57,046.5 1,057.0 1.8 1996 59,902.8 1,024.1 1.7 2001 62,871.0 1,100.8 1.8 2002 63,303.0 1,098.0 1.7 2007 65,566.3 1,871.8 2.9 Sources:1.Health and Welfare Survey Projects, 1974›2002. National Statistical Office. 2. Disability Survey, 2007. National Statistical Office.

163 1.8 Epidemiological Transition Overall, according to a death certificates analysis, the major and rising causes of death among Thai citizens are non-communicable diseases, accidents, and HIV/AIDS (which is currently a major health problem of the country). The prevalence rates of communicable diseases, which used to be significant health problems, have been declining except for re-emerging diseases such as tuberculosis that is associated with HIV/AIDS (Figure 5.6). This is consistent with the results of the Burden of Disease Study which revealed that the disease burdens in terms of disability-adjusted life years (DALYs) from non-communicable diseases were three times as much as those from communicable diseases, and that the longer the people live, the greater the tendency for them to have non-communicable diseases (Table 5.7). Figure 5.6 Mortality rates due to major causes of death, Thailand, 1967›2009

100 95 90 88.5

87.4 (1) 86.02 87.6

Heart diseases 84.83 84.9 85 (1) 83.1

81.4 Accidents, all types 81.69 81.3 80 Cancer(1) 78.9 (3) 75 AIDS 81.45 72.1 80.12 (1) 73.3 78.99 69.2 77.44

Malaria 76.54

70 75.49 Tuberculosis(1) 68.72 68.44 65 (2) Diarrhoea 61.5 59.8 60 58.5 58.9 56.9 56.7 55 54.7 58.61 57.6 55.1 52.7 50.9 49.85 55.1 50 49.5 45.6 49.7 48.47 45 42.7 42.72 40.6 41.8 45 43.8 40 36.8 41.2 38.5 33 33.5 37.4 35 35.1 36.54 30.3 32.2 30.29 28.2 29.3 28.6 Mortality rate per 100,000 population 30 26.2 27.7 27.6 31.5 29.8 25 23.1 27.9 26.8 28.4 16.5 26.1 24.6 20 22.4 19.3 28.1 19.7 15.2 16.67 15 12.6 13.1 16 12

11.1

14.9 10.8

10.1

10.2 9.7

8.6 8.9

12.9 8.3

7.8 7.7 10 7.6 7.6 11.3 10.9 6.5 6.1 7 6.1 7.1 4 4.9 3 5 6.7 3.33 2.5 2.7 1.93 1.2

1.2 0.7

0.6

0.4

0.3

0.3

0.2

0.2

0.3 0 3.1 2.5 2.1 0.1 Year 0.001 0.21 1.7 1.4

0.58

0.18

0.35

0.26

0.33

0.14

0.13

0.08

0.1

0.13

1967

1972

1977

1982

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2008 2009

Sources: (1) Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. (2) Bureau of Epidemiology, Department of Disease Control, MoPH. (3) Working Group on Forecast of HIV-infected Cases. Forecast of HIV-infected Cases in Thailand, 2000-2020, 2001.

164 Table 5.7 Percentage of causes of disability-adjusted life years (DALYs) lost among Thai people by age group, 2004 Percentage of DALYs lost by age group Cause of DALYs lost 0 - 4 5 - 14 15 - 44 45 - 59 60 and over Total - Communicable diseases 55.3 33.6 25.6 14.6 10.3 20.2 - Non-communicable diseases 32.9 34.7 50.7 73.7 85.8 65.1 - Accidents 11.7 31.6 23.7 11.7 3.9 14.8

Source: Working Group on Burden of Disease and Risk Factors, Thailand. International Health Policy Program, MoPH, 2006. 1.9 Disability-Adjusted Life Years Lost among Thai People In measuring the health status of Thai people using DALY6 as the indicator, it was found that the number one cause of DALYs lost is HIV/AIDS for males, cerebrovascular diseases for females, the second and third causes were road traffic injuries and alcohol abuse-related diseases respectively among males, and HIV/AIDS and diabetes respectively among females (Table 5.8). Besides, when considering the health problems by age group, the differences in life-threatening problems are as follows: Age group 0›14 years: major health problems are low birth weight and perinatal asphyxia; Age group 15›29 years: major health problems are HIV/AIDS, road traffic injuries, drug abuse, schizophrenia, and alcohol abuse; Age group 30›59 years: major health problems are HIV/AIDS, road traffic injuries, diabetes, and liver cancer; Age group 60 years and over: major health problems are cerebrovascular diseases, emphysema, and diabetes.

6 Disability-Adjusted Life Year (DALY): One DALY is one lost year of healthy life; calculated from the formula çDALYs = years lost to premature death + years lost to illness or disabilityé.

165 Table 5.8 Major diseases attributable to disability-adjusted life years (DALYs) lost among Thai people by sex, 2004

Males Females No. Disease DALYs loss Percent Disease DALYs loss Percent 1 HIV/AIDS 645,426 12.1 Cerebrovascular disease 307,131 7.9 2 Road traffic injuries 600,004 11.3 HIV/AIDS 290,711 7.5 3 Alcohol abuse 329,068 6.2 Diabetes 267,549 6.9 4 Cerebrovascular diseases 305,105 5.7 Depression 191,490 4.9 5 Liver cancer 294,868 5.5 Liver cancer 140,480 3.6 6 Ischemic heart disease 178,011 3.3 Road traffic injuries 135,832 3.5 7 Chronic obstructive 175,549 3.3 Ischemic heart disease 117,790 3.0 pulmonary disease 8 Diabetes 168,702 3.2 Knee osteoarthritis 117,042 3.0 9 Depression 136,895 2.6 Chronic obstructive 112,663 2.9 pulmonary disease 10 Cirrhosis 133,046 2.5 Cataract 110,572 2.8 Source: Working Group on Burden of Disease and Risk Factors, Thailand. International Health Policy Program, MoPH, 2006.

1.10 Chronic Non-Communicable Diseases in Developing Countries The problem of chronic non-communicable diseases (NCDs) is on the rise in developing countries. According to the 2005 WHO survey on chronic NCDs and their impact in 23 developing countries, including Thailand, the most common NCDs are cardiovascular diseases, diabetes, cancer and chronic respira- tory diseases, which account for more than 60% of all deaths (approximately 35 million). Among the deaths, 32% were due to cardiovascular diseases and diabetes, 13% due to cancer, and 7% due to chronic respiratory illnesses. And it is expected that the number of deaths will rise to 41 million in 2015. Moreover, it was found that in 2005 the burden of disease (DALYs lost) due to chronic NCDs was 50% of all diseases, 12% of which was due to diabetes and cardiovascular diseases (including heart and cerebrovascular diseases) and 9% due to cancer and chronic respiratory diseases; and it is expected that in the next 10 years (in 2015), the burden of disease will rise for all groups of illnesses (Table 5.9). Therefore, WHO has set the target to reduce the mortality rate due to chronic NCDs by an additional 2 percentage points each year.

166 Table 5.9 Proportion of disability adjusted life years (DALYs) lost due to chronic NCDs among peoples in 23 developing countries including Thailand

Percent of DALYs lost Group of diseases 2005 2015 Cardiovascular disease and diabetes 12 13 Cancer 5 6 Chronic respiratory diseases 4 5 All chronic NCDs 50 55

Source: D. Abegunde, C. Mathers, T. Adam, M. Ortegon, & K. Strong (2007). Chronic Diseases 1: The burden and costs of chronic diseases in low-income and middle-income countries. Lancet, 370, 8, 1929-38.

2. Major Health Problems 2.1 Communicable Diseases 2.1.1 Vaccine-preventable Diseases Since the Ministry of Public Health launched the Expanded Programme on Immuniza- tion (EPI) in target population groups, the immunization coverage has remarkably improved (Table 5.10 and Figure 5.7).

167 Table 5.9 Proportion of disability adjusted life years (DALYs) lost due to chronic NCDs among peoples in 23 developing countries including Thailand

Percent of DALYs lost Group of diseases 2005 2015 Cardiovascular disease and diabetes 12 13 Cancer 5 6 Chronic respiratory diseases 4 5 All chronic NCDs 50 55

Source: D. Abegunde, C. Mathers, T. Adam, M. Ortegon, & K. Strong (2007). Chronic Diseases 1: The burden and costs of chronic diseases in low-income and middle-income countries. Lancet, 370, 8, 1929-38.

2. Major Health Problems 2.1 Communicable Diseases 2.1.1 Vaccine-preventable Diseases Since the Ministry of Public Health launched the Expanded Programme on Immuniza- tion (EPI) in target population groups, the immunization coverage has remarkably improved (Table 5.10 and Figure 5.7).

167 (5)

2008

(4)

2006

(3)

2003

ntrol, MoPH.

003. Department of

(2)

2002

(2)

2001

(2)

2000

(2)

1999

(2)

1998

(2)

1997

(2)

1996

(1)

1995

(1)

1994

(1)

1993

(1)

1992

(1)

Coverage (percent) in fiscal year

1991

(1)

1990

(1)

1989

(1)

1988

(1)

1987

(1)

1986

(1)

1985

(1)

1984

(1)

1983

(1)

1982

Data for 1982›1995 were derived from the Department of Communicable Disease Control, MoPH. Data for 1996›2002 were derived from the Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. Coverage of immunization against vaccine-preventable diseases in different target groups, 1982›2008 Data for 2003 were derived from the survey on coverage of the basic immunization program and the polio immunization campaign, 2 Disease control, MoPH. Data for 2006 were derived from the child situation survey, Thailand, Dec 2005 › Feb 2006. National Statistical Office. Data for 2008 were derived from the survey on basic immunization coverage for school children in 2008. Department of Disease co

(1)

(2) * Data from the 1st Provincial Health Survey (1995).

(3)

(4)

(5)

:

(%) 34 40 53 59.3 71.8 71.3 73.8 83.2 89.3 89.8 91.5 92.2 92.7 93.7 94.3 92.3 95.8 93.0 94.5 89.3 89.7 97.6 97.6 98.7

(%) 21 48 53 60.5 73.9 72.8 74.8 84.2 89.4 89.8 91.5 92.2 92.9 93.7 94.3 92.5 95.9 92.1 94.4 89.1 89.8 97.6 97.1 98.7

3

3

‹(%) ------15.4 57.1 65.6 79.3* 90.7 88.5 93.0 90.4 94.9 87.9 88.8 96.0 88.3 98.3

Activity

+ Booster(%) 30 38 40 48 50 53.1 59.6 75.9 81.6 81.6 87.8 86.4 86.9 92.8 93.0 82.5 85.7 80.4 74.0 75.5 74.5 93.3 89.2 96.7

3

2

Children <1 yr BCG (%)OPV 73 75 76 78.4 89.5 87.4 88.6 94.1 96.3 96.8 97.4 98.1 97.9 98.4 98.4 96.9 96.5 95.6 98.8 89.4 98.1 99.5 98.0 99.9 DPT Measles(%) - - - - - 48.2 51.1 61.4 78.4 81.5 86.3 86.1 86.0 89.8 90.8 73.0 87.2 90.5 83.8 83.1 83.7 96.1 91.4 98.1 HB

Pregnant women TT

Table 5.10 Sources

168 Figure 5.7 Coverage of immunization: BCG, DPT3, OPV3, HB3 measles among children and TT2+ booster among pregnant women, 1982›2008

120

100

80

60 BCG DPT Coverage (Percentage) 3 40 OPV3 Measles

20 HB3

TT2 + Booster 0 Year

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Sources: (1) Department of Disease Control, MoPH. (2) Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

As a result of such high immunization coverage, the morbidity rates of vaccine-preventable diseases have a tendency to decline (Table 5.11 and Figures 5.8 and 5.9) Besides, it was noted that hepatitis B infection had a rising incidence, probably resulting from a more extensive surveillance effort (Figure 5.10).

169 Table 5.11 Incidence rates of major vaccine-preventable diseases in Thailand, 1977›2009

Incidence of vaccine-preventable diseases per 100,000 population Year Measles Neonatal Diphtheria Pertussis Poliomyelitis Hepatitis B tetanus 1977 20.2 72.1 5.2 7.2 2.1 n.a. 1979 28.9 70.0 4.4 11.2 2.3 0.09 1981 51.1 59.8 1.6 6.2 0.5 0.14 1983 70.2 53.6 2.1 9.8 0.3 0.12 1985 66.2 60.4 1.4 4.8 0.1 0.55 1987 78.3 47.9 1.0 2.7 0.04 1.57 1989 22.5 28.1 0.1 2.2 0.03 3.30 1991 46.9 14.5 0.09 0.5 0.009 5.98 1993 25.2 4.7 0.04 0.6 0.015 4.39 1995 16.4 6.4 0.03 0.2 0.003 3.13 1996 9.5 0.05 0.08 0.13 0.03 2.20 1997 22.03 0.04 0.06 0.17 0.00 2.27 1998 22.39 0.03 0.08 0.16 0.00 2.53 1999 5.38 1.55 0.08 0.08 0.00 2.60 2000 6.67 0.03 0.02 0.16 0.00 2.71 2001 11.86 0.36 0.02 0.12 0.00 2.80 2002 16.48 1.14 0.02 0.02 0.00 3.44 2003 7.17 0.01 0.01 0.04 0.00 3.68 2004 6.66 0.02 0.02 0.03 0.00 4.54 2005 5.67 0.01 0.00 0.04 0.00 4.41 2006 5.31 0.00 0.00 0.11 0.00 5.48 2007 6.20 0.50 0.01 0.04 0.00 6.94 2008 12.32 0.38 0.01 0.03 0.00 8.39 2009 9.57 0.13 0.02 0.04 0.00 8.46

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

170 Figure 5.8 Incidence of neonatal tetanus and measles in Thailand, 1977›2009

90 80 Measles 70 Neonatal tetanus 60 50 40 30

Incidence per 100,000 population 20 10 0 Year

1987 1989 1991 1977 1993 1979 1981 1983 1985 1995 1997 1999 2001 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

Figure 5.9 Incidence of pertussis, diphtheria, and poliomyelitis in Thailand, 1977›2009

12 Pertussis 10 Diphtheria

8 Poliomyelitis

6

4

Incidence per 100,000 population 2

0 Year

1977

1983

1979 1987 1989 1995 1981

1985

1991 1993

1997 1999 2001 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

171 Figure 5.10 Incidence and mortality rates of hepatitis B in Thailand, 1979›2009

Mortality Incidence

0.025 8.39 9 6.94 8

0.02 0.02 Hepatitis B vaccination began 0.020 5.48 7 population 100,000 per Incidence 5.98 6 5.61 5.35 0.015 4.54 4.52 4.54 5 4.39 4.41

0.01

0.01

0.01

0.01 3.44 0.01 4 0.010 3.13 3.68

0.008

3.30 0.008 2.53 2.71 3

0.006 0.006 2.27 2.60 2.80

0.005

0.005 0.008 2.20 2

1.57 0.004

0.004

Mortality rate per 100,000 population

0.005 0.004

0.003

0.003 1.00 1.43 0.003

0.002

0.002

0.002

0.002 0.002 0.49 1

0.0

0.00

0.09

0.00 0.14 0.12 0.55 0.003 0.000 0.14 0 Year

0.0

1979

1982

1985

1988

1991

1994

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

2.1.2 Diarrhoea Acute diarrhoea is still a crucial public health problem with a relatively slight change in incidence among children and adults, particularly among children under five years of age whose incidence is higher than that in adults. However, the mortality rate has been declining considerably (Figure 5.11) due to improved and extensive coverage health services as well as the success of the campaign on oral rehydration therapy (ORT).

172 Figure 5.11 Incidence and mortality rates of diarrhoea in Thailand, 1977›2009

Incidence of diarrhoea in chidren under 5 Incidence of diarrhoea in all age groups Mortality of diarrhoea in chidren under 5 Mortality of diarrhoea in all age groups 12,000 5 4.59

10,639.40

10,476.55 4.5

10,312.45

10,140.23

10,000 9,691.30 10,000.00 4 population 100,000 per rate Mortality

8,483.6

8,000 7,753.8 3.5 3.03 3.02 7,140.9 6,794.6 3 2.64

2.89 5,804.7 6,000 2.5

7,242.3

7,193.6

5,095.6 2.2

4,285.8 1.71 2 4,000 5,741.4 1.56

3,031.3 3,135.7 1.5 1.19 1.17 1.22 Incidence per 100,000 population 1.04

2,097.83

2,150.21

2,050.78

1,988.03 0.88 0.86 1,988.11 0.83 1,945.7 1

1,667.2 2,000 0.64 1,686.0 1,741.3 0.82 1,719.49 2,023.64

0.55 1,207.3 1,398.7 0.7 0.62

0.40

0.72 0.22 858.3 1,564.3 0.43 0.5

0.23 383.52 1,258.1 1,488.5 0.62 0.10

224.66 0.62 513.19 852.68 0.58

0 0.35 0.33 0 Year

0.26

0.26

0.18

0.13

0.14

0.13

0.10

0.08

1985 1987 1989 1991 1993 1995 1997 1999 1977 2001 2002 1979 2003 2004 1981 2005 2006 1983 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control.

2.1.3 Acute Respiratory Infection among Children Currently, acute respiratory infection is still a crucial public health problem in Thailand. Pneumonia is the number one cause of death, among all infectious diseases, in children under five. The incidence of pneumonia in children has fallen from 5.2% in 1995 to 1.58% in 2009; and its mortality rate (per 100,000 population) has steadily dropped from 15.1 in 1990 to 1.74 in 2009 (Figure 5.12).

173 Figure 5.12 Incidence and mortality of pneumonia in children under five in Thailand, 1990›2009

Incidence mortality rate 6 5.6 30 5.2

5 25 mortality rate per 100,000 population 100,000 per rate mortality 4.7 4.5 4.6 4.0 4 19.20 20

3 15.10 2.73 15 10.78

Incidence (Percent) 9.58 9.57 9.05 1.96 1.92 1.85 2 8.97 1.74 1.67 1.64 10 1.83 1.60 1.58 1.63 1.33 1.58 1 3.74 2.94 5 2.59 2.14 1.90 3.75 1.77 1.59 1.10 1.78 1.50 1.74 0 0 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources: (1) Department of Disease Control, MoPH. (2) Bureau of Epidemiology, Department of Disease Control, MoPH.

2.1.4 Leptospirosis Leptospirosis is a re-emerging infectious disease having an incidence rate between 0.2 and 0.7 per 100,000 population during the period 1981›1996. But over the past four years the incidence and mortality rates was on the rise, i.e. the incidence per 100,000 population rising from 0.67 in 1996 to 23.2 in 2000, but dropping to 4.61 in 2005 (Figure 5.13). Over 50% of the patients live in the Northeastern region of the country (Figure 5.14). However, for the period 2008›2009, both the incidence and mortality rates were on the rise.

174 Figure 5.13 Incidence and mortality rates of leptospirosis in Thailand, 1981›2009

0.7 25 Mortality 23.2 0.6 0.59 Incidence rate per 100,000 population Incidence 20 0.5 16.31 0.43 0.4 15 10.97 0.3 9.87 10 0.27 7.79 0.17 6.29 6.66 8.57 0.2 0.19 5.12 5.22 3.86 0.15 0.12 5

Mortality rate per 100,000 population 0.1 0.13 4.61 0.67 3.65 0.11 0.09 0.1 0.26 0.23 0.23 0.51 0.37 0.28 0.18 0.24 0.03 0.07 0.06 0 0 Year 0 0 0 0 0.01 0.003 0 0.01

1981

1984

1987

1990

1993

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MOPH.

Figure 5.14 Morbidity rate of leptospirosis by region in Thailand, 1985›2009

North Central Northeast South

100

10

1

0.1

Morbidity rate per 100,000 population 0 Year 1985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 North 0.27 0.78 0.89 0.67 0.66 0.7 0.49 0.36 0.32 0.36 0.58 0.32 0.37 0.94 3.08 8.72 13.9 6.43 6.76 3.48 4.55 7.87 4.54 4.13 4.41 Central 0.23 0.2 0.4 0.21 0.18 0.1 0.1 0.11 0.07 0.06 0.1 0.12 0.18 0.38 0.07 2.00 1.43 0.99 1.17 0.85 0.71 1.95 1.09 1.00 1.02 Northeast 0.22 0.23 0.19 0.41 0.32 0.3 0.33 0.38 0.2 0.11 0.18 1.59 10.9 9.42 25 54.6 36.3 26.5 17.7 11.3 9.02 10.2 9.64 13.7 17.6 South 0.23 0.23 0.4 1.2 0.58 0.4 0.28 0.38 0.15 0.32 0.22 0.1 0.19 0.39 1.08 4.55 5.61 2.08 1.9 2.21 3.1 4.93 5.02 6.67 10.5

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

175 2.1.5 Leprosy The Leprosy Control Programme in Thailand has been implemented for over 40 years with the initiation of His Majesty the King and the support of the World Health Organization as well as several NGOs. The Programme has been quite successful in reducing the leprosy prevalence rate from 5 per 1,000 population in 1955 to 0.01 per 1,000 population in 2009 the rate for WHO to recognize Thailand as having eliminated leprosy (Figure 5.15). For the whole country, to date 170,000 leprosy patients have been cured as the leprosy control programme has been successfully implemented in a holistic manner according to His Majesty the Kingûs advice. The success of the Programme has been partially attributable to the introduction of the short-course multiple-drug therapeutic (MDT) regimens, recommended by WHO in 1984.

Figure 5.15 Incidence of leprosy in Thailand, 1977›2009

1 0.88 0.9 0.89 0.81 0.83 0.9 0.8 0.8 0.8 0.81 0.65 0.6 0.54 0.41 0.4 MDT 0.3 0.23

Incidence per 1,000 population 0.2

0.13

0.12

0.14 0.08

0.05

0.04

0.05

0.05 0.04

0.05

0.04

0.03

0.03

0.02 0.02

0.02

0.02

0.01 0 0.01 Year

2000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1977 1978 2001 1979 2002 1980 2003 1981 2004 1982 2005 1983 2006 1984 2007 2008 2009

Source: Department of Disease Control, MoPH. Note: MDT = Multiple-drug therapy

2.1.6 Rabies As a result of the Rabies Control Programme implemented by the Ministry of Public Health in collaboration with the Department of Livestock Development of the Ministry of Agriculture and Cooperatives, the rabies morbidity/mortality rate dropped considerably from 0.53 per 100,000 population in 1977 to 0.01 per 100,000 population in 2008; however, in 2009, the rate rose to 0.04 on 100,000 population (Figure 5.16).

176 Figure 5.16 Morbidity/mortality rate of rabies in Thailand, 1977›2009

0.6 0.53 0.53 0.51 0.5 0.48 0.5 0.42 0.45 0.44 0.4 0.4 0.42 0.38 0.35 0.33 0.3 0.3 0.26 0.2 0.2 0.16 0.13 0.11 0.11 0.09 0.1 0.12 0.05

0.04

0.04

0.03

0.03

0.09 0.03

0.02

0.07 0.01 0.04 Morbidity/mortality rate per 100,000 popluation 0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1977 2000 1978 2001 1979 2002 1980 2003 1981 2004 1982 2005 1983 2006 1984 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

2.2 Vector-Borne Diseases 2.2.1 Dengue Haemorrhagic Fever Dengue haemorrhagic fever (DHF) has been a major public health problem of the country over the past 30 years without a declining trend. In particular, for the periods 1997›1998 and 2001› 2002, there was a rising trend with epidemics occurring for two years and non-epidemic for the following two years. However, the DHF case-fatality rate has been declining (Figures 5.17 and 5.18).

177 Figure 5.17 Incidence and mortality rates of dengue haemorrhagic fever, Thailand, 1977›2009

2 1.85 350 325.13 Mortality 1.8 1.74 Incidence 300

1.6 Incidence per 100,000 population 100,000 per Incidence 1.4 226.53 250 211.42 1.2 1.05 187.52 200 1 0.99 163.43 0.87 154.94 167.21 141.78 0.75 150 0.8 137.27 0.69 0.69 120.42 111.92 0.54 101.46 104.21 0.6 93.48 99.56 100 0.55 0.47 0.42 73.79 Mortality rate per 100,000 population 89.24 0.46 0.45 0.39 89.27 0.4 54.06 77.27 74.89 60.71 0.33 71.16 0.31 63.09 0.28 0.28 52.88 0.31 62.59 50 0.2 45.89 49.38 0.24 0.24 40.39 30.19 0.12 0.15 25.25 40.09 0.19 0.11 0.08 28.22 0.21 0.09 0.05 0.16 0 0.08 0.09 Year

1985 2008 1987 1989 1991 1993 1995 1997 1999 1977 2001 1979 2003 1981 2005 1983 2007 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

Figure 5.18 Case-fatality rate of dengue haemorrhagic fever, 1977›2009

Percentage 2.5

2 1.95

1.5 1.11 1.00 1 0.76 0.68 0.57 0.44 0.5 0.39 0.31 0.33 0.22 0.18 0.15 0.14 0.31 0.25 0.12 0.09 0 0.17 0.15 0.12 0.13 0.11 Year

1985 1987 1989 1991 1993 1995 1997 1999 1977 2001 1979 2003 1981 2005 1983 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

178 2.2.2 Malaria Thailand has succeeded, to a certain extent, in controlling malaria, leading to a consider- able reduction in incidence and mortality rates (Figure 5.19). However, in some regions particularly the Thai- Myanmar and Thai-Cambodian border areas, the problem remains critical with regard especially to drug resistance. It is noted that during 1997›1999 the malaria incidence rose slightly but the mortality rate was stable. This phenomenon is postulated to be related to the discontinuation of DDT spraying, EI Nino phenom- ena and the restructuring of communicable disease control programmes. As a result, Malaria Units were upgraded/restructured to be çVector-borne Disease Control Unitsé, which are extensively responsible for the prevention and control of dengue hemorrhagic fever, filariasis and encephalitis. In the beginning, there might be some problems, but since 2000, the incidence and mortality rates have been declining. Figure 5.19 Incidence and mortality rates of malaria in Thailand, 1977›2009

12 12 10.9 Mortality

10.2

10.1

10.0

10 Incidence 10 population 100,000 per rate Mortality

8.9

8.2

7.9 8 8.0 Economic crisis 8

6.8

8.1

7.7 7.8

6.1

5.9

5.7

7.1

5.6

1,000 population

6 5.9 6

5.2

5.7

3.9 4 5.1 4

3.2

4.4

3.9

2.2

2.1

Incidence per

2.1

2

2

1.8

3.1

1.6

2.9

1.5 2 2.7 2

2.5

1.2

2.3

2.1

0.82

1.8

0.64

1.7

0.57

1.6

0.48

0.45

0.51

0.41

1.4

1.3

1.2

1.2

1.0

0.9

0.7 0 0.6 0

0.1

0.3

0.3

0.4

0.3

0.001

0.002

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 1977 2001 1978 2002 1979 2003 1980 2004 1981 2005 1982 2006 1983 2007 1984 2008 2009

Sources: (1) Bureau of Vector-borne Disease, Department of Disease Control, MoPH. (2) Bureau of Policy and Strategy, MoPH.

2.2.3 Encephalitis As a result of economic and social development and intensive campaigns on immunization for the target groups of children in high-risk areas, the incidence and mortality rates of encephalitis have significantly declined (Figure 5.20). During the period 2008›2009, the incidence of encephalitis slightly increased while the mortality remained stable.

179 Figure 5.20 Incidence and mortality rates of encephalitis in Thailand, 1977›2009

6 4 Incidence

5.19 Mortality rate per 100,000 population 100,000 per rate Mortality 5 Mortality

4.58

4.21 3 4.0 4 3.83 encephalitis vaccination began

3.38

3.21

3.29

3.25

1.08

3.18

3.18

2.91

0.96

3 2.75 2

0.97 0.8

0.75

2.22

1.72

2 0.55

1.65

0.52

0.5

0.46

1.34 0.44 1

1.2

0.37

0.36

0.96

0.98

Incidence per 100,000 population

0.89

0.31

0.86

0.76

0.75

0.7

1 0.67

0.59

0.59

0.66

0.23

0.56

0.47

0.51

0.44

0.2

0.19

0.18

0.13

0.12

0.10

0.08

0.07

0.07

0.07

0.05

0.05

0.04

0.02

0.03

0.02

0.03

0.03 0 00.03 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 1977 2001 1978 2002 1979 2003 1980 2004 1981 2005 1982 2006 1983 2007 1984 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

2.2.4 Filariasis Overall, the filariasis control efforts have been able to reduce the prevalence rate (per 100,000 population) from 8.46 in 1992 to 0.25 in 2009 (Figure 5.21) and reduce the microfilaria positivity rate (MPR) in alien workers to less than 1% over the period of almost 30 years (1977›2009), except that in 1996 the rate was greater than 1% as a result of intensive health checkups for foreign workers (Figure 5.22). However, filariasis is still a public health problem in some areas, particularly the provinces along the Thai-Myanmar and Thai-Malaysian borders. This is largely because of the environmental conditions being favourable to mosquito breeding and the border areas being the places where workers especially from Myanmar cross over to find jobs in Thailand.

180 Figure 5.21 Prevalence rate of filariasis, Thailand, 1992›2009

10 8.46 8 6.93 6.11 6 5.83 4.91 4 2.08 2 1.45

Prevalence per 100,000 Population 0.99 0.71 0.58 0.53 0.57 0.43 0.40 0.35 0.32 0.31 0.25 0 Year 19921993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Department of Disease Control, MoPH.

Figure 5.22 Microfilaria positivity rate in alien workers, 1977›2009

MPR MPR % 1.2 1.09 1 0.8 0.79 0.63 0.6 0.43 0.44 0.44 0.44 0.42 0.42 0.42 0.4 0.34 0.36 0.29 0.34 0.38 0.34 0.36 0.20 0.2 0.18 0.3 0.25 0.21 0.20

0.16 0.03

0.04

0.04

0.02 0.02 0.04 0.03 0 0.02 0.0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1977 2000 1978 2001 1979 2002 1980 2003 1981 2004 1982 2005 1983 2006 1984 2007 2008 2009

Source: Department of Disease Control, MoPH.

181 2.3 HIV/AIDS, Tuberculosis and Sexually Transmitted Infections 2.3.1 HIV/AIDS (1) HIV Infection Situation According to the report on sentinel surveillance of HIV infection in the seven major target groups of population, implemented in all provinces during the period 1989-2009, the situation and trends can be summarized as follows: Blood donors. The prevalence increased from 0.28% in 1989 to the peak of 0.81% in 1992, and then gradually dropped to 0.21% in 2009 (Figure 5.23). Pregnant women attending antenatal clinics. The prevalence rose from 0.68% in 1991 to the peak of 2.29% in 1995, and then gradually dropped to 0.76% in 2009 (Figure 5.23). Injecting drug users. The prevalence was approximately 30›43% throughout the period 1989›1997. After 1997, the prevalence rose to the peak of 50.77% in 1999, and fell to 34.98% in 2009 (Figure 5.24). Male clients attending STI clinics. The prevalence jumped from 2.50% in 1990 to the peak of 8.5% in 1994 and remained stable at 7›9% during 1995›1999, but declined to 5.49% in 2009 (Figure 5.24). Direct female Commercial Sex Workers (CSWs). The prevalence rose from 3.47% in 1989 to the peak of 33.15% in 1994, and fell to 3.88% in 2009 (Figure 5.24). Indirect female CSWs. The prevalence escalated from 2% in 1990 to the peak of 10.14% in 1996. Since then the rate has gradually declined to 2.21% in 2009 (Figure 5.24). Military recruits or conscripts. The prevalence increased from 1.6% in 1990 to the peak of 4% in 1993, and since then has dropped to 0.5% in 2009 (Figure 5.25). It is noteworthy that the HIV/AIDS epidemic in Thailand originated in homosexual males during the period 1986›1987, then it spread to injecting drug users, female commercial sex workers, male sex seekers and, eventually, to families. Nevertheless, the reduction in the HIV transmission in the heterosexual group during 1995›1996 was possibly a result of intensive health education campaigns among the high-risk group, coupled with the 100% condom use campaigns among female CSWs (Figure 5.30).

182 Figure 5.23 Prevalence of HIV infections in blood donors and pregnant women at the ANC clinics in government hospitals, 1989›2009

3 Pregnant women at the ANC clinics Blood donors

2

1

Prevalence (percentage)

0 Year

June 2002 June 1997 June 1993 June 1998 June 1990 June 1999

June 2003 June 2007 June 1994 June 2008 June 2001 June 2004 June 2009 June 1991 June 2005

June 2000

June 1995 June 1996 June 1992 June 2006

June 1989

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

183 Figure 5.24 Prevalence of HIV infections in direct and indirect female CSWs, male clients at STI clinics, and injecting drug users, Thailand, 1989›2009

60 Direct female CSWs Indirect female CSWs Male clients at STI Injecting drug users 50 clinics

40

(percent) 30

Prevalence 20

10

0 Year

June 1997 June 2001 June 2002 June 1999 June 2003 June 2000 June 2004 June 2005 June 2006 June 2007 June 2008

June 1989

June 1998 June 1991 June 1992

June 1994

June 1996

June 1990 June 2009

June 1993

June 1995

Group June June June June June June June June June June June June June June June June June June June June June 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Direct female 3.47 9.30 15.24 22.97 28.25 27.64 33.15(1)27.78 26.14 21.13 16.00 18.46 16.56 12.34 10.63 7.36 6.80 4.59 6.77 5.57 3.88 CSWs Indirect female 0.00 2.00 4.34 5.02 7.58 8.00 9.48(1) 10.14 8.22 6.74 6.56 5.51 5.03 4.07 3.88 4.00 3.37 2.27 3.27 2.28 2.21 CSWs Male clients 0.00 2.50 5.05 5.71 8.00 8.50 8.16 8.00 7.07 9.30 8.71 5.96 5.08 4.76 4.00 5.00 4.13 3.39 5.02 4.05 5.49 at STI clinics Injecting 40.09 34.51 34.04 37.50 35.21 34.27 37.00 43.26 40.00 46.88 50.77 47.17 50.00 44.91 33.33 42.22 37.64 36.33 28.90 45.91 34.98 drug users Pregnant 0.00 0.00 0.68 1.00 1.39 1.80 2.29 1.81 1.71 1.53 1.74 1.46 1.37 1.39 1.23 1.04 1.01 0.87 0.85 0.75 0.76 women at ANC clinics Blood donors 0.28 0.43 0.45 0.81 0.74 0.68 0.63 0.56 0.56 0.39 0.44 0.31 0.30 0.24 0.27 0.23 0.22 0.29 0.26 0.26 0.21 Source: Bureau of Epidemiology, Department of Disease Control, MoPH. Note: (1) Data for December 1994.

184 Figure 5.25 Prevalence of HIV infections in Thai male military recruits, November 1989 › November 2010

4.5 4.0 4 3.6 3.5 3.5 3.3 Batch 1 2.9 2.9 Batch 2 3 3.0 3.2 2.5 2.4 2.5 2.2 2.2 2 2.1 1.9 1.6 1.6 1.5 1.9 1.4 Prevalence (Percent) 1.6 0.9 1 1.2 0.8 0.6 1.0 0.5 0.50.5 0.5 0.50.50.6 0.5 0.5 0.8 0.4 0.5 0.5 0.5 0.5 0.4 0.4 0.5 0.5 0.50.5 0 Year

Nov 1990 Nov 1991 Nov 1992 Nov 2010 Nov 1993 Nov 1994 Nov 1995 Nov 1996 Nov 1997 Nov 1998 Nov 1999 Nov 2000 Nov 2001 Nov 2002 Nov 2003 Nov 2004 Nov 2005 Nov 2006 Nov 2007 Nov 2008 Nov 2009

Nov 1989

Sources: Armed Forces Research Institute of Medical Sciences, Medical Department. Institute of Pathology, Phra Mongkutklao Medical Centre, Royal Thai Army.

(2)Prevalence of AIDS Cases According to the report on the number of AIDS patients during 1984›2009 by geographic region, the highest prevalence rates (per 100,000 population) were reported in the Central Region and the North, while the lowest rate was reported in the Northeast (Figure 5.26). Nonetheless, the number of reported cases remains lower than actuality; as a matter of fact only 4.2›52.3%7 of all the cases are actually reported. (3)Projection of the Numbers of HIV-Infected Persons and AIDS Cases The Ministry of Public Health and the Office of the National Economic and Social Devel- opment Board (NESDB), using the Asian Epidemic Model (AEM) technique, have estimated that between 2005 and 2011 the numbers of new HIV-infected and AIDS cases are on a declining trend while the cumulative numbers of HIV-infected cases and deaths due to AIDS slightly increase (Table 5.12 and Figure 5.27).

7 Bureau of Epidemiology, MOPH. Assessment of the Completeness of AIDS Patients Reporting, for 2004, 2007.

185 Table 5.12 Projection of the numbers of HIV-infected persons, AIDS cases and deaths, 2005›2011

Category Projected number of cases or deaths 2005 2006 2007 2008 2009 2010 2011 No. of new infections 16,513 15,174 13,936 12,787 11,753 10,853 10,097 No. of infections, accumulated 1,073,518 1,088,692 1,102,628 1,115,415 1,127,168 1,138,020 1,148,117 No. of AIDS cases (alive) 562,243 556,848 546,578 532,522 516,632 499,324 481,770 No. of new AIDS cases 50,254 50,814 51,091 50,657 49,049 46,272 42,992 No. of deaths due to AIDS 18,843 20,797 24,830 26,935 27,680 28,123 27,557 No. of deaths due to AIDS, 513,268 534,065 558,895 585,830 613,510 641,633 669,191 accumulated Source: Thai Working Group on HIV/AIDS Projection in Thailand 2005›2025 Using the Asian Epidemic Model. Figure 5.26 Rates of reported AIDS cases by region, Thailand, 1984›2009

90 North 80 Central 70 South 60 Northeast 50 Total 40 30

Rate per 100,000 population 20 10 0 Year

1984 1994 1985 1995 1986 1996 1987 1997 1988 1998 1989 1999 1990 2000 1991 2001 1992 2002 1993 2003 2004 2005 2006 2007 2008 2009

Region 1984 1986 1988 1990 1992 1994 19961998 2000 2002 2003 2004 20052006 2007 2008 2009 North - - 0.04 0.61 7.76 55.08 76.66 71.17 62.86 45.73 54.26 57.15 41.31 15.7 24.30 16.54 9.22 Central 0.01 0.01 0.03 0.40 2.85 23.97 47.15 54.22 53.65 44.83 44.76 49.28 35.73 16.51 23.23 18.58 14.96 South - - 0.01 0.07 1.35 12.46 25.81 36.06 35.98 29.15 39.84 43.88 32.18 8.63 14.73 10.46 6.47 Northeast - - 0.01 0.11 1.14 8.82 20.15 23.27 21.74 18.16 27.12 29.66 18.15 5.06 6.50 7.09 5.16 Total --0.02 0.30 3.06 23.49 40.89 44.66 42.06 33.71 40.85 43.32 30.29 11.36 16.57 13.18 9.40 Source: Bureau of Epidemiology, Department of Disease Control. Note: The number of reported cases is about 4.2›52.3% of actuality.

186 Figure 5.27 Projections of the number of persons living with HIV/AIDS each year, cumulative number of HIV-infected persons, and number of new infections, Thailand, 1985›2020

Living with HIV/AIDS Cumulative HIV New HIV

Number in Thousands 1,400

1,200

1,000

800

600

400

200

0 Year 19851990 1995 2000 2005 2010 2015 2020

Source: Department of Disease Control, MoPH.

2.3.2 Tuberculosis The tuberculosis prevalence (per 100,000 population) was actually declining between 1985 and 1989 from 150 to 80; but between 1990 and 2005 it did not decrease, rather it increased slightly (Figure 5.28). Owing to the HIV/AIDS epidemic, tuberculosis is becoming a public health problem. In all upper northern provinces, the TB-HIV coinfection rate rose from 4.1% in 1991 to 15.1% in 2005. Overall, for the entire country for over 20 years, the coinfection prevalence has increased from 14.5% in 1989 to 30.14% in 2009 (Figure 5.29). According to the 2008 WHO report, Thailand was ranked 18th among 22 countries with high burden of tuberculosis in the world. And WHO has also estimated that annually Thailand has 40,000 new tuberculosis cases in the infective stage; and totally each year there will be 90,000 cases of all types of tuberculosis with 13,000 deaths.

187 Figure 5.28 Rate of newly registered tuberculosis patients in Thailand, 1985›2009

160 150 All patients 140 Patients with positive sputum smear 120

99

98

94 100 94

93

92

85

83

83

81

79

79

79 80

78

79

78

78

77

76

76

76 80 76

70 60 40

Rate per 100,000 population 20

62 62 56 53 52 53 49 49 45 34 34 37 34 33 38 40 45 45 49 48 48 44 46 51 52 0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Department of Disease Control, MoPH.

Figure 5.29 Percentage of tuberculosis infections in HIV/AIDS patients in Thailand, 1989›2009

35 31.8 30.2 30.1 30.1 30 28.6 28.7 26.2 29.9 26.6 26 25.4 24.5 25.2 25 26.6 24.3 25.2 20 16.5 15 14.5 Percentage 12.0 10.4 10 8.8 5

0 Year

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

188 2.3.3 Sexually Transmitted Infections (STIs) Overall, the trends in STI prevalence in Thailand between 1977 and 2005 were improving. In particular, after 1986, the prevalence rate of STIs has fallen from 7.85 per 1,000 population in 1986 to 0.37 per 1,000 population in 2009 (Figure 5.30) as a result of the intensive campaigns on HIV/AIDS prevention and control. However, there have been signs of increase during 2007-2009, which need to be closely monitored.

Figure 5.30 Incidence of sexually transmitted infections and condom use rate among female commercial sex workers, Thailand, 1977›2009

Incidence First AIDS case identified Condom use 9 100% condom use project 120 7.79 8 7.85 7.55 7.6 99.0

98.9

98.0

98.6

98.7

97.6

97.9

97.3 96.6

96.6 7.23 98 94 97 7.8 7.04 100

7 7.04 7.23 96.1 Condom use rate (percent) 6.93 90 92 6 6.44 6.05 80 5.95 73 5 Campaign on HIV/AIDS prevention & control 4.48 60 4 56 3.21 3 40 2.07

Incidence per 1,000 population 2 25 1.64 20 1 1.13

0.73

0.49

0.38

0.31

0.32

0.27

0.26 0.25

0.25 0.37

0.22

0.2

0.17

0.17 0 0.21 0 Year

1983

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 1977 1985 2008 2009 1979 1981

Source: Bureau of Epidemiology and Cluster of STIs, Department of Disease Control, MoPH. Note: Sexually transmitted infections include syphilis, gonorrhoea, chancroid, lymphogranuloma venereum, granuloma inguinale, and pseudogonorhoea. 2.4 Problems of Emerging Diseases 2.4.1 Avian Influenza According to reports on avian influenza situation since 2003 Thai detected the first case of avian flu on 23 January 2004 and to date there have been 17 confirmed cases, of whom 12 have died; a case-fatality rate being 70.6%. As the government has implemented a drastic prevention and control mea- sures, the disease outbreak can be successfully prevented. Since 2007 there has been no report of human-to- human transmission of the disease (Table 5.13).

189 Table 5.13 Avian influenza: numbers of confirmed cases and deaths in Thailand, 2003›2009

No. of cases or deaths Case / death 2003 2004 2005 2006 2007 2008 2009 Total Confirmed cases 0 17 5 3 0 0 0 25 Deaths 0 12 2 3 0 0 0 17 Case-fatality rate (%) 0.0 70.6 40.0 100.0 0.0 0.0 0.0 68.0

Source: National Institute of Health, Department of Medical Sciences, MoPH.

2.4.2 Hand-Foot-Mouth Disease Hand-foot-mouth disease is another emerging disease; its outbreak was reported in 1997 in Malaysia. For Thailand, there have been reported cases since 2000; and in 2009 the morbidity rate was 13.88 per 100,000 population with 2 deaths (Figure 5.31).

Figure 5.31 Morbidity rate of hand-foot-mouth disease, 2001-2009

30 26.81 25 20 17.84 13.88 15

10 5.65 6.33 3.65 5 2.49 1.94 1.23 Morbidity rate per 100,000 population 0 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

190 Laboratory testing for enterovirus 71 conducted by the National Institute of Health of the Department of Medical Sciences in 2009 found that 7.0% of the samples were positive for the virus (Table 5.14).

Table 5.14 Number of cases and laboratory testing results for hand-foot-mouth disease, 2004›2009

Surveillance situation Year Lab tests positive for enterovirus 71 (%) Cases Deaths 2004 769 0 0 2005 2,270 0 5.97 2006 3,961 7 13.5 2007 16,846 0 12.9 2008 11,277 4 5.87 2009 8,806 2 7.0

Source: National Institute of Health, Department of Medical Sciences, MoPH.

2.4.3 Pandemic (H1N1) 2009 Pandemic (H1N1) 2009, or pandemic influenza A(H1N1), has spread and resulted in a public health crisis all over the world. As of 14 May 2010, the World Health Organization (http://www.who.int) reported that there were confirmed cases of the disease in 214 countries with at least 18,036 deaths (Table 5.15). In Thailand, between 28 April 2009 and 18 October 2010, pandemic (H1N1) 2009 also spread, similar to that in other countries worldwide, beginning with a reported case coming into Thailand from another country in early May 2009. After that the disease began to spread on a limited scale and then on a wider scale. As of 13 October 2010, there were 225 deaths and it was reported that there might be millions of infected people nationwide. The first wave of the epidemic lasted for 6 months from May to October 2009 with an infection rate of 13%, or 8.3 million infected persons. And the second wave of epidemic occurred between January and April 2010 with the infection rate of 8.9%, or 5›6 million infected persons.

191 Table 5.15 Summary of reported deaths due to pandemic (H1N1) 2009, by WHO region, as of 14 May 2010

WHO Region Cumulative total Deaths WHO Regional Office for Africa (AFRO) 168 WHO Regional Office for the Americas (AMRO) At least 8,361 WHO Regional Office for the Eastern Mediterranean (EMRO) 1,019 WHO Regional Office for Europe (EURO) At least 4,861 WHO Regional Office for South-East Asia (SEARO) 1,798 WHO Regional Office for the Western Pacific (WPRO) 1,829 Total At least 18,036

∑’Ë¡“: http://www.who.int-Update 2010.

2.5 Non-communicable Diseases 2.5.1 Cancer Cancer is a major health problem among Thai people. According to the 2003 report on cancer in Thailand of the National Cancer Institute, among Thai males with cancer, the largest proportion of them had liver and bile duct cancer, followed by lung and intestinal cancer, while among Thai females with cancer, the largest proportion of them had breast cancer, followed by cervical cancer and liver and bile duct cancer (Figure 5.32). The incidence of cancer commonly found in various organs are as follows: (1) Cervical and Breast Cancers Cervical and breast cancers are fatal diseases that affect Thai women resulting in their premature death; and the trend is rising each year (Table 5.16) especially among female residents in Bangkok with a rising incidence of such cancers (Figure 5.33). According to the cancer registry in five member prov- inces, the highest rate of cervical cancer was recorded in Chiang Mai Province, while the highest rate of breast cancer was recorded in Bangkok (Table 5.17). Classified by age, females aged 35 and older have a greater incidence rate of cervical and breast cancers than those aged under 35. In comparison with those in the U.S., most American females (77%) had breast cancer when they were over 50 years of age, while it is only 40›59% among Thai females in the same age group (Table 5.18). Besides, it was found that 80% of Thai female breast cancer patients were in the invasive stage8. According to the 2008›09 health examination survey among females aged 15›59 years across the country, it was found that 42.5% of respondents had ever undergone a cervical cancer screening test, while the 2009 NSO survey reported a higher percentage of 60.2% (Table 5.19). 8 Thammanit Angsusingh. Screening Mammography. Breast Cancer Treatment Centre, Siriraj Hospital.

192 Regarding breast self-examination, it was found in 2004 that approximately 50% of respon- dents had ever done a breast self-examination, while the 2006 survey, revealed that only 25% had ever done so. Concerning breast examination conducted by health personnel, between 2004 and 2009, about 18›23% of females had ever received such service, (Table 5.19). However, only 2›4% of females aged 40-59 nationwide had ever taken a mammogram (Table 5.19).

Figure 5.32 Top 10 commonly found cancers in Thailand, 2003

Males Liver and bile duct 38.6 Trachea, bronchus and lung 24.9 Colon and rectum 11.30 Prostate 5.5 Non-Hodgkin lymphoma 5.0 Leukemia 4.9 Bladder 4.6 Oral cavity 4.5 Stomach 4.1 Esophagus 3.2 ASR (World) 010203040

Females Breast 20.9 Cervix uteri 18.1 Liver and bile duct 14.60 Trachea, bronchus and lung 9.7 Colon and rectum 7.9 Ovary 5.1 Leukemia 3.7 Oral cavity 3.7 Thyroid 3.7 Non-Hodgkin lymphoma 3.2 ASR (World) 051015 20 25

Source: Cancer in Thailand, 2001›2003.

193 Table 5.16 Incidence of cancers commonly found among Thai females, 1990, 1993, 1996,1999, 2000 and 2001

Incidence rate per 100,000 population Number Type of cancer 1990 1993 1996 1999 2000 2001 1 Cervical cancer 23.4 20.9 19.5 19.8 24.7 18.1 2 Breast cancer 13.5 16.3 17.2 19.9 20.5 20.9 3 Liver cancer 16.3 15.5 16.0 14.3 12.3 14.6 4 Lung cancer 12.1 11.1 10.0 9.9 9.3 9.7 5 Ovarian cancer 4.5 4.7 5.2 6.2 6.0 5.1

Source: Cancer in Thailand, 2001›2003.

Figure 5.33 Incidence of cervical and breast cancers among females in Bangkok, 1993›2001

breast cancers cervical cancers 50

38.7 40 34.1 31.4 32.1 28.8 30 26.2 28.7 30.0 23.9 25.4 25.1 20 20.9

Incidence per 100,000 population 10

0 Year 1993 1994 1995 1996 1997 2001

Source: Cancer in Thailand, 2001›2003.

194 Table 5.17 Percentage of cancers of the reproductive organs recorded at provincial cancer registries, 1993, 1996, 1999 and 2001

Cervical cancer, % Breast cancer, % Ovarian cancer, % Province 1993 1996 1999 2001 1993 1996 1999 2001 1993 1996 1999 2001

Chiang Mai 25.7 25.6 29.4 25.1 15.2 17.6 20.7 21.8 6.0 4.7 6.9 4.9 Lampang 23.1 23.6 22.3 23.8 15.0 16.4 20.8 25.5 4.4 3.7 4.6 6.3 Khon Kaen 18.0 15.0 15.9 15.3 8.6 11.6 13.7 15.6 4.5 5.6 6.2 5.2 Bangkok 18.5 20.7 19.3 20.9 20.6 25.4 24.3 34.1 4.2 5.9 6.1 6.6 Songkhla 15.8 16.1 20.6 16.2 11.5 12.1 17.2 20.8 3.1 4.6 5.7 5.0

Source: Cancer in Thailand, 2001›2003.

Table 5.18 Cases and proportions of breast cancer among Thai women by age group, 1983›2009

Siriraj Hospitalûs Surgery Thanyarak Thanyarak Thanyarak Thanyarak Thanyarak Thanyarak Department 1,353 cases Centre Centre Centre Centre Centre Centre (1983-1994) 5,994 cases 219 cases 449 cases 597 cases 518 cases 839 cases (1995-2004) (2005) (2006) (2007) (2008) (2009) Age (yrs) Cases Percent Cases Percent Cases Percent Cases Percent Cases Percent Cases Percent Cases Percent < 40 311 23.0 996 16.6 39 13.4 53 11.8 64 10.72 67 12.93 89 10.61 40-49 437 32.3 2,487 41.5 97 33.4 158 32.2 206 34.51 171 33.01 219 26.10 50-59 353 26.1 1,721 28.7 92 31.6 139 31.0 188 31.49 158 30.50 289 34.45 60-69 162 12.0 597 10.0 37 12.7 68 15.1 90 15.08 89 17.18 144 17.16 70 and over 90 6.6 193 3.2 26 8.9 31 6.9 49 8.21 33 6.37 98 11.68 Total 1,353 100 5,994 100 291 100 449 100 597 100 518 100 839 100

Source: Thammanit Angsusing. Screening Mammography, Thanyarak Breast Cancer Centre.

195 Table 5.19 Percentage of Thai women who have ever taken screening tests for cervical and breast cancers by age group, 2004, 2006, 2007›2009 Percentage by age group (years), 2004 (1) Percentage Screening 15-29 30-44 45-59 Total 2006 (2) 2007 (3) 2008-2009 (2,4) - Pap smear for cervical 29.0 62.2 55.0 48.5 49.8 52.7 42.5-60.2 cancer - Breast self-examination 35.0 58.3 53.5 48.7 24.6 - 23.6 - Breast examination by 13.2 28.1 27.9 22.7 24.5 - 17.9-20.3 health personnel - Mammogram (40-59 yrs) - - - 4.0 - - 2.5

Sources: 1. Report on the Third National Health Examination Survey, 2003-2004. Health Systems Research Institute, MoPH. 2. Report in Reproductive Health Survey, 2006 and 2009. National Statistical Office. 3. Survey on Risk Factors for NCDs and Injuries, 2007, Bureau of NCDs, Department of Disease Control, MoPH. 4. Report on the Fourth National Health Examination Survey, 2008-2009. National Health Examina- tion Survey Office, Health Systems Research Institutes, MoPH.

(2) Liver Cancer Peopleûs food consumption patterns have changed to eating out or eating readily-cooked food bought from restaurants or food stalls where the food might have been contaminated with pathogens or toxic substances due to unhygienic practices of the food handlers. Consumers, then, are likely to be vulnerable to food-borne diseases. Eating improperly heated food, especially freshwater fish, might cause opisthorchiasis or liver fluke disease which is a major cause of liver cancer. Besides, the high prevalence of hepatitis B infection in the past is also the cause of chronic hepatitis, cirrhosis and liver cancer (Table 5.20) as Thailand is found to have the highest incidence of liver cancer in the world9.

9 Vatanasapt, V., Sriamporn, S. (1999). Cancer in Thailand 1992 - 1994 (IARC Technical Report No. 34), Lyon,IARC.

196 Table 5.20 Incidence of liver cancer Thailand, 1993, 1996, 1999, 2000 and 2001

Incidence (per 100,000 population) Year Males Females 1993 37.4 15.5 1996 40.5 16.0 1999 38.6 14.3 2000 31.2 11.5 2001 38.6 14.6

Source: Cancer in Thailand, 2001›2003. (3)Lung Cancer The incidence of lung cancer (per 100,000 population) increased sevenfold from 3.96 in 1985 to 26.8 in 1997, and dropped to 18.6 in 2000, but rose again to 24.9 in 2001, which was probably associated with tobacco consumption and air pollution (Figure 5.34).

Figure 5.34 Incidence of lung cancer in Thailand, 1985›2001

30 24.9(1) 25 Market open Legal and tax measures (1) to foreign against tobacco 26.8 20 tobacco consumption 18.3 (1) 15 18.6 12.94 10 5 Incidence per 100,000 population 3.96 0 Year 1985 1990 1993 1997 2000 2001

Source: Cancer in Thailand, 2001›2003. Note: (1) Incidence of lung cancer in males.

Besides, according to the report on inpatient services at the National Cancer Institute between 1986 and 2008, 15% to 23% of inpatients were males, 3 to 8 times higher than in females (Figure 5.35).

197 Figure 5.35 Percentage of lung cancer patients registered for treatment at the National Cancer Institute, 1986›2008 Males Percentage Females 25 23.4 21.2 21.9 20.7 20.0 21.0 21.0 20.9 18.9 19.3 19.6 19.1 19.3 20 17.8 17.6 18.0 19.1 16.8 18.7 17.116.2 15.2 17.5 15

10 8.1 5.8 4.8 5.4 5.6 5.7 5.2 5 4.5 4.0 4.5 4.3 3.9 3.8 3.2 3.0 2.8 3.8 3.3 3.3 3.8 3.7 3.7 3.0 0 Year

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source: National Cancer Institute, Department of Medical Services, MoPH. Note: As percentage of all cancer cases.

2.5.2 Heart Diseases, Diabetes, Hypertension and Stroke Currently, the incidence of non-communicable diseases, that are the leading causes of morbidity and mortality among Thai people, including heart diseases, cancer, diabetes, hypertension and stroke, is on the rise. Such an increasing trend results from unhealthy consumption behaviours (eating foods with high carbohydrate, sugar and fat content), physical inactivity and overweight, as evidently demonstrated by the following hospital admission rates (per 100,000 population). - Heart diseases. The admission rate has risen from 56.5 in 1985 to 109.4 in 1994 and to 793.03 in 2009. - Cancer. The admission rate has risen from 34.7 in 1994 to 133.10 in 2009. - Diabetes. The admission rate has also risen from 33.3 in 1985 to 91.0 in 1994 and 736.48 in 2009. - Hypertension. The admission rate has risen from 261.61 in 1999 to 981.48 in 2009. - Stroke. The admission rate has risen from 48.76 in 1994 to 227.19 in 2009 (Figure 5.36).

198 Figure 5.36 Rate of hospitalizations of patients with heart diseases, cancers, diabetes, hypertension and stroke, 1985-2009

1,000 981.48 900 Heart diseases 860.53

800 Cancers 778.12 793.03 659.57 749.54 700 Diabetes 687.71 736.48

618.5 675.74 530.7 650.43 600 Hypertension 503.1 544.28 477.35 586.8

458.4

500 451.4 Stroke 490.5

400 376.4 389.83 444.2

285.6 340.99 252.6 259.02 380.7 300 261.61 287.5 340.95

277.7 227.19

216.58

Rate per 100,000 population

205.45 194.8 257.59

188.33

174.88

169.9

173.6

200 158.0 218.9 175.7 151.5

129.7 125.6 149.8 133.1 138.34 130.77

114.4

76.5

109.4 127.5

101.7

115.33

78.6 100.1 92.72 105.81 73.6 78.24

67.9 63.4 74.98 134.31 100 56.5 96.4 99.6104.2 78.5 69.3 91.0 69.53 101.7107.0114.3 124.4 53.8 73.6 68.4 72.3 62.6 66.9 71.1 80.4 99.0 0 48.2 56.1 48.76 57.65 60.4 Year 33.3 33.8 33.8 41.2 43.5 34.7 41.2 48.6

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Inpatients Report. Bureau of Policy and Strategy, MoPH. Note: The rate for cancers, since 1994, covers only liver, lung, cervical, and breast cancers.

Besides, the Bureau of Non-communicable Diseases, Department of Disease Control, MoPH, conducted surveys on risk behaviours for NCDs and chronic diseases among Thais aged 15›74 years in 2004, 2005 and 2007 and reported the following (Table 5.21): The prevalence of overweight rose from 15.3% to 19.1% or an increase of approximately 1.8 million people. The prevalence of obesity rose from 2.6% to 3.7% or an increase of approximately 0.5 million people. The prevalence of hypertension rose from 8.0 % to 9.4% or an increase of approximately 0.7 million people. The prevalence of diabetes rose from 3.2 % to 3.9% or an increase of approximately 0.4 million people. The prevalence of stroke, paresis and paralysis rose from 0.8% to 1.1% or an increase of approximately 0.2 million people. The prevalence of ischemic heart disease rose from 1.1% to 1.5% or increase of approximately 0.2 million people.

199 5 Table 5.21 Comparison of prevalence of health status and behavioural risk factors for NCDs among Thai people in 2004, 2005 and 2007

Prevalence (percentage of people with risk or illness) Health status and behavioural risk 2004 2005 2007 change (2004-2007) Overweight (BMI ≥ 25-30 kg/m2) 15.3 16.1 19.1 +3.8 (7.0 million) (7.3 million) (8.8 million) (1.8 million) Obesity (BMI ≥ 30 kg./m2) 2.6 3.0 3.7 +1.1 (1.2 million) (1.4 million) (1.7 million) (0.5 million) People with hypertension 8.0 8.3 9.4 +1.4 (3.6 million) (3.7 million) (4.3 million) (0.7 million) People with diabetes 3.2 3.7 3.9 +0.7 (1.4 million) (1.6 million) (1.8 million) (0.4 million) People with stroke (paresis/paralysis) 0.8 0.9 1.1 +0.3 (0.3 million) (0.4 million) (0.5 million) (0.2 million) People with ischemic heart disease 1.1 1.1 1.5 +0.4 (0.5 million) (0.5 million) (0.7 million) (0.2 million)

Source: NCD Behavioural Risk Factor Surveillance Centre, Bureau of NCDs, Department of Disease Control, MoPH. Note: Data on disease prevalence were obtained from history taking with the patients and thus were only from those who had known of that own illnesses.

Besides, the first through fourth health examination survey on Thai people (1991›2009) revealed that the prevalence of hypertension had a tendency to rise from 5.4% in 1991 to 11.0% in 1997 and to 21.4% in 2008›2009. Similarly, the diabetes prevalence had risen from 2.3% in 1991 to 4.6% in 1997 and 6.9% in 2008›2009; and for hyperlipidemia (high blood cholesterol), the rise was from 11.3% in 1991 to 19.4% in 2008-09 (Figure 5.37). This is evident that the prevalence of non-communicable diseases among Thais has got a rising trend; and more importantly, the proportion of patients who has never had any diagnosis is also higher, resulting in a lower rate of patients receiving medical treatment. Thus, the people in this group do not have a chance to receive preventive care for their complications that might occur after getting ill with the diseases (Figure 5.38 ).

200 Figure 5.37 Prevalence of chronic diseases that are major health problems among Thai people, 1991›2009

Percentage 25 22.1 21.4 1991 19.4 20 1997 15.4 15 2004 11.0 11.3 2009 10 6.8 6.9 5.4 5 4.6 2.3 0 Hypertension Hyperlipidemia Diabetes (SBP ≥ 140 mmHg (Total cholesterol ≥ 240 mg/dl) (FBS ≥ 126 mg/dl) DBP ≥ 90 mmHg)

Sources: 1. Report on the First National Health Examination Survey, 1991›1992. Thai Health Research Institute. 2. Report on the Second National Health Examination Survey, 1996›1997. Thai Health Research Institute. 3. Report on the Third National Health Examination Survey, 2003›2004. Health Systems Research Institute and Bureau of Policy and Strategy, MoPH. 4. Report on the Fourth National Health Examination Survey, 2008-2009. National Health Examina- tion Survey Office, Health Systems Research Institute, MoPH. Notes:1.Data on prevalence of diabetes and hypertension were obtained from blood test and blood- pressure taking, thus, being data from patients with known and unknown illness status. 2. Data on hyperlipidemia for 1996 were based on the total cholesterol level of 200 mg/dl; so they were uncomparable.

201 Figure 5.38 Prevalence of diabetes and hypertension as well as appropriate treatment among Thai people, 2004 and 2009

2004 2009 Male 23.3% Female 20.9% Prevalence of hypertension Male 21.5% Female 21.3%

Male 21.4% Female 36.2% Diagnosed (Knowing of their Male 39.5% Female 59.4% illness) Male 16.9% Female 30.7% Receiving Male 30.3% Female 51.3%

Male 5.7% Male 14.4% Female 11.7% Treatment effective Female 27.3%

Male 6.4% Female 7.3% Prevalence of diabetes Male 6.0% Female 7.7% Male 56.7% Female 77.6% Male 65.5% Female 49.2% Diagnosed (Knowing of their illness) Male 51.6% Female Male 32.6% Female Receiving 49.1% 75.7%

Male 8.5% Treatment effective Male 27.1% Female 15.2% Female 42.0%

Sources:1.Report on the Third National Health Examination Survey, 2003›2004. Health Systems Research Institute and Bureau of Policy and Strategy, MoPH. 2. Report on the Fourth National Health Examination Survey, 2008-2009. National Health Examina- tion Survey Office, Health Systems Research Institute, MoPH.

202 2.5.3 Emphysema. The prevalence of emphysema has risen from 0.07 per 100,000 popula- tion in 1989 to 3.8 per 100,000 population in 2009 (Figure 5.39).

Figure 5.39 Mortality rate due to emphysema, 1989›2009

7 6.3 6.5 6 5.5 4.6 5 4.4 4.4 4.3 4.5 4.4 4.5 4.1 3.8 4 3.6 3.5 3 2.32 2.5 1.93 2 1.52 1.43 1.5 1.18 1.12 1 0.12 0.13 0.2 0.26 Mortality rate per 100,000 Population 0.5 0.07 0 Year

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, MoPH.

2.5.4 Chronic Obstructive Pulmonary Disease (COPD). A major cause of COPD is cigarette smoking or exposure to smog for a long period of time. According to the 2004 and 2009 National Health Examination Surveys, 0.5% of the people aged 15 and over had COPD. In 2010, it was estimated that the prevalence of COPD among Thais would be 7,035 per 100,000 population10 (Figure 5.40).

10 The projection was based on the assumption that in the next 10 years the smoking rate will decrease each year by 0.42% among males and 0.16% among females.

203 Figure 5.40 Projection of chronic obstructive pulmonary disease prevalence, Thailand, 2001›2010

8,000 7,035 5,820 6,000 4,888 4,152 4,000 3,592 2,866 2,814 3,154 2,268 2,583 2,000

Prevalence rate per 100,000 Population 0 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Sawang Saenghiranwattana. Chronic Obstructive Pulmonary Disease: Current Situation and Trends, 1999.

2.5.5 Coronary Artery and Valvular Heart Diseases. Both diseases have a rising trends (Figures 5.41 and 5.42) as they are associated with to tobacco use, physical inactivity, hyperlipidaemia and overweight. Figure 5.41 Number of patients with coronary artery disease treated at the Chest Disease Institute, 2005›2009

Number of patients 31,403 32,631 35,000 30,594 26,099 30,000 23,687 25,000 20,000 15,000 10,000 5,000 0 Year 2005 2006 2007 2008 2009

Source: Chest Disease Institute, Department of Medical Services, MoPH.

204 Figure 5.42 Number of Patients with valvular heart disease Treated at the Chest Disease Institute, 2005›2009

Number of Patients 25,000 19,966 18,069 20,000 15,743 14,785 15,352 15,000

10,000

5,000

0 Year 2005 2006 2007 2008 2009 Source: Chest Disease Institute, Department of Medical Services, MoPH.

2.5.6 Kidney Diseases According to the inpatient statistics of the MoPHûs Bureau of Policy and Strategy, the morbidity rate of kidney diseases (per 100,000 population) has risen from 461.91 in 2004 to 878.96 in 2009. The kidney failure rate has more than doubled, rising from from 217.04 in 2004 to 512.65 in 2009, the number being as high as 55% of all kidney disease patients (Table 5.22). It is noteworthy that women are more likely than men to have kidney failure (Figure 5.43). The risk factors for such disease including diabetes and hypertension are steadily on the rise.

Table 5.22 Morbidity rate of kidney diseases by group of illnesses, 2004›2009 Morbidity rate (per 100,000 population) Group of kidney diseases 2004 2005 2006 2007 2008 2009 Kidney diseases 461.91 574.29 626.02 721.83 920.32 878.96 Acute nephritic syndrome 4.25 4.48 5.65 6.60 5.73 9.04 Renal tubulo-interstitial diseases 133.37 159.80 161.44 173.01 199.80 175.21 Renal failure 217.04 287.05 325.10 395.79 510.17 512.65 Urolithiasis 85.39 95.94 98.66 99.25 156.47 123.58 Other nephritic diseases 21.86 30.08 35.16 47.16 48.15 58.48

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

205 Figure 5.43 Morbidity rates of renal failure in males and females, 2004›2009

Males Females 600

520.60

515.79

509.41 500 499.97

407.74 400 383.52

338.73

311.12

302.95

300 270.75

229.48 200 204.34 100

Morbidity rate 100,000 Population 0 Year 2004 2005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. 2.5.7 Cirrhosis Consumption of alcohol for a long time negatively affects the liver as it has been found that, between 1977 and 2009, the mortality rates of liver disease and chronic cirrhosis were reported at 4.3 to 13.2 per 100,000 population, the rates being 6 to 19 in males and 2 to 7 in females, i.e. 2 to 4 times higher in males than in females (Figure 5.44). Cirrhosis is partly caused by hepatitis B viral infection, whose prevalence was high in the past, and currently it has a declining trend. Figure 5.44 Mortality rate of liver disease and cirrhosis, Thailand, 1977-2009

Males Total Females 22 20 19.1 18.1 18 17.3 17.0 16.6 16.3 18.6 17.8 17.4 16 13.1 13.8 17.6 14.4 14.17 16.7 14 12.9 12.1 12.6 12.2 13.312.3 14.4 15.0 13.0 12.4 12.1 11.6 11.011.3 10.9 13.7 11.6 12.83 11.6 12 10.0 12.2 9.9 10.613.2 12.5 11.9 10 8.7 11.2 8.7 9.1 9.4 9.55 9.9 11.4 11.7 8.6 8.2 8.0 7.8 7.5 8 9.1 7.4 6.9 8.6 9.5 9.2 7.2 6.8 8.64 6.4 7.0 7.5 7.0 6.6 6 5.1 4.98.0 5.1 5.2 5.1 6.3 5.4 4.98 7.5 5.3 5.2 4.4 6.6 6.3 7.1 4 5.1 4.3 4.8 4.9 4.7 4.2 5.2 5.1 4.48 5.4 2 2.7 3.8 Mortality rate per 100,000 Population 0 2.2 Year

2008

1983

1986

1989

1992

1995

1998

2001

2004

2007 1977 2009 1980

Source: Bureau of Policy and Strategy, MoPH.

206 2.6 Injuries and Accidents 2.6.1 Road Traffic Accidents The situation of road traffic accidents in Thailand can be categorized by the time period as follows: The First Period, before 1986: Economic Recession. The number of accidents was not so high during this period. Each year, there were about 18,000›25,000 accidents with about 2,000›4,000 deaths or a mortality rate of 3.9›5.7 per 100,000 population. And there were approximately 8,000›9,000 injury cases each year, or an injury rate of 17.2 per 100,000 population. The Second Period, 1987›1992: Economic Recovery. During this period there were about 40,000›60,000 accidents each year, nearly two times higher than during the previous period, with about 8,000›9,000 deaths or a mortality rate of 7.4›16.0 per 100,000 population. It was noteworthy that casualties increased almost threefold anad the number of injuries increased to 20,000›25,000 each year or an injury rate of 24.0›43.9 per 100,000 population, an approximately twofold rise. The Third Period, 1993›1996: Bubble Economy. Each year there were 80,000›100,000 accidents, a twofold increase, with about 14,000›16,000 deaths or a mortality rate of 16.3›28.2 per 100,000 population, a nearly twofold increase. And there were about 40,000›50,000 injuries each year or an injury rate of 43.4›85.6 per 100,000 population, an approximately twofold increase. The Fourth Period, 1997›2001: Economic Crisis. The number of accidents dropped to 70,000›80,000 each year with around 12,000 deaths or a mortality rate of 20.0›22.7 per 100,000 population. And each year there were 48,000›52,000 injuries or an injury rate of 77.5›86.9 per 100,000 population. This was a declining trend compared with the previous period. The Fifth Period, 2002 onwards: Economic Recovery and Road Safety Operations. Each year there were approximately 90,000-125,000 accidents with 12,000-14,000 deaths or a mortality rate of 19-22.26 per 100,000 population. And there were approximately 60,000-95,000 injuries a year or an injury rate of 110.8-151.72 per 100,000 population. After the implementation of the road safety programme, the number of road accidents has dropped to 85,000›90,000 with about 10,000›11,000 deaths per year, or a mortality rate of 17›18 per 100,000 population. And each year there are about 60,000›70,000 injuries or an injury rate of 98›112.41 per 100,000 population (Figure 5.45). It has been found that the largest proportion of road accident-related deaths occur in the working-age group (15›34 years), 4›5 times higher in males than in females (Table 5.24 and Figure 5.46). Primarily, traffic accidents are mostly caused by humans (69.9%) and a small propor- tion by the vehicles and environment (1.6% and 0.3%, respectively, (Figure 5.47). By category of road traffic accidents, the most commonly found category is speeding (16.3%), followed by cutting across the path of another vehicle in short distance, following another vehicle too closely and drunk driving (Figure 5.48).

207 According to the road traffic accident report of the Royal Thai Police, most of the accidents involve motorcycles, the proportion had a rising trend of 50.7% in 1998 to 62.0% in 2009. That is consistent with the report of the Land Transport Department which reveals that the number of registered motorcycles has risen threefold from 534,458 units in 1998 to 1,635,807 units in 2009. An analysis of motorcycle riding accidents conducted by the Bureau of Epidemiology of the MoPHûs Disease Control Department revealed that more than 40% of seriously injured cases had drunk alcohol before riding a motorcycle (Table 5.25). This kind of situation caused a direct loss of property worth 3,815.5 million baht in 2009 (Table 5.23). But actually there are other incalculable losses including life losses, medical expenses, disabilities, etc.

Figure 5.45 Death and injury rates from road traffic accidents, Thailand, 1984›2009

Road Safety Economic Recession Recovery Bubble Crisis operations crisis 2008-2009 Accidents injury rate Death rate 140,000 151.72 150.60 160

Death and injury rates per 100,000 population 120,000 133.00 140 126.62 125.57

102,610

122,040 124,530 112.41 120

100,000 94,362 110.8

88,556

110,686

84,892

85.91 85.98 107,565 100 80,000 85.56 80.09 77.58 86.90 101,752 97.69 73.68 80 61,329 83.24

60,000 86,659

84,806

43,646

43,625

43,439

77,616

91,623

43,557

73,725

73,737 41.14 82,386 60 40.7 67,800 40,000 Number of accidents (cases) 43.42 40

25,639 41.3 43.88 23.96

24,432

18,995 18,334 25.68 20.97 22.27 17.18 35.82 20.00 18.76 22.01 19.85 20,000 16.0414.2 16.28 28.22 20 17.34 24.03 22.75 19.55 22.26 20.67 5.74 17.45 15.74 15.11 19.41 18.29 16.89 0 7.41 14.16 5.38 3.94 0 Year

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Police Information System Centre, Royal Thai Police.

208 Table 5.23 Numbers and rates of accidents, deaths and injuries and estimated damages, 1984›2009

Year Population No. of accidents Deaths Injuries Property damages (cases) Rate per Rate per (baht) No. 100,000 No. 100,000 (persons) pop. (persons) pop. 1984 50,583,105 18,334 2,904 5.74 8,770 17.34 56,265,453 1985 51,795,651 18,955 2,788 5.38 8,901 17.18 60,645,504 1986 52,696,204 24,432 2,086 3.94 9,242 17.45 55,061,650 1987 53,873,172 25,639 3,991 7.41 12,947 24.03 129,539,616 1988 54,960,917 43,439 8,651 15.74 22,370 40.70 329,527,667 1989 55,888,393 43,557 8,967 16.04 23,083 41.30 439,028,000 1990 56,303,273 43,646 7,997 14.20 23,161 41.14 477,603,000 1991 56,961,030 49,625 8,608 15.11 24,995 43.88 639,616,000 1992 57,788,965 61,329 8,184 14.16 20,702 35.82 607,793,000 1993 58,336,072 84,892 9,496 16.28 25,330 43.42 1,021,464,000 1994 59,095,419 102,610 15,176 25.68 43,541 73.68 1,408,216,000 1995 59,277,900 94,362 16,727 28.22 50,718 85.56 1,631,117,000 1996 60,116,182 88,556 14,405 23.96 50,044 83.24 1,561,708,187 1997 60,816,227 82,386 13,836 22.75 48,711 80.09 1,571,786,469 1998 61,155,888 73,725 12,234 20.00 52,538 85.91 1,378,673,826 1999 61,577,827 67,800 12,040 19.55 47,770 77.58 1,345,985,811 2000 61,770,259 73,737 11,988 19.41 53,111 85.98 1,242,205,524 2001 62,093,855 77,616 11,652 18.76 53,960 86.90 1,240,801,187 2002 62,554,482 91,623 13,116 20.97 69,313 110.80 1,494,936,815 2003 62,939,819 107,565 14,012 22.26 79,692 126.62 1,750,964,040 2004 62,526,693 124,530 13,766 22.01 94,164 150.60 1,623,081,112 2005 62,195,839 122,040 12,858 20.67 94,364 151.72 3,238,226,110 2006 62,623,416 110,686 12,693 20.27 83,290 133.00 3,643,747,912 2007 62,933,515 101,752 12,492 19.85 79,029 125.57 4,620,398,166 2008 63,214,022 88,689 11,561 18.29 71,059 112.41 5,415,524,563 2009 63,457,439 84,806 10,717 16.89 61,996 97.69 3,815,520,899

Source: Police Information System Centre, Royal Thai Police.

209 Percent

45 12.1 57 11.1 34 10.9

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

No.

Percent

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

No.

Number and percentage of deaths from road traffic accidents by age group, 1996›2009

Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

:

5 - 9 389 2.3 227 1.8 146 1.8 261 2.2 287 2.2 256 2.0 214 1.6 196 1.5 183 1.5 151 1.4 149 1.4 129 1.3 150 1.5 89 0.9

0 › 4 291 1.7 175 1.3 210 2.6 254 2.2 287 2.2 243 1.9 205 1.5 164 1.3 154 1.3 158 1.5 135 1.3 119 1.2 139 1.4 146 1.5

35 ›39 1,410 8.4 1,177 9.1 742 9.3 1,113 9.6 1,221 9.3 1,306 10.1 1,225 9.1 1,198 9.4 1,094 8.9 1,016 9.2 956 9.2 918 9.2 826 8.5 826 8.7

(years)

10 › 14 599 3.6 392 3.0 237 3.0 300 2.6 387 2.9 356 2.7 428 3.2 363 2.8 425 3.4 359 3.3 375 3.6 346 3.5 347 3.6 356 3.7 15 › 19 2,786 16.6 2,052 15.8 1,075 13.5 1,501 13.0 1,647 12.5 1,623 12.5 1,869 13.9 1,829 14.3 1,811 14.7 1,534 13.9 1,408 13.5 1,371 13.7 1,226 12.6 1,1 20 › 24 2,995 17.8 2,236 17.3 1,184 14.8 1,702 14.6 1,861 14.1 1,810 14.0 2,003 14.9 2,040 15.9 1,819 14.7 1,598 14.5 1,405 13.5 1,207 12.1 1,125 11.6 1,0 25 › 29 2,262 13.5 1,743 13.5 1,051 13.2 1,470 12.6 1,641 12.4 1,575 12.2 1,686 12.6 1,623 12.7 1,530 12.4 1,334 12.1 1,244 11.9 1,142 11.4 1,085 11.2 1,0 30 › 34 1,733 10.3 1,343 10.4 830 10.4 1,286 11.1 1,452 11.0 1,437 11.1 1,415 10.5 1,279 10.0 1,233 10.0 1,103 10.0 986 9.5 915 9.2 991 10.2 899 9.5 40 › 44 1,017 6.1 904 7.0 665 8.3 914 7.9 1,092 8.3 1,063 8.2 1,086 8.1 1,030 8.0 950 7.7 891 8.1 886 8.5 856 8.6 845 8.7 800 8.4 45 › 49 870 5.2 750 5.8 488 6.1 785 6.8 884 6.7 912 7.0 903 6.7 847 6.6 832 6.8 759 6.9 745 7.2 772 7.7 758 7.8 749 7.9 50 › 54 594 3.6 484 3.7 329 4.1 561 4.8 638 4.8 650 5.0 697 5.2 651 5.1 654 5.3 614 5.6 648 6.2 621 6.2 586 6.0 639 6.7 55 › 59 546 3.3 468 3.6 320 4.0 444 3.8 507 3.8 463 3.6 488 3.6 493 3.8 510 4.1 449 4.0 421 4.0 483 4.8 498 5.1 543 5.7 60 › 64 421 2.5 371 2.9 287 3.6 392 3.4 448 3.4 450 3.5 408 3.0 371 2.9 422 3.4 395 3.5 352 3.4 319 3.2 357 3.7 381 4.0 65 › 69 304 1.8 209 1.6 205 2.6 283 2.4 352 2.7 341 2.6 355 2.7 316 2.5 295 2.4 272 2.4 277 2.7 345 3.5 291 3.0 329 3.5 70 › 74 162 1.0 157 1.2 115 1.5 168 1.4 241 1.8 204 1.6 222 1.7 225 1.8 232 1.9 201 1.8 233 2.2 239 2.4 238 2.5 229 2.4 75 › 79 112 0.6 67 0.5 66 0.8 83 0.7 135 1.0 124 1.0 139 1.0 116 0.9 126 1.0 123 1.1 125 1.2 121 1.2 151 1.6 159 1.7 80 › 84 39 0.2 37 0.3 22 0.3 56 0.5 59 0.5 65 0.5 56 0.4 43 0.3 43 0.3 52 0.5 45 0.4 64 0.6 49 0.5 76 0.8

Age group

85 and over 26 0.1 21 0.1 10 0.1 26 0.2 46 0.3 60 0.5 39 0.3 27 0.2 27 0.2 32 0.2 31 0.3 22 0.2 24 0.2 33 0.3

Table 5.24

Source

210 Figure 5.46 Proportion of deaths from road traffic accidents by sex, 1996›2009

Males Females Percentage 120

100 82.4 81.7 81.0 80.0 79.8 80.5 80.7 82.0 80.4 81.3 80.6 79.6 79.2 79.7 80

60

40

20.8

20.0

20.2

20.3

19.6

20.5

19.4

19.5

18.7

19.0

19.3

18.3

17.6 20 18.0

0 Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

Figure 5.47 Major causes of road traffic accidents, 2009

Humans, 69.9 %

Vehicles, 1.6 % Others, 23.4 % Unknown, 4.8 % Enviroment, 0.3 % Roads, 0.0 % Source: Royal Thai Police.

211 Figure 5.48 Causes of road traffic accidents by traffic-police charge, 2009

Cause of accident Drugged driving 0.05 Overloading 0.06 No signals while broken down 0.13 Driving with no lights on 0.22 Animal cutting across 0.34 Sleepy driving 0.56 Inexperienced driving 1.44 Defect accessories 1.58 Not driving in the far-left lane 2.08 Violating stop sign 2.11 Driving in the wrong lane 2.52 Not yielding to privileged vehicle 2.55 Violating traffic lights 3.37 No signaling when parking, 3.80 slowing down or turning Unknown 4.79 Illegal overtaking 5.29 Drunk driving 5.35 Following too closely 8.82 Cutting across at short distance 15.18 Speeding 16.33 Others 23.41 Percentage 051015 20 25

Source: Royal Thai Police.

212 Table 5.25 Numbers of road traffic accidents and motorcycles and proportion of seriously injured drinking motorcyclists, 1991›2009 Year Number of road Motorcycle Proportion of No. of registered Proportion of traffic accidents accident charges motorcycle motorcycles seriously injured (cases) (cases) accidents (units) drinking motorcy- (percent) clists (percent) 1991 48,625 - - 693,241 - 1992 61,329 - - 715,877 - 1993 84,892 - - 859,176 - 1994 102,610 - - 1,091,216 - 1995 94,362 - - 1,339,076 - 1996 88,556 - - 1,247,906 - 1997 82,386 - - 988,472 - 1998 73,725 37,414 50.7 534,458 - 1999 67,800 34,943 51.5 497,422 - 2000 73,737 37,498 50.8 682,929 - 2001 77,616 41,215 53.1 849,907 - 2002 91,623 53,732 58.6 1,186,957 43.7 2003 107,565 66,110 61.5 1,643,179 49.4 2004 124,530 77,642 62.3 1,943,590 48.6 2005 122,040 78,830 64.6 2,011,816 46.5 2006 110,686 75,752 68.4 2,001,711 44.4 2007 101,752 68,140 67.0 1,665,400 44.0 2008 88,689 59,162 66.7 1,796,376 41.7 2009 84,806 52,608 62.0 1,635,807 -

Sources: 1. Police Information Centre, Royal Thai Police. 2. Land Transport Department, Ministry of Transport. 3. Bureau of Epidemiology, Department of Disease Control, MoPH.

213 Figure 5.49 Trends in GDP growth, fuel use for transportation, injuries and deaths from road traffic accidents, 1994›2009

Injuries Fuel use Deaths

GDP P 70,000

90,754

90,507

60,000 85,298

78,501

50,000 70,928

64,894

59,290

40,000 54,519

51,338

49,233

47,326

46,371

46,265 46,110 31,388 31,455

41,862 27,763 30,000 26,564 26,343 36,293 23,104 23,686 20,450 20,366 17,354 20,665 20,000 18,777 18,429 18,395 17,72017,987 18,914 GDP, in 100 million baht 16,707 17,707 17,865 18,312 17,602 17,973 19,537 14,514 16,906 17,513 15,923 17,704 17,986 17,788 10,000 16,681 16,254 10,717

Deaths, 3-case Injuries, Fuel use in millions litres

16,727

15,176

14,405 13,766

14,012

12,858 13,116

12,492

13,836 12,234

12,693

11,561

11,652

11,988 0 12,040 Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources 1. Yordphol Tanaboriboon el al. Situation of Road Traffic Accidents in Thailand, 2006. 2. Police Information Centre, Royal Thai Police. 3. Department of Alternative Energy Development and Efficiency, Ministry of Energy 4. Office of the National Economic and Social Development Board.

Even though the royal decree on safety or crash helmets has been enforced in all provinces throughout the country since 1 January 1996, the data from the injury surveillance system have shown that motorcycle riders/passengers who do not wear helmets as well as motor vehicle drivers/passengers who do not use safety belts are 80% more likely to have serious injuries from traffic accidents than those who do so (Figure 5.50); and nearly half of those motorcycle accident victims with severe injuries have drunk alcohol before riding (Figure 5.51).

214 Figure 5.50 Proportion of serious injuries from traffic accidents among riders/drivers and passengers with and without safetybelt/helmet use, 2000›2009 Severe injuries among those without helmet use

Percentage Severe injuries among those without safety belt 120 97.4 100 91.6 92.9 89.2 89.4 85.0 83.6 84.7 86.2 85.4 85.1 84.1 83.8 85.7 82.4 83.1 81.7 81.7 80 70.7 66.1 60

40

20

0 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Report on Injury Surveillance in Thailand. Bureau of Epidemiology, Department of Disease Control, MoPH. Note: Data for 2008›2009 are riders/drivers only. Figure 5.51 Proportion of severe injuries among motorcycle riders with and without alcohol drinking, 2000› 2009 Injuries among riders with alcohol drinking

Injuries among riders without alcohol drinking Percentage 100 41.7 42.2 41.9 45.0 49.7 44.9 42.8 42.0 41.7 39.9 80 60 58.3 57.8 58.1 55.0 55.1 57.2 57.8 58.3 60.1 40 50.3

20

0 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Report on Injury Surveillance in Thailand. Bureau of Epidemiology, Department of Disease Control, MoPH. 215 2.6.2 Water-Related Accidents Water-related accidents are an important problem that has not received adequate attention as expected, compared to the problem of road traffic accidents, even through the drowning rate in Thai children is 5 to 15 times higher than that in developed countries11. During 1977›2010, the rate of deaths from drowning and falling into water was 4.4›7.5 per 100,000 population (Figure 5.52). An epidemiological analysis of water-related accidents in Thailand during the period 1996›2010 revealed that, among those who died from drowning, males were 3 times more likely than females to become the victims; the highest number being among school-age children (Figure 5.53), probably due to their lack of experience in playing safely in the water and thus being less capable of helping themselves.

Figure 5.52 Rate of deaths from accidental drowning in Thailand, 1977›2010

8 7.5 7 6.67 6.7 6.7 6.4 6.3 6.22 6.21 6.11 6.25 6 5.69 5.85 5.86 5.98 6.6 6.8 6.5 6.5 5.26 5.42 5.21 6.16 5 5.6 5.63 5.85 5.04 5.44 4.67 4.74 4.84 4.96 4 4.39 4.7 4.76 3 2

Death rate per 100,000 Population 1 0 Year

1985 2010 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1977 2000 1978 2001 1979 2002 1980 2003 1981 2004 1982 2005 1983 2006 1984 2007 2008 2009

Source: Bureau of Policy and Strategy, MoPH.

11 Adisak Plitponkarnpim. Child Safety Promotion and Injury Prevention Research Centre of Ramathibodi Hospital, 2006.

216 Figure 5.53 Percentage of reported deaths from accidental drowning by age and gender in Thailand, 1996›2010 Percentage 30

25

1996 20 1998 2000 2002 2003 15 2004 2005 2006 2007 10 2008 2009 2010 5

0 < 4 5-14 15-24 25-34 35-44 45-64 > 64 Age(Year) 1996 13.8 25.3 15.7 12.7 12.5 14.2 5.7 1998 17.2 24.2 12.9 13.6 11.7 14.1 6.3 2000 15.2 21.3 10.8 13.4 13.1 17.3 8.9 2002 14.3 23.4 9.6 12.2 13.1 18.6 8.8 2003 14.3 21.3 10.7 11.9 14.7 17.2 9.8 2004 13.0 22.0 9.8 12.2 14.4 19.6 9.0 2005 11.8 22.9 9.7 12.1 15.2 18.8 9.5 2006 11.2 20.6 8.7 11.5 15.5 22.1 10.4 2007 11.5 20.1 8.8 12.1 15.7 21.3 10.6 2008 11.4 18.8 8.4 12.5 15.3 22.8 10.8 2009 9.9 19.5 9.0 11.2 16.1 22.9 11.3 2010 10.0 18.5 8.4 10.9 15.6 24.0 12.6 Percentage Males Females 100

77.7

78.0

77.2

76.4

76.4

75.6

74.8

74.9

74.9

74.3

73.4

73.2

73.2

71.9

80 71.5

60

40

28.5

28.1

26.8

26.8 26.6

25.7

25.2

25.1

24.4

25.1

23.6

23.6

22.8 22.3

22.0 20

0 Year 19961997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: Mortality Report. Bureau of Policy and Strategy, MoPH. 217 2.7 Occupational and Environmental Diseases According to the epidemiological surveillance of occupational diseases, significant situations can be summarized as follows: 2.7.1 Pesticide Poisoning Based on the Department of Healthûs cholinesterase level examinations among farmers during 1992›2007, 13›39% of farmers had abnormal enzyme levels resulting from pesticide exposure. The trend is unlikely to decline and the rate of pesticide poisoning is between 2 and 6 cases per 100,000 population (Table 5.26). Table 5.26 Cholinesterase test-results and morbidity/mortality due to pesticide poisoning among farmers, 1992›2009 Cholinesterase test(1) Pesticide poisoning (2) Year Number Tested Abnormal Illness Deaths Morbidity rate (persons) abnormal (percent) (cases) (cases) per 100,000 (cases) pop. 1992 42,471 8,669 20.41 3,599 31 6.23 1993 242,820 48,500 19.97 3,299 44 5.65 1994 411,998 72,590 17.62 3,143 41 5.32 1995 460,521 78,481 17.04 3,398 21 5.71 1996 156,315 40,520 25.92 3,196 31 5.32 1997 563,354 89,926 15.96 3,297 27 5.42 1998 369,573 77,789 21.05 4,398 15 7.16 1999 360,411 48,217 13.38 4,169 31 6.78 2000 278,612 52,604 18.88 3,109 21 5.03 2001 89,945 21,758 24.19 2,652 15 4.27 2002 115,105 33,858 29.4 2,571 14 4.11 2003 NA NA NA 2,342 9 3.72 2004 NA NA NA 1,864 9 2.98 2005 84,046 26,034 31.0 1,321 0 2.12 2006 133,255 36,776 27.6 1,183 0 2.00 2007 89,376 34,428 38.52 1,452 0 2.31 2008 - - - 1,705 2 2.70 2009 - - - 1,691 0 2.66

Sources: (1)`Department of Health, MoPH. (2)`Bureau of Epidemiology, Department of Disease Control, MoPH.

218 2.7.2 Occupational Diseases in the Industrial Sector There are several heavy metals used in industries such as lead, arsenic, cadmium, mercury, and chromium, whose residues and contamination in the environment and food are hazardous to humans exposed to such metals; the resulting health problems are as shown in Table 5.27.

Table 5.27 Morbidity rates due to occupational and environmental diseases by group of illness, 1999›2009

Disease Morbidity rate (per 100,000 population) 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Occupational diseases 7.51 7.01 4.85 4.60 4.19 4.49 2.86 2.45 3.15 3.22 3.57 Occupational lung 0.14 0.19 0.13 0.14 0.22 0.20 0.22 0.10 0.37 0.21 0.41 diseases Lead poisoning 0.10 0.08 0.17 0.09 0.05 0.08 0.02 0.03 0.03 0.04 0.04 Other heavy metal 0.06 0.04 0.05 0.08 0.04 0.89 0.02 0.04 0.05 0.06 0.07 poisonings (manganese, arsenic cadmium) Organic solvent poisoning 0.25 0.18 0.16 0.13 0.11 0.15 0.20 0.19 0.21 0.25 0.23 Source: Bureau of Epidemiology, Department of Disease control, MoPH.

Besides, the Bureau of Epidemiology has conducted a study on the health impact on indus- trial workers exposed to trichloroethylene in Thailand; as much as 90,000 tons of such chemical was imported for industrial use in 2008 (Department of Industrial Works, 2008). If used carelessly, such a chemical is fatally dangerous to human health. According to the 2003›2008 surveillance on occupational and environmental diseases, there were 68 reported cases of solvent poisoning (11 cases per year on average), including 11 due to exposure to trichloroethylene, 8 due to benzene, 3 due to toluene, and 46 due to unidentified chemicals. 2.8 Mental Health Problem Mental health problems, based on the prevalence of mental disorders and suicide situation, tend to be worsening among the Thai people as the rate of outpatients attending mental health clinics has increased from 24.6 per 1,000 population in 1991 to 49.0 per 1,000 population in 2009 (Figure 5.54); and the numbers of patients with psychosis, depression and epilepsy are on the rise (Table 5.28). In addition, the rate of admissions of patients with psychosis and mental disorders has also risen from 90.74 per 100,000 population in 1981 to 265.4 per 100,000 population in 2009 (Figure 5.55).

219 Figure 5.54 Rate of outpatient visits with mental and behavioural disorders, 1983›2009

Economic crisis 60 50 45.9 42.4 49.0 40 35.9 42.3 32.3 34.5 34.0 29.4 37.1 37.6 30 27.2 33.4 35.6 24.8 30.7 21.0 20.2 21.0 28.2 20 16.7 24.6 26.4 21.7 19.5 Rate per 1,000 Population 15.8 16.4 10 0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 1983 2008 1984 2009

Source: Outpatients Report. Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

Figure 5.55 Rate of admissions of patients with psychosis and mental disorders, Thailand, 1981-2009

Economic crisis 300 265.4 250 242.0 222.2 245.4 227.2 200 174.35 151.1 186.43 150 132.39 160.7 110.33 151.0 98.23 107.67 100 90.74 79.35 84.17 118.25 70.81 62.45 93.07 Rate per 1,000 Population 62.09 60.29 80.03 50 68.85 68.22 63.16 60.67 62.92 0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 1981 2008 1982 2009 1983 1984

Source: Inpatients Report. Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

220 Table 5.28 Prevalence of mental disorders, 1997-2009 Prevalence (per 100,000 population) Mental disorder 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 -Psychosis 440.1 435.3 424.8 451.0 519.6 828.0 751.4 682.7 572.3 640.6 581.5 612.3 578.1 -Anxiety disorder 789.9 822.6 764.7 812.2 776.0 862.5 865.6 667.6 596.8 548.8 580.5 532.8 527.3 -Major depression 55.9 74.3 99.5 130.3 94.9 134.8 163.8 140.6 149.9 186.0 196.5 229.9 260.8 - Mental retardation 44.7 52.9 58.2 52.4 51.7 62.3 56.6 55.5 51.7 60.8 58.5 52.7 48.4 -Epilepsy 109.3 125.8 NA 149.8 182.5 200.3 193.5 180.5 195.2 172.1 195.1 184.7 193.1 Source: Department of Mental Health, MoPH.

Suicide is one of the indicators reflecting serious mental conditions. According to a report of the Royal Thai Police, after the 1997 economic crisis the suicidal rate tended to be on the rise; the rate in males being almost four times greater than that in females. However, after 2005, the rate has had a declining trend for both males and females (Figure 5.56).

Figure 5.56 Rate of suicides, 1992-2009

12 Males Females 10.5 9.66 9.9 10 9.4 9.5 9.3 9.3 8.05 7.79 7.83 8 7.22 6.95 6 5.77 4.79 5.01 3.75 4 3.29 Economic crisis

Rate per 100,000 Population 2.81 3.3 2 2.9 2.7 2.30 2.37 2.64 2.4 2.5 2.7 1.08 1.83 2.02 2.09 2.18 1.05 1.19 1.43 1.58 0 Year 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources:1.Data for 1992-2003 were derived from the database of the Royal Thai Police. 2. Data for 2004-2009 were derived from the Bureau of Policy and Strategy, Office the Permanent Secretary, MoPH.

221 2.9 Nutritional Diseases 2.9.1 Malnutrition The trend in overall nutritional status of preschool children has been rather stable. However, with respect to geographical variation, preschool children in the Northeast and North are more likely to be malnourished than those in other regions (Tables 5.29). According to the World Health Report,12 it was estimated that in 2000 approximately 27% or 168 million of all children under 5 years of age worldwide were malnourished (weigh-for-age scale), making them more vulnerable to death due to diarrhoea and pneumonia.

Table 5.29 Nutritional status (weight-for-age, percentage) of children aged 0›6 years by region, 2004›2006

Central Northeast North South Total Rather Lower Rather Lower Rather Lower Rather Lower Rather Lower Year low than low than low than low than low than standard standard standard standard standard 2004 2.68 1.35 8.02 3.03 7.56 2.67 5.24 2.81 6.23 2.53 2005 3.01 1.91 6.58 3.23 5.98 3.39 4.99 2.68 5.30 2.83 2006 2.90 2.81 6.44 2.98 4.74 2.72 4.36 3.27 5.19 2.94

Sources: Department of Health, MoPH. Note: Since 2004, the Department of Health has changed the criteria for assessing nutritional status of children. The rate of underweight primary schoolchildren dropped steadily from 17.8% in 1989 to 6.23% in 2007›2008. (Figure 5.57).

12 Pathom Sawanpanyalert (editor). World Health Report 2002: Reducing Risks and Promoting Health. 2003 (in Thai).

222 Figure 5.57 Proportion of underweight primary schoolchildren, 1989›2008

Percentage 25 Economic crisis

20 17.8 15.2 16.0 14.0 14.1 15 12.2 12.2 10.5 10.6 11.5 11.5 10 8.3 8.3 6.23 5

0 Year 1989 1991 1993 1995 1997 1999 2001 2003

2007-2008

2004-2005 Source: Department of Health, MoPH. Note: For 1995, 1996, and 2002 there were no surveys on malnutrition among primary schoolchildren. For 2003, data were derived from Thailand Diet and Nutrition Survey, Fifth Round, Department of Health, MoPH. For 2005, data were derived from Child and Youth Survey, 2004›2005. Thai Health Promotion Foundation, 2006. For 2007›2008, data were derived from Child Watch Survey, 2007›2008. Ramjitti Institute.

2.9.2 Anaemia among Pregnant Women The rate of anaemia among pregnant women had a declining trend, i.e. dropping from 27.3% in 1988 to 12.9% in 1996, but it rose slightly during the economic crisis. However, the rate dropped again to 10.6% in 2005 (Figure 5.58). Besides, according to the Fourth National Health Examination Survey in 2009, 12.5% of pregnant women had abnormality in their thalassemia screening.

223 Figure 5.58 Proportion of anaemic pregnant women (Hct <33%), 1988›2005

Percentage 35

30 27.3

Economic crisis 25 21.6 18.8 20 18.3 16.1 15.3 14.8 15 14.1 13.4 13.9 13.3 13.0 12.9 13.0 12.6 11.9 12.0 10.6 10

0

0 Year

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Source: Department of Health, MoPH.

2.9.3 Iodine Deficiency Disorders As a result of strong efforts on the elimination of iodine deficiency disorders (IDD), the prevalence of IDD in primary schoolchildren in 15 provinces with high rates of severe goitre dropped from 19.31% in 1989 to 0.69% in 2004 (Figure 5.59); and the national average of goitre prevalence rate also dropped to 1.3% in 2003. But the IDD surveillance programme in pregnant women for preventing intellectual problems among newborn babies revealed that the trend in iodine deficiency among pregnant women rose from 34.5% in 2000 to 57.4 in 2005; however, the rate had a declining trend during 2007›2008 (Figure 5.60).

224 Figure 5.59 Situation of iodine deficiency disorders among primary schoolchildren, 1989›2004 Percentage 25

20 19.31 16.78 15 13.53 14.86 12.96 10.93 10 8.19 7.12 5.28 5 3.87 3.16 2.81 3.31 1.59 1.31 0.69 0 Year 19891990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Source: Department of Health, MoPH. Note: Data were collected only from 15 provinces with a severe goitre problem.

Figure 5.60 Percentage of pregnant women with iodine deficiency (iodine in urine <10 µg/dl), 2000›2008

Percentage 70

60 57.4 49.4 47.0 46.9 50 45.1 44.5 39.7 40 34.5 30

20

10

0 Year 20002001 2002 2003 20042005 2006 2007 2008

Source: Department of Health, MoPH.

225 2.9.4 Neonates with Birth Weight under 2,500 Grams Even though the rate of low birth weight (below 2,500 grams) in general has declined from 10.2% in 1990 to 8.3% in 2009 (Figure 5.61), after the economic crisis the rate of low birth weight in Thailand has been stable or rising slightly, particularly among the poor and unemployed population groups whose rates are markedly higher than that among the non-poor; and the rates are highest in the South and the Northeast.

Figure 5.61 Percentage of newborns with low birth weight (under 2,500 grams), 1990›2009

Percentage Economic crisis 12 10.2 9.4 9.3 10 8.7 8.8 8.9 8.9 8.7 8.2 8.5 8.6 8.5 8.1 8.5 8.6 8.3 8 6 4 2 0 Year

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

2007 2009

2008

Sources:1.Department of Health, MoPH. 2. For 2006, data were derived from the Child Situation Survey in Thailand, Dec 2005 › Feb 2006, National Statistical Office.

2.10 Health Problems of the Elderly 2.10.1 Diseases and Deficiencies in the Elderly According to the report on burden of disease or disability-adjusted life years (DALYs) lost among elderly persons (aged 60 years and over), most Thai elders have DALYs lost due to chronic diseases and bodily degeneration, most of which are cerebrovascular disease and other illnesses (Table 5.30).

226 Table 5.30 Ranking of disability-adjusted life years lost among Thai elderly persons by sex and cause, 2004

Male Female Rank Disease DALY % % DALY Disease (ù000) (ù000) 1 Stroke 170 12.1 12.7 203 Stroke 2 COPD 127 9.0 8.9 141 Diabetes 3 Liver cancer 114 8.1 6.2 99 Ischemic heart disease 4 Ischemic heart disease 96 6.8 6.1 97 Osteoarthritis 5 Diabetes 69 4.9 5.3 84 Cataracts 6 Osteoarthritis 67 4.8 4.9 78 Dementia 7 Bronchus and lung cancer 64 4.5 4.1 66 Liver and bile duct cancer 8 Deafness 48 3.4 4.0 64 COPD 9 Cataracts 47 3.3 3.8 61 Deafness 10 Dementia 38 2.7 2.8 45 Nephritis & nephrosis

Source: Working Group on Burden of Disease, Thailand, 2004.

2.10.2 Major Causes of Death in the Elderly Among the elderly, the most common causes of death are, in order of magnitude, cancer, heart disease, cerebrovascular disease, pneumonia, kidney disease and diabetes. It has been found that the mortality rate (per 100,000 population) from cancer has risen from 169.1 in 1985 to 427.9 in 2009. The rate of mortality due to cerebrovascular disease (per 100,000 population) has also risen from 54.9 in 1996 to 112.8 in 2009; and the rates of mortality have also risen for diabetes from 28.8 to 66.4 for the same period and for pneumonia from 42.0 in 1991 to 119.9 in 2009 (Figure 5.62).

227 Figure 5.62 Mortality rates due to major causes of death in the elderly, 1985›2009

Heart diseases Cancer Diabetes Liver diseases Paralysis Pneumonia Kidney diseases Transportation accidents Cerebrovascular diseases Emphysema 500 450 400 350 300 250 200 150

Mortality rate per 100,000 Population 100 50 0 Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Mortality Report, Bureau of Policy and Strategy, MoPH.

228 Mortality rate (per 100,000 population) among the elderly Year Diabetes Heart Cancer Liver Kidney Paralysis Pneumo- Transporta- Cerebrovas- Emphy- diseases diseases diseases nia tion cular sema accidents diseases 1985 28.8 245.0 169.1 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1986 24.9 259.3 177.6 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1987 30.3 304.3 199.1 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1988 32.4 331.1 209.6 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1989 37.2 372.3 231.9 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1990 39.4 379.2 248.8 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 1991 39.9 386.7 253.9 62.6 38.3 49.5 42.0 16.9 n.a. n.a. 1992 49.5 400.3 266.8 63.4 48.0 51.5 42.3 20.1 n.a. n.a. 1993 50.8 389.7 262.9 57.1 45.9 42.4 45.3 19.5 n.a. n.a. 1994 57.2 412.2 283.9 56.3 47.5 44.9 56.0 24.1 n.a. n.a. 1995 56.2 440.7 242.1 52.2 55.3 45.5 51.0 26.3 n.a. n.a. 1996 57.4 407.5 236.2 41.4 38.2 37.4 46.8 22.4 54.9 18.4 1997 48.5 356.1 199.4 33.1 40.5 32.0 33.7 17.1 49.1 13.3 1998 47.7 310.0 213.0 34.4 46.7 31.3 28.9 13.3 38.0 11.0 1999 74.8 257.7 273.7 34.0 56.1 32.3 61.1 18.5 63.8 23.0 2000 82.1 179.9 297.6 34.0 75.5 33.9 59.9 22.6 79.7 29.5 2001 88.4 182.2 218.2 40.6 89.6 34.8 73.0 21.5 110.1 38.8 2002 72.1 149.4 342.6 35.5 87.2 29.2 85.5 18.9 118.7 40.2 2003 66.7 177.1 399.5 38.3 108.0 26.8 107.4 16.7 166.8 54.9 2004 75.8 163.8 393.1 30.7 98.9 32.8 119.2 17.3 166.3 37.7 2005 73.0 172.3 393.6 39.5 100.3 26.6 107.8 16.2 134.3 37.4 2006 71.3 175.3 402.5 39.2 83.0 25.9 110.3 15.2 110.9 35.1 2007 74.1 179.9 411.0 36.1 117.3 22.6 116.3 16.3 112.6 37.3 2008 73.3 183.0 424.8 36.3 124.3 20.3 121.5 16.0 113.9 36.2 2009 66.4 173.2 427.9 34.4 116.9 18.2 119.9 16.9 112.8 30.7

Source: Bureau of Policy and Strategy, MoPH. Note: n.a. = Data not available

229 2.10.3 Health Status of the Elderly 1) Prevalence of Chronic Diseases and Deficiencies in the Elderly The 2006 risk survey among Thai elderly persons conducted by the Ministry of Social Development and Human Security revealed that three-thirds of them had chronic illnesses, mostly including hypertension, bone/joint diseases, diabetes, eyes diseases, and cardiovascular disease. And according to the 2007 survey conducted by the National Statistical Office, 31.7% of Thai elders had hypertension, followed by diabetes (13.3%), heart diseases (7.0%), paralysis/paresis (2.5%), cerebrovascular disease (1.6%), and cancer (0.5) (Figure 5.63). It is noteworthy that the prevalence of chronic diseases and deficiencies in the elderly has a rising trend even though revealed by different surveys conducted during periods of time; however, such a trend is consistent with their causes of death.

Figure 5.63 Percentage of elderly persons with chronic diseases by disease and sex, 2007

Percentage 50 45 31.7 40 35.7 Males 35 Females 30 26.7 13.3 Total 25 7.0 20 16.4 2.5 15 1.55 0.5 10 9.5 8.6 5 2.3 5.0 1.5 1.6 0.4 0.6 0 2.7 diseases HypertensionDiabetes Heart diseases Paralysis/paresis Cerebrovascular Cancer diseases

Source: Report on Elderly Population Survey in Thailand, 2007. National Statistical Office.

2) Common Causes of Illness in Elderly Persons According to the report on common illnesses among Thai elderly persons between 2004 and 2009, based on the analysis of individual inpatientsû data from the National Health Security Office, the Comptroller Generalûs Department of the Ministry of Finance, and the Social Security Office, most of them sought medical services for hypertension, followed by diabetes, ischemic heart disease, paresis/paralysis, heperlipidemia, degenerative joint disease and dementia; and their rates of hospitalization (per 100,000 popu- lation) are rising each year (Figure 5.64).

230 Figure 5.64 Rates of hospitalization due to common illnesses among elderly persons, 2004›2009

Dementia Degenerative joint Ischemic heart Hyperlipidmia Hypertension Diabetes Paresis/paralysis 8,000 7,000 6,000 5,000 4,000 3,000 2,000

Rates per 100,000 Population 1,000 0 Year 2004 2005 2006 2007 2008 2009

Hospitalization rate (per 100,000 population) Disease 2004 2005 2006 2007 2008 2009 - Dementia 57.66 76.61 72.88 90.38 99.31 113.9 - Degenerative joint 156.27 218.06 211.67 239.07 265.54 272.9 - Ischemic heart disease 1,420.07 1,873.15 1,868.28 2,156.14 1,856.54 1,898.6 - Hyperlipidemia 446.59 787.18 984.17 1,437.68 1,909.20 2,180.2 - Hypertension 3,511.72 5,027.00 5,330.04 6,419.47 7,213.10 7,741.8 - Diabetes 2,627.40 3,663.68 3,732.38 4,328.11 4,655.91 4,852.7 - Paresis/paralysis 795.56 975.88 895.23 969.15 994.57 1,013.7

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH Data sources: Data for 2004›2007, Individual Inpatients Data, National Health Security Office and Comptroller Generalûs Department. Data for 2008›2009, Individual Inpatients Data, National Health Security Office and Social Security Office.

231 3) Chronic Diseases as Risk Factors for Cardiovascular Disease in the Elderly According to the analysis of data on chronic illness and major disease burden among elderly persons, obtained from the Fourth National Health Examination Survey (2008›2009) conducted by the National Health Examination Survey Office of the Health Systems Research Institutes, nearly half of the elderly had hypertension, one-third had (with pot belly or obesity, BMI ≥25 hg/m2), one-fourth had high blood cholesterol (cholesterol ≥240 mg/dl), and 15% had diabetes (Figure 5.65). However, 22.2% of the elderly had diabetes but were unaware of their own diabetic condition, while 50% of the elders with diabetes could control their blood sugar level; and 37.2% of elderly persons with hypertension were unaware of their high blood pressure, but only 28.2% of would control their blood pressure level (Figure 5.66). Figure 5.65 Prevalence of chronic diseases and cardiovascular disease among Thais aged 60 years and over, 2008›2009 48.1 Hypertension 48.9 47.1 36.8 Metabolic syndrome 43.8 28.0 36.0 Abdominal obesity 47.9 21.2 29.9 Obesity (BMI 25 kg/m2) 36.2 ≥ 22.2 26.1 High cholesterol 31.2 19.9 Total 15.9 Diabetes 17.6 Females 13.8 3.9 Males Ischemic heart Diabetes 3.9 3.9 3.5 Cerebrovascular diseases 2.9 4.1 Percentage 03010 20 40 50 60

Source: Fourth National Health Examination Survey (2008›2009) conducted by the National Health Examination Survey Office of the Health System Research Institute.

232 Figure 5.66 Proportions of diagnosis and treatment efficacy 2008-2009 among elderly persons with diabetes and hypertension Percentage 100 90 22.2 80 2.7 37.2 70 Undiagnosed 60 26.1 7.3 Diagnosed but untreated 50 40 27.3 Treated but illness not under 30 49.0 control 20 28.2 Treated and illness 10 under control 0 Illness Diabetes Hypertension Source: Fourth National Health Examination Survey (2008›2009) conducted by the National Health Exami- nation Survey Office of the Health System Research Institute. It has been estimated that there are as many as 5.4 million chronically ill elderly persons who are at risk for cardiovascular disease (based on a total of 7.3 million people aged 60 and over in 2009) (Figure 5.67). Figure 5.67 Estimated numbers of elderly persons aged 60 years and over with chronic diseases rated to cardiovascular diseases, 2008›2009 No. of persons 4,000,000 3,500,000

3,000,000 2,400,000 2,300,000 2,000,000 1,900,000 1,800,000 1,100,000 1,000,000 280,000 250,000 0 Group of diabetes

obesity

Obesity

diabetes

Diabetes

Metabolic

syndrome

Abdominal

Hypertension

Ischemic heart

Cerebrovascular

High cholesterol Source: Fourth National Health Examination Survey (2008›2009) conducted by the National Health Examination Survey Office of the Health System Research Institute.

233 4) Dementia among the Elderly More and more elderly persons especially females tend to have dementia (Figure 5.68).

Figure 5.68 Rate of hospitalizations with dementia among elderly persons, 2004-2009

Males Females 116.8 110.4 120 102.89 93.35 100 94.85 86.74 77.03 74.95 80 76.1 70.33 59.8 60 55.05

40

Rate per 100,000 Population 20

0 Year 20042005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. Data sources:Data for 2004›2007, Individual Inpatients Data, National Health Security Office and Comptroller Generalûs Department. Data for 2008›2009, Individual Inpatients Data, National Health Security Office and Social Security Office.

Besides, according to the Fourth National Health Examination Survey (2008›2009, con- ducted by the National Health Examination Office of the Health Systems Research Institute, through the dementia screening with the preliminary brain condition testing checklist (developed by the Institute of Geriatric Medicine, Department of Medical Services, MoPH), approximately 880,000 elderly persons were found so have dementia, or a prevalence of 12.3%. The dementia prevalence rises with age, i.e. 7.1% (5.6% and 8.3% in elderly males and females, respectively) in the 60›69 age group and as many as one-third in the 80 and over age group (22% in males and 40% in females) (Figure 5.69).

234 Figure 5.69 Prevalence of dementia among elderly persons by age and sex, 2008›2009

Males Females Total Percentage 60

50 40.0 40 32.5 30 22.1 18.1 20 14.7 15.0 12.3 10.6 8.9 10 8.3 7.1 5.6 0 Age group 60-6970-79- 80 + Total (Year)

Source: Results of dementia survey in elderly persons in the Fourth National Health Examination Survey (2008›2009) conducted by the National Health Examination Survey Office of the Health System Research Institute.

5) Bodily Degeneration among the Elderly According to the health status assessment focusing on bodily degeneration among elderly persons, more than half of them (57.7%) have a problem with seeing, more males having such a problem than females; and the older they get, the smaller proportion of them having such a problem, probably due to the fact that they have undergone a cataract surgery and thus they can see more clearly (Figure 5.70). Regarding the hearing capacity, 14.6% of them have hearing impairment; not much difference is found between males and females, but the older they become, a much larger proportion of them have such a problem (Figure 5.71).

235 Figure 5.70 Proportion of elderly persons with visual impairment by sex and age group, 2008

With visual impairment Without visual impairment Percentage 100 42.3 37.5 46 35 44.8 58.9 80

60 62.5 65 57.7 54 55.2 40 41.1 20

0 sex and age(Year) Total Male Female 60-69 70-79 80+

Source: Health Care System for Vulnerable Elderly Persons in Communities, 2008. Institute of Geriatric Medicine, Department of Medical Services, MoPH.

Figure 5.71 Proportion of elderly persons with hearing impairment by sex and age group, 2008

With visual impairment Without visual impairment Percentage 100 85.4 85.0 85.8 92.3 83.9 68.3 80

60

40

20 31.7 14.6 15.0 14.2 7.7 16.1 0 sex and age(Year) Total Male Female 60-69 70-79 80 +

Source: Health Care System for Vulnerable Elderly Persons in Communities, 2008. Institute of Geriatric Medicine, Department of Medical Services, MoPH.

236 Besides, according to the database on falls among people aged 60 years and over of the National Health Examination Survey Office of the Health Systems Research Institute, under the Fourth National Health Examination Survey (2008›2009), and the 2007 survey among the elderly in Thailand, conducted by the National Statistical Office, the proportion of falls among elderly persons tends to rise from 10.3% in 2007 to 18% in 2008›2009, for both males and females. Among males, the prevalence rose from 7.4% to 14.4% and among females from 12.6% to 21.9% during the same period (Figure 5.72).

Figure 5.72 Prevalence of falls among elderly persons during the past 6 months in 2007 and 2008›2009

Total Males Percentage Females 25 21.9

20 18 14.4 15 12.6 10.3 10 7.4

5

0 Year 2007 2008 - 2009

Sources:1.Report on Elderly Population Survey in Thailand, 2007, National Statistical Office. 2. Falls among Elderly Persons in Thailand in the Fourth National Health Examination Survey (2008-2009), National Health Examination Survey Office of the Health Systems Research Institute.

237 238 Chapter 6 deals with the information about health resources, health financing and capacity of health service systems in seven parts, i.e. (1) health workforce, (2) health facilities, (3) health technology, (4) health expenditure, (5) accessibility to health services, (6) efficiency and quality of health services delivery, and (7) equity in health services, as detailed below: 1. Health Workforce Health workforce is an input that is extremely important for health service systems. The production of health personnel has been undertaken continuously, resulting in an increase in the number of health personnel and their distribution to various health facilities within and outside MoPH. However, there are some problems in this regard, particularly the inadequacy of health personnel, compared with the suitable standard, the problem of distribution to cover all geographical areas, and the quality of personnel, which might be associated with personnelûs workloads. In analyzing the health workforce situation, the following aspects are taken into consideration: quantity of existing personnel, production situation, loss situation and distribution situation, as shown in Figure 6.2.

Figure 6.2 Aspects in the analysis of health workforce situation

Quantity of existing health Production and workforce development of - by type of personnel Loss of health personnel health workforce - by expertise - by service facility

Distribution of health workforce - Distribution by geographical region - Distribution by level of service

1.1 Situation and Trends in Quantity of Health Workforce 1.1.1 Trends in Ratio of Population to Health-care Provider by Type of Personnel The overall situation of health workforce during the past period, using the ratio of population to health-care provider, has shown that the trends in quantities have been improving steadily (Figure 6.3).

240 Figure 6.3 Ratios of population to health-care provider, 1979›2009

population/ Doctors Dentists Pharmacists Professional nurses provider ratio 50,000

40,000 30,000 20,000

10,000

0 Year

1979

1981 1983 1985 1993 1987 1989

2001 2009 1995 2003 1997 1991 2005 2007 2008

1999

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: In 1979, data were adjusted and the ratios were recalculated due to the incompleteness of data.

Data from the MoPH health resource survey might be inaccurate due to incompleteness of data obtained, especially for dentists; the population/dentist ratio reported by the Bureau of Policy and Strategy was 1.6-fold to 2.3-fold lower than that revealed by the Dental Health Personnel Report of the Department of Health (Figure 6.4).

241 Figure 6.4 Ratios of population to dentist, 1999›2009 (from 2 sources of data)

Population/dentist ratio 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Pop./dentist(BPS) 15,295 14,917 14,384 17,606 17,182 15,143 14,901 14,959 13,525 13,148 14,833 Pop./dentist(DOH) 9,436 9,074 8,624 8,252 8,022 7,811 7,340 7,086 6,731 6,572 6,393

Sources:- Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. - Report on Dental Health Personnel, 1999›2009, Department of Health, MoPH.

1.1.2 Health Workforce by Agency 1) Doctors In 2009, there were 35,789 physicians or medical doctors who were alive and living in Thailand (Medical Council, 2010). But according to the report on health resources survey of 2009, there were only 19,089 doctors, which was 13% lower than that reported in the 2008 survey, due to data incompleteness. Therefore, in 2009, based on the data from the Medical Council, the proportions of doctors were recalculated for each agency and region as shown in Figures 6.5 and 6.21; and it was found that the proportion was lower in the public sector but higher in the private sector, i.e. from 93.2% in 1971 to 82.9% in 2009 in the public sector and from 6.7% to 17.1% in the private sector during the some period (Figure 6.5). Most of the doctors in Bangkok work for other ministries, followed by the private sector, while in the provinces, most of them work for MoPH (Figure 6.6); this feature is similar for all professions.

242 Figure 6.5 Proportions of doctors by agency, 1971›2009

MoPH Proportion (%) Other ministries 60 Local agencies Private sector 54.0 54.9 State enterprises 51.5 49.7 50 53.5 44.8 50.4 41.3 41.8 46.1 40 42.5 43.3 35.8 38.4 37.9 37.1 32.2 32.0 30 27.8 24.6 22.1 20.3 24.2 18.0 23.7 22.7 20 21.1 20.9 18.7 18.3 11.2 11.3 11.4 17.1 10 8.3 9.0 6.7 8.4 4.2 4.2 4.0 3.4 4.0 4.0 3.2 4.3 6.5 1.8 3.0 3.5 1.4 2.4 0 2.8 2.5 2.5 2.5 1.8 3.0 0.8 Year 0.8

1999

1971 2007 2009 2008

1975

1979

1983

1987

1991 2003 1995

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion and number of doctors for each type of agency were recalculated using the formulas below: Proportion for each agency = (New number of doctors by agency/ Number of all doctors alive and living in country) x 100 New number of doctors Proportion of doctors by agency = Number of all doctors for each agency from 2009 MoPH report X alive and living in 100 country

243 Figure 6.6 Proportions of doctors by agency and region, 2008

Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

Private sector 31.60 20.70 11.90 12.50 5.00 Local agencies 5.70 0.30 0.50 0.20 0.30 State enterprises 1.00 1.90 0.40 0.00 0.02 Other ministries 49.70 10.70 18.20 12.80 16.80 MoPH 12.00 66.40 69.00 74.50 77.90

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH.

2) Dentists In 2009, Thailand had a total of 10,571 dentists who were alive and living in Thailand (Dental Council, 2010), whereas the 2009 health resources survey revealed that there were only 4,278, which was 11% lower than that found in the 2008 survey due to data incompleteness. So, for 2009, the figure from the Dental Council was used for recalculating the proportions of dentists by agency and region as shown in Figures 6.7 and 6.22. Overall, it was found that the proportion of dentists was declining in the public sector (MoPH, other ministries, state enterprises and local agencies) from 96.2% in 1971 to 92.8% in 2009, but rising in the private sector from 3.8% in 1971 to 7.2% in 2009 (Figure 6.7). As for dentists in Bangkok, most of them work for other ministries, followed by the local agency (i.e. Bangkok Metropolitan Administration, or BMA) and the private sector, while in other regions, most of them work for MoPH (Figure 6.8).

244 Figure 6.7 Proportions of dentists by agency, 1971›2009

Proportion (%) 70 MoPH 66.1 66.6 Other ministries 64.9 Local agencies 64.8 60 61.8 55.7 Private sector 51.7 52.4 State enterprises 50 48.6 40.4 42.1 42.4 40 37.6 33.0 30 27.5 28.7 29.5 25.4 25.4 21.7 22.8 20 22.6 16.2 16.6 20.8 19.6 12.6 10.6 10.0 13.3 10.5 10 9.2 8.4 9.0 5.8 6.5 7.9 7.2 5.3 4.8 4.2 6.3 3.8 8 3.7 1.6 3.5 3.2 3.8 3.7 4.8 4.2 5.8 2.1 1.10.9 4.0 0 3.1 2.6 3.5 Year

1999

1971 2007 2009 2008

1975

1979

1983

1987

1991 2003 1995

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion and number of dentists for each type of agency were recalculated using the formulas below: Proportion for each agency = (New number of dentists by agency/ Number of all dentists alive and living in country) x 100 New number of dentists Proportion of dentists by = for each agency agency from 2009 MoPH report X Number of all dentists 100 alive and living in country

245 Figure 6.8 Proportions of dentists by region, 2008 Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

Private sector 17.30 8.70 5.50 4.20 2.00 Local agencies 12.40 1.70 0.80 0.60 0.90 State enterprises 2.10 1.40 0.30 0.00 0.09 Other ministries 61.80 5.90 16.30 17.90 12.00 MoPH 6.50 82.40 77.00 77.30 85.00

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. However, according to the dental personnel survey of the Department of Health covering 93% of all dentists alive and living in the country, the number being 1.6-fold to 2.3-fold greater than that shown in the health resources report, and the proportion of dentists was mostly in the private sector while only 30% worked for MoPH. The proportions of dentists by agency did not change much (Figure 6.9). Figure 6.9 Proportions of dentists by agency, 2001›2009 (according to DoH database) Proportion (%) 120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Private sector 51.0 51.4 53.2 53.4 53.9 54.1 53.4 53.3 52.6 Local agencies 1.8 1.7 1.6 1.7 1.6 1.5 1.5 1.5 1.5 State enterprises 0.7 0.7 0.6 0.6 0.5 0.5 0.5 0.8 0.8 Other ministries 15.2 13.8 13.3 13.5 13.2 13.0 12.3 12.2 11.7 MoPH 31.3 32.4 31.3 30.8 30.7 31.0 32.4 32.2 33.4 Source: Report on Dental Health Personnel, 2001›2009. Department of Health, MoPH. 246 3) Pharmacists In 2009, there were a total of 24,401 pharmacists alive and living in the country (Pharmacy Council, 2010), while the 2009 health resources survey showed that there were only 7,689, which was 10% lower than that for the 2008 survey due to data incompleteness. Thus, for 2009, the data from the Pharmacy Council were used for recalculating the proportions of pharmacists by agency and region as shown in Figures 6.10 and 6.24. It was found that, during 1971›1985, about half of pharmacists (approximately 50%) worked in the private sector (drug manufacturing industries, import companies and drugstores), while only 43.0%›50.9% worked in the public sector. But after the government launched the compulsory working for newly graduated pharmacists in 1984 and 2006, the proportion of pharmacists working in the public sector especially MoPH rose to 73.4% in 2009, while that in the private sector dropped to only 14.7% in the same year (Figure 6.10). Most of those pharmacists in Bangkok work in the private sector, which is close to that for other ministries, but for other regions, most of them work for MoPH (Figure 6.11). Figure 6.10 Proportions of pharmacists by agency, 1971›2009

MoPH Other ministries Proportion (%) Local agencies 80 Private sector 74.8 74.6 71.373.0 73.4 70 State enterprises 60 57.0 55.4 51.0 51.8 50 48.9 42.6 40.6 40 36.7 37.9 32.2 30 22.8 25.0 18.9 19.1 20 15.1 14.4 15.7 13.7 15.9 14.914.7 17.8 18.0 17.9 10.8 12.3 6.8 9.7 9.8 9.8 10 4.3 4.4 5.4 5.9 6.5 5.5 5.8 4.8 3.0 2.3 1.5 1.5 2.0 3.0 2.9 2.3 2.2 2.7 1.8 2.0 0 1.7 1.9 0.8 0.8 0.6 Year

1999

1971 2008 2009

1975

1979

1983

1987

1991 2003 1995 2007 Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion and number of pharmacists for each type of agency were recalculated using the formulas below: Proportion for each agency = (New number of pharmacists by agency/ Number of all pharmacists alive and living in country) x 100 New number of pharmacists = Proportion of pharmacists by for each agency agency from 2009 MoPH report X Number of all phar- 100 macists alive and living in country 247 Figure 6.11 Proportions of pharmacists by region, 2008

Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

Private sector 42.8 14.1 8.7 8.2 4.4 Local agencies 7.7 0.2 0.5 0.3 0.3 State enterprises 3.4 0.8 0.1 0.0 0.0 Other ministries 35.2 4.8 5.4 4.4 4.8 MoPH 10.9 80.1 85.4 87.1 90.5

Source: Report on Health Resources Survey. Bureau of Policy and Strategy, MoPH.

4) Professional Nurses In 2009, Thailand had 120,948 professional or registered nurses actually working and living in the country (Nursing Council, 2010). But the 2009 health resources survey revealed that there were only 101,760 professional nurses or 7% lower than that found in the 2008 survey due to data incompleteness. Thus, in 2009, the figure from the Nursing Council was used to recalculate the proportions of nurses by agency and region as shown in Figures 6.12 and 6.25, which showed that the proportion in the public sector (MoPH, other ministries, state enterprises and local agencies) was declining from 93.1% in 1971 to 89.3% in 2009, while that in the private sector was rising from 6.8% in 1971 to 10.7% in 2009 (Figure 6.12). Most of the nurses in Bangkok work for other ministries, while in other regions they mostly work for MoPH (Figure 6.13).

248 Figure 6.12 Proportions of professional nurses by agency, 1971›2009

MoPH Other ministries Proportion (%) Local agencies Private sector 80 73.9 73.4 State enterprises 68.5 70 65.2 67.2 60.8 60 58.9 52.6 50 47.6 48.9 42.9 44.3 40 39.7 30 33.2 32.2 29.4 22.1 20.9 20 16.8 14.4 11.8 15.0 14.5 12.3 11.9 10.4 9.6 9.6 14.1 10 7.6 8.2 6.5 14.2 12.1 12.2 11.1 10.7 6.8 7.7 9.5 9.1 5.6 4.9 4.2 3.7 3.72.0 2.4 2.9 3.3 3.5 5.4 6.5 4.9 3.3 3.5 1.1 1.6 0 0.6 0.7 Year

1999

1971 2008 2009

1975

1979

1983

1987

1991

2003 1995

2007

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion and number of nurses for each type of agency were recalculated using the formulas below: Proportion for each agency = (New number of nurses by agency/ Number of all nurses alive and living in country) x 100 New number of nurses for each agency = Proportion of nurses by agency from 2009 MoPH report X Number of all nurses 100 alive and living in country

249 Figure 6.13 Proportions of professional nurses by agency and region, 2008 Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

Private sector 33.7 10.8 6.7 6.1 3.1 Local agencies 9.2 1.0 0.5 0.8 0.4 State enterprises 1.6 1.5 0.2 0.06 0.03 Other ministries 38.9 6.4 9.4 8.0 6.3 MoPH 16.5 80.3 83.2 85.1 90.2 Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Another important aspect in the management of health workforce is their part-time work in the private sector. Among all part-time health-care providers, doctors had the largest proportion (50%›60%), followed by professional nurses (28%›38%); the rising trend was noted for doctors (Figure 6.14).

Figure 6.14 Proportions of part-time health-care providers in the private sector, 2003›2009 Proportion (%) 120 100 80 60 40 20 0 2003 2004 2005 2006 2007 2008 2009 Doctors 50.1 51.8 51.8 56.0 55.4 59.5 56.7 Dentists 4.7 5.3 5.5 5.8 6.0 6.1 5.3 Phamacists 4.6 4.7 5.1 4.4 5.1 4.8 5.0 Professional nurses 37.5 34.4 34.9 32.2 32.5 28.8 32.0

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH.

250 1.1.3 Specialties of Health Workforce Specialties of health-care providers reflect the direction towards specialized care rather than integrated services. There has been a rising trend for doctors in Thailand to undertake specialty training. In 2009, the proportion of doctors with medical specialty certification in various fields was as high as 85.2% of all medical doctors (Figure 6.15).

Figure 6.15 Proportions of medical general practitioners and specialists, 1971›2009

Proportion (%) 120 Gerneral practioners 100 Specialists

94.04

97.01 90.96

85.2

83.6

83.0

83.92

82.7

81.4

80.3

79.19

80 74.53

73.0

70.93

68.82

65.27

61.67

61.8

57.77

58.0

56.6

55.39 60 54.89

54.04

53.89

51.98

50.22

42.23

38.33

49.78

34.73

40 48.02

46.11

45.96

45.11

31.18

44.61

43.4

29.07

42.0

25.47

38.2

20.81

20 16.08

27.0

9.04

5.96

19.7

18.7

17.3

17.0

14.8 2.99 16.4 0 Year

1999

1971 1973 1975 2009 1977 1979 1981 1983 1985 1987 1989 1991 2001 1993 2003 1995 2005 1997 2007 2008

Source: Office of the Secretary-General, Medical Council of Thailand.

Similarly, for dentists in Thailand, there was a rising trend for them to undertake dental specialty training in 2003, but the proportion of dentists with dental specialty certification dropped to a rather stable level during 2004›2008 and rose again in 2009 to 35.4% of all dentists (Figure 6.16).

251 Figure 6.16 Proportions of general and specialized dentists, 1971›2009

Proportion (%) 120

97.2

95.6

93.8

100 92.3

91.5

89.9

87.4

99.1 85.3

83.9

83.2

82.6

82.1

78.4

75.2

80 73.0

72.6

72.5

71.5

71.1

70.6

64.8 General dentists 64.6 60 Specialized dentists

35.4 40 35.2

29.4

28.9

28.5

27.4

27.5

27.0

24.8

21.6

17.9

17.4

16.8

16.1

14.7

20 12.6

10.1

8.5

7.7

6.2

4.4 0.9 2.8 0 Year

1999

1971 2009 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 2001 1993 2003 1995 1997 2005 2007 2008

Source: Dental Health Division, Department of Health, MoPH.

1.2 Production and Development of Health Workforce 1.2.1 Production of Doctors At present, there are 18 medical schools in Thailand (17 public and 1 private), includ- ing another state-run university (Kasetsart University), which started producing medical graduates in 2007 Apart from distributing more doctors to the rural areas, MoPH has been undertaking two projects as follows: (1) The Project on Increased Production of Medical Doctors for Rural People. A total of 5,097 medical students have been admitted under the project since 1996 and 2,156 of whom have graduated. (2) The çOne District, One Doctoré Project. A total of 1,098 medical students have been admitted from the district level since 2005; to date there have been no graduates yet. However, upon graduation, they will be required to work for MoPH for 12 years. The number of medical student admissions is on the rise, particularly during 2007›2008; and the number of newly graduated doctors has also been rising steadily (Figure 6.17).

252 Figure 6.17 Numbers of medical student admissions and newly graduated doctors, 1997›2009 2,600 2,521 New medical students 2,319 2,400 2,244 2,200 Medical graduates 2,000 1,800 1,528 1,635 1,595 1,578 1,572 1,600 1,476 1,550 1,540 1,449 1,417 1,363 1,400 1,482 1,201 1,250 1,272 1,430 1,200 1,326 1,374 948 No. of students & graduates 1,000 899 800 0 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Sources: Student admissions data, from the Bureau of Policy and Planning, Office of the Higher Education Commission (HEC). Medical graduates data, from the Medical Council of Thailand. 1.2.2 Production of Dentists At present, the production of dentists in Thailand is undertaken by 10 institutions (9 public and 1 private); the private one is Rangsit University, which started accepting dental students in 2005. At present, there are approximately 900›1,000 new dentists graduating each year, but for the period 2002›2009, there were only 400›450 new graduates annually as shown in Figure 6.18. Figure 6.18 Numbers of dental students admitted and dental graduates, 1997›2009 1,050 1,000 1,011 950 900 850 800 793 793 792 Students admitted 750 689 700 Graduates 650 600 550 528 528 504 486 502 500 469 478 460 No. of students & graduates 453 450 420 423 437 422 449 383 410 405 400 358 349 350 318 332 300 0 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Sources: Student admissions data, from the Bureau of Policy and Planning, Office of the Higher Education Commission (HEC). Dental graduates data, from the Dental Council of Thailand.

253 1.2.3 Production of Pharmacists At present, Thailand has 14 schools of pharmacy (11 public and 3 private). Between 1997 and 2009, there were increases in both admissions and graduates. The number of graduates dropped slightly in 2003›2004, but rose to 1,493 in 2009 (Figure 6.19)

Figure 6.19 Numbers of pharmacy students admitted and graduates, 1997›2009

Students admitted Graduates 2,000 1,802 1,800 1,863 1,800 1,692 1,743 1,577 1,600 1,487 1,509 1,493 1,374 1,400 1,310 1,349 1,221 1,200 1,198 1,183 1,200 1,164 1,152 1,027 990 1,000 947 960

No. of students & graduates 876 800 763 600 0 Year 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources: Student admissions data, from the Bureau of Policy and Planning, Office of the Higher Education Commission (HEC). Data on graduate, from the Pharmacy Council of Thailand.

1.2.4 Professional Nurses At present, Thailand has 74 nursing colleges/institutions (64 public and 10 private) including one state-run institution (Suranaree Technology University) which began offering a nursing education programme in 2009. Between 2006 and 2009, there was a plan to admit approximately 7,000 nursing students each year and the number of nursing graduates is shown in Figure 6.20.

254 Figure 6.20 Numbers of nursing students admitted and graduates, 1997›2009

9,000 Students admitted 8,000 Graduates 7,770 7,770 7,380 7,574 7,000 6,936 6,741 6,741 6,458 6,000 5,902 5,864

students and graduates

No. of 4,973 5,175 5,000 4,730 4,514 4,380 4,740 4,428 4,760 4,200 4,505 4,627 4,444 4,486 4,000 4,294 4,319 4,400

Year 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Sources: Student admissions data, from the Nursing Council of Thailand, Ministry of Public Health and the report on projection of nursing personnel demand and supply for 2009›2019. Data on graduates, from the Nursing Council of Thailand

1.2.5 Losses of Health Workforce in the Public Sector This section mainly focuses on the issue of resignation from civil service which reflects the change in the type of agency for which health-care providers work, especially shifting from the public to the private sector or to other occupations. Even though shifting to the private sector does not mean a loss in the entire system, the impact is not minimal as most rural residents rely on public services. In MoPH, the significant problem is the resignation of medical doctors; the net loss is on a rising trend, the peak being during the economic booming period in 1996 (before the economic crisis). During that time period, as many as 21 community hospitals had no doctors at all (Table 6.1). After the 1997 economic crisis, the situation improved considerably, possibly due to the downturn in the private sector. Until the economic recovery period of 2001›2003, the resignation of doctors from MoPH became a serious issue again. However, the loss declined in 2004, but rose again between 2005 and 2009 with the annual loss of 600›800 doctors, most likely due to the recovery in the private sector (Table 6.1). However, as the number of newly graduated doctors has been rising, the proportion of net loss has been declining steadily.

255 Table 6.1 Number and proportion of doctors lost in relation to newly appointed doctors, Office of the Permanent Secretary, MoPH, 1994›2009 No. of doctors Fiscal year Increases Decreases (resignation) Net loss (No./ Newly Re-appointed Total Civil servants State Total percent) graduated employees 1994 526 - 526 42 - 42 42 / 8.0 1995 576 - 576 260 - 260 260 / 45.1 1996 568 - 568 344 - 344 344 / 60.6 1997 579 30 609 336 - 336 306 / 52.8 1998 618 93 711 299 - 299 206 / 33.3 1999 830 57 887 204 - 204 147 / 17.7 2000 893 98 991 201 - 201 103 / 11.5 2001 883 82 952 193 83 276 194 / 22.0 2002 878 38 916 401 163 564 526 / 59.9 2003 1,013 39 1,052 287 508 795 756 / 74.6 2004 998 32 1,030 468 - 468 436 / 43.7 2005 741 37 778 663 - 663 626 / 84.5 2006 1,188 110 1,298 777 - 777 667 /56.1 2007 1,128 150 1,278 736 - 736 586/51.9 2008 1,024 159 1,183 785 - 785 626/61.1 2009 999 191 1,190 669 - 669 478/47.8 Source: Bureau of Central Administration, Office of the Permanent Secretary, MoPH. Notes:1.Parent agencies adjusted their own data for fiscal years 1995›2003. 2. According to the cabinet resolution, since 1999 MoPH has been required to accept the graduates who have been awarded scholarships as state employees under MoPH, rather than as civil servants. 3. In 2004, MoPH appointed all state employees as civil servants. 1.3 Distribution of Health Workforce by Geographical Region 1.3.1 Ratio of Population to Health-care Provider by Region The population/doctor ratio has been on an improved trend since 1979 and the regional disparities have significantly declined. Between 2001 and 2009, a regional comparison of the popula- tion/doctor ratio revealed that the ratio for the Northeast has steadily declined, but still higher than those in other regions; the North, South and Central having a comparable ratio (Figure 6.21).

256 Figure 6.21 Population/doctor ratios by region, 1979›2009

Population/doctor ratio 30,000 25,713 Bangkok 25,000 Central North 19,675 20,000 South 15,641 Northeast 15,000 13,112 12,694 11,652 10,879 10,970 10,936 10,000 10,061 8,297 8,116 7,409 5,028 7,705 5,805 5,591 5,308 7,179 6,317 4,888 4,766 3,694 5,000 6,663 2,870 6,079 5,844 4,869 4,609 3,3543,386 2,250 1,404 1,418 4,091 3,653 3,279 2,002 1,210 958 999 760 924 3,301 2,683 2,839 1,864 0 850 Year 955 565

1979 1983 2009

1987

1991

1995

1999

2003

2007 2008 8,000 6,000 4,000 2,000

Population/doctor ratio 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 760 952 924 879 867 886 850 955 565 Central 3,375 3,566 3,301 3,134 3,054 2,963 2,683 2,839 1,864 North 4,488 4,499 4,766 4,534 3,768 3,351 3,279 3,386 2,002 South 5,127 4,984 4,609 3,982 4,306 3,789 3,354 3,694 2,250 Northeast 7,614 7,251 7,409 7,466 7,015 5,738 5,308 5,028 2,870

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion of doctors for each type of region was recalculated using the formulas below: Total number of Doctor proportion by region from 2009 MoPH report X doctors alive and 100 living in country Similarly, the population/dentist ratio in the Northeast has steadily declined; however, the ratio for the Northeast, for the period 2006›2009, was still different from those in other regions (Figure 6.22). 257 Figure 6.22 Population/dentist ratios by region 1979›2009 300,000 280,655

250,000 Bangkok Central 200,000 215,938 North South 163,352 Northeast 150,000

114,900 100,279 Population/dentist ratio 100,000 89,696 89,963 87,858 83,938 63,506 74,381 41,176 20,472 50,000 44,595 13,434 2,9181 38,487 26,351 9,369 51,591 44,852 34,208 17,694 22,02013,169 25,687 25,663 15,918 13,100 6,338 6,982 7,624 28,108 27,225, 16,578 6,045 6,802 4,599 18,420 17494 16,85214,851 5,910 0 13,331 Year 5,179 2,991 6,921 4,869 5,5152,500

1979 1983 2009

1987

1991

1995

1999

2003

2007 2008

35,000 30,000 25,000 20,000 15,000

Population/dentist ratio 10,000 5,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 3,190 6,614 6,921 5,583 5,064 7,035 4,869 5,515 2,500 Central 16,588 17,810 16,852 15,775 14,840 14,104 13,131 13,169 5,910 North 20,993 17824 17,694 16,039 18,111 14,803 14,852 13,434 6,045 South 19,963 20,105 19,578 15,620 17,366 15,968 15,918 13,100 6,338 Northeast 32,499 28,432 26,351 24,699 23,378 22,081 22,020 20,472 9,369

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion of dentists for each type of region was recalcu- lated using the formulas below: Dentists proportion by region from 2009 MoPH report Total number of X dentists alive and 100 living in country 258 However, according to the report on dental health personnel of the Department of Health, the population/dentist ratios are lower (larger number of dentists). The ratio for the Northeast was higher than those for other regions (Figure 6.23).

Figure 6.23 Population/dentist ratios by region, 1999›2009 (based on DoH database)

30,000 25,000 20,000 15,000 10,000 5,000 Population/dentist ratio 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 1,722 1,690 1,605 1,506 1,458 1,422 1,305 1,266 1,230 1,195 1,168 Central 12,864 12,042 11,524 11,474 11,259 11,235 10,494 9,967 9,268 9,116 8,909 North 14,956 14,468 13,566 13,471 13,137 12,752 11,830 11,571 10,820 10,276 9,903 South 14,640 14,032 13,383 13,852 13,443 12,160 11,877 11,118 10,657 10,345 10,101 Northeast 28,005 25,034 24,462 22,112 21,739 21,967 21,120 20,527 18,540 18,597 17,641

Source: Report on Dental Health Personnel, 2001›2009, Department of Health, MoPH.

Regarding the population/pharmacist ratio, there has been a steadily declining trend; the ratio for the Northeast has had a steady decline and the ratios are comparable for the North, the South and the Central (Figure 6.24).

259 Figure 6.24 Population/pharmacist ratios by region, 1979›2009

250,000 226,083 225,000 Bangkok 200,000 202,214 Central 166,581 175,000 North 150,000 South 124,147 125,000 Northeast 100,000 87,386 75,000 82,339 Population/pharmacist ratio 61,845 12,197 54,658 13,184 8,194 3,876 66,796 46,561 45,020 9,743 2,663 50,000 58,063 33,610 8,801 7,717 43,517 25,954 5,841 2,626 25,000 24,910 19,644 7,170 3,521 2,223 25,855 16,610 4,765 1,417 2,304 2,313 2,095 21,14516,149 7,835 13,382 11,458 0 Year 2,143 2,280 2,132

1979 1983 2009

1987

1991

1995

1999

2003

2007

20,000

15,000

10,000

5,000

Population/pharmacist ratio 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 2,485 4,667 4,765 4,632 3,562 4,047 3,527 4,143 1,417 Central 10,213 9,557 7,170 6,819 6,700 6,580 5,841 6,270 2,223 North 11,082 10,115 9,743 9,037 8,372 8,443 8,194 7,844 2,663 South 9,712 9,569 8,801 8,292 8,125 7,759 7,717 7,551 2,626 Northeast 17,979 14,987 13,184 13,048 12,869 12,385 12,197 11,495 3,876

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion of pharmacists for each region was recalculated using the formulas below: Total number of Pharmacists proportion by region from 2009 MoPH report X pharmacists alive and 100 living in country 260 The population/professional nurse ratio has also been declining; the Northeast has the ratio closer to those for other regions (Figure 6.25). Figure 6.25 Population/professional nurse ratios by region, 1979›2009

10,000 9,492 9,000 Bangkok 8,000 Central 7,000 6,751 North 6,000 South 5,000 4,651 4,557 Northeast 4,068 4,000 3,297 3,665 2,964 3,000 2,477 2,273 2,760 1,635 1,707 737 Population/professional nurse ratio 2,000 2,174 2,362 1,470 1,270 511 1,777 1,178 1,022 1,145 999 504 1,000 1,463 973 734 697 638 493 413 1,022 855 621 619 522 517 460 347 215 0 305 285 240 Year

1979 1983 2009

1987

1991

1995

1999

2003

2007 2008 1,600 1,400 1,200 1,000 800 600 400 200 Population/professional nurse ratio 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 287 279 285 289 285 273 240 332 215 Central 749 684 631 593 550 563 554 519 493 North 856 785 734 684 528 648 638 567 504 South 807 765 692 659 622 614 619 558 511 Northeast 1,498 1,278 1,145 1,045 968 1,009 999 819 737

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: As the 2009 data were incomplete, the proportion of professional nurses for each region was recalculated using the formula below: Total number of profes- Professional nurses proportion by region from 2009 MoPH report X sional nurses actually 100 working and living in country 261 For health personnel at subdistrict health centres, the overall population to health worker ratio was stable between 2006 and 2008. But in 2009, the trend was improving, especially for the Northeast with the highest ratio and the South with lowest ratio (Table 6.2). Overall, the regional disparities were declining, partly due to the implementation of the policy on primary care unit development with the assignment of nurses to work at health centres. Table 6.2 Health personnel at subdistrict health centres by region, 1987›2003 and 2006›2009

No. of health workers (and staff to population ratio) Region 1987 1996 1997 1998 1999 2000 2001 2002 2003 2006 2007 2008 2009 Central 4,217 7,724 7,917 8,928 9,017 8,769 8,150 8,027 7,604 8,174 8,166 8,804 9,002 (1:1,833)(1:1,125)(1:1,109) (1:1,207)(1:1,180)(1:1,059)(1:1,453)(1:1,470)(1:1,552)(1:1,625)(1:1,634)(1:1,523)(1:1,556) North 3,233 5,734 6,826 6,970 7,167 7,068 6,558 6,456 6,043 6,349 6,337 7,159 7,484 (1:2,387)(1:1,512)(1:1,293) (1:1,389)(1:1,349)(1:1,292)(1:1,572)(1:1,603)(1:1,713)(1:1,662)(1:1,674)(1:1,489)(1:1,449) South 2,318 4,628 5,038 5,152 5,264 5,146 4,843 4,761 4,463 4,609 4,588 5,415 5,688 (1:2,064)(1:1,161)(1:1,079) (1:1,129)(1:1,127)(1:1,141)(1:1,378)(1:1,416)(1:1,511)(1:1,557)(1:1,572)(1:1,339)(1:1,327) Northeast 4,573 9,114 10,430 10,236 10,569 10,248 9,693 9,591 9,015 9,632 9,619 11,050 11,051 (1:3,167)(1:1,785)(1:1,582) (1:1,681)(1:1,655)(1:1,666)(1:1,938)(1:1,971)(1:2,097)(1:1,956)(1:1,968)(1:1,722)(1:1,681) Disparity between population/worker 1:1.73 1:1.59 1:1.43 1:1.39 1:1.40 1:1.57 1:1.33 1:1.34 1:1.35 1:1.20 1:1.20 1:1.13 1:1.08 ratios of the Central and Northeast Total 14,341 27,200 30,211 31,286 32,017 31,231 29,244 28,835 27,125 28,764 28,710 32,428 33,225 (1:2,421) (1:1,434) (1:1,309) (1:1,390)(1:1,366) (1:1,324) (1:1,628) (1:1,657) (1:1,762) (1:1,733) (1:1,745) (1:1,552) (1:1,534) Sources: 1. For 1987›2000, data were derived from the Bureau of Health Service System Development, Department of Health Service Support, MoPH. 2. For 2001›2003, data were derived from the Bureau of Central Administration, Office of the Permanent Secretary, MoPH. 3. For 2006›2009, data were derived from the Bureau of Policy and Strategy, Office of the Perma- nent Secretary, MoPH. Notes: The figure in ( ) is the ratio of one health worker to population outside municipal areas and sanitary districts. A comparison of population/health-care provider ratios for Bangkok and the Northeast reveals that the disparities have declined steadily, especially for doctors, at about 5-fold, and for dentists, pharmacists and nurses at about 2.5-fold to 4-fold between 2008 and 2009, due to data incompleteness; based on the re-estimated number of personnel, the regional disparities have dropped by half to 1.5- to 2.7-fold (Figure 6.26). But for dentists, based on the data from the Health Department, the Bangkok-Northeast dispari- ties would remain high at 15-fold for 2009 (Figure 6.26).

262 Figure 6.26 Disparities of population/health-care provider ratios for Bangkok and the Northeast, 2001›2009

18

16

14

12

10

8

6

Disparities of ratio for Bangkok-Northeast 4

2

0 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Doctors 10.0 9.5 8.0 8.5 8.1 6.5 6.2 5.3 5.1 Dentists(BPS) 10.2 4.3 3.8 4.4 3.6 3.1 4.5 3.7 1.5 Dentists(DoH) 15.2 14.7 14.9 15.4 16.2 16.2 15.1 15.6 15.1 Phamacists 7.2 3.2 2.8 2.8 3.6 3.1 3.5 2.8 2.7 Professional nurses 5.2 4.6 4.0 3.6 3.4 3.7 4.2 2.5 1.5

Sources:- Report on Health Resources, Bureau of Policy and Strategy, MoPH. - Report on Dental Health Personnel, 1999›2009, Department of Health MoPH. Note: For 2009, due to data incompleteness, the numbers were re-estimated.

263 1.3.2 Ratios of Population to Health-care Provider by Province A comparison of population/health-care provider ratios for all 76 provinces grouped in five quintiles and shown in different colours for each quintile on a shaded area map (Figures 6.27 and 6.28) reveals that most provinces in the Northeast have a higher ratio, compared with those in other regions, except for the provinces with a university hospital. The provinces near Bangkok and in the East as well as those in the upper South, such as Phuket, have more health personnel than other provinces.

Figure 6.27 Geographical distribution of doctors and dentists: population/doctor and population/dentist ratios, 2008

N N

Population per doctor 2008 Population per dentist 2008 955 - 3,010 5,515 - 12,883 3,125 - 3,810 12,909 - 15,157 3,904 - 4,959 15,265 - 17,392 4,995 - 6,134 17,597 - 20,780 6,191 - 8,520 21,560 - 32,698

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

264 Figure 6.28 Geographical distribution of pharmacists and nurses: population/pharmacist and population/ nurse ratios, 2008

NN

Population per pharmacist 2008 Population per nurse 2008 4,143 - 7,064 269 - 474 7,190 - 7,782 475 - 556 7,791 - 9,282 557 - 643 9,360 - 11,030 650 - 823 11,269 - 17,192 838 - 1,196

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

1.4 Distribution of Health Workforce by Level of Services and Workload 1.4.1 Proportion of Health Workforce by Level of Services Based on the level and type of health facilities, the proportion of doctors working in private hospitals is higher than those of other professions, and the proportion in community hospitals is lower than other professions. For professional nurses, most of them work at community hospitals, followed by general and regional hospitals. But for dentists and pharmacists, most of them work at community hospitals (Figure 6.29).

265 Figure 6.29 Proportion of health personnel by type of hospitals, 2009

120 100 80 60

Proportion (%) 40 20 0 Doctors Dentists Phamacists Professional nurses Community hospitals 19.3 39.7 33.9 30.5 General hospitals 11.8 10.8 13.3 17.3 Regional hospitals 13.1 6.7 9.7 12.5 Private hospitals 17.1 7.2 14.7 10.8 Others 38.7 35.6 28.4 26.9

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. 1.4.2 Beds-to-Doctor Ratios and Average Number of Doctors by Service Level In 2008, it was found that community hospitals had the highest beds/doctor ratio, close to that for general hospitals, followed by regional hospitals and private hospitals. For the doctors per hospital comparison, on average, a community hospital had 5.7 doctors; a general hospital had 45 doctors; a regional hospital had 120 doctors; and a private hospital had 14 doctors (Figure 6.30). (Private hospitals also had some part-time doctors, whose number was greater than full-time doctors). However, when considering the trends in beds-to-doctor ratios of community hospitals, using data from the Department of Health Service Support, before the economic crisis, the ratio increased markedly due to a considerable increase in the number of beds but no increase in the number of doctors. But after the crisis, the ratio began to decline due to increasing numbers of doctors, the rate being greater than that for beds (Figure 6.31).

266 Figure 6.30 Beds/doctor ratios and doctors/hospital ratios by type of hospitals, 2008

Community Hospitals General Hospitals Regional Hospitals Private Hospitals Other Hospitals Ratio 140 120.4 120 100 80 60 44.8 41.8 40 14.5 20 8 7.7 5.8 6.6 3.7 5.7 0 Beds/Doctor Doctor/Hospital

Source: Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH.

Figure 6.31 Numbers of beds and doctors, and beds/doctor ratio at community hospitals, 1977›2009

Econome Econome No. of beds crisis recovery No. of doctor Bubble economy Ratio 35,000 5,000 18

33,046 Beds 32,755

31,435 33,046

31,279 13.9 31,275

29,930 4,500

29,780

29,930 16 30,000 Doctor 13.7 33,046 3,977 4,000 Beds/Docto 27,180 4,319 14

3,583 11.8 3,523 25,000 3,500

10.9

10.9 10.8 3,229 12

10.4 22,830 3,050 9.8 20,000 3,000

9.1

8.9 10 9.6 8.9 18,560 10.3

8.3 9.7 2,500

8.1 8.1 2,885

2,732 7.5 15,740 2,725 7.7 8 15,000 7.1 2,000 10,80011,09011,910 1,956 9,460 1,766 1,500 6 10,000 1,549 1,592 1,574 1,665 7,220 1,339 4 5,540 1,162 1,000 5,000 4,750 736 2 580 500 2,540 441 0 0 0 Year

1977 1979 1983

1981 1987

1985 1991

1989 1995

1993 1999

1997 2003

2001 2007 2009 2005

Sources:- Bureau of Health Service System Development, Department of Health Service Support, MoPH. - Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

267 1.4.3 Workload of Health Workforce by Level of Services For the 7-year period of 2002›2009, the health resources surveys revealed that doctors at community hospitals had the highest workload followed by those at general hospitals, while those at university hospitals had the lowest; and doctors at private hospitals had a workload close to that for doctors at regional hospitals. The workload of doctors at community hospitals was on a declining trend, but those at other agencies had a stable workload (Table 6.3).

Table 6.3 Workloads of doctors, 2002, 2005 and 2007›2009

2002 2005 2007 2008 2009 Health facility Workload Compa-Workload Compa- Workload Compa- Workload Compa- Workload Compa- per rative per rative per rative per rative per rative doctor index doctor index doctor index doctor index doctor index Community hospitals 34,379 2.1 29,997 1.9 28,487 2.0 25,728 1.7 23,006 1.5 General hospitals 18,805 1.1 17,987 1.1 19,742 1.4 16,680 1.1 17,260 1.1 Regional hospitals 12,020 0.7 13,046 0.8 13,305 0.9 14,373 0.9 11,721 0.7 University hospitals 4,931 0.3 3,812 0.24 2,701 0.19 2,934 0.2 3,353 0.2 Private hospitals 12,849 0.8 14,273 0.9 15,681 1.1 15,168 1.0 15,295 1.0 Total 16,535 1.0 15,788 1.0 14,469 1.0 15,340 1.0 15,808 1.0

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Notes:*In order that the inpatient workload for each type of hospitals is in the same output, the number of inpatients is adjusted as follows: 1. For community and private hospitals = no. of inpatients X 14 2. For regional/general, university and BMA hospitals = no. of inpatients X 18 3. For 2009, data were incomplete.

268 2. Health Facilities 2.1 Situation and Trends of Health Facilities Health facilities, both public and private, have the following trends and distributions: 2.1.1 Health Facilities in the Public Sector In Bangkok, there are 5 medical school hospitals, 26 general hospitals, 13 specialized hospitals/institutions, and 68 public health centres (with 76 branches) in all districts. Regional level. There are 6 medical school hospitals, 25 regional hospitals, and 48 specialized hospitals. Provincial level. There are 69 general hospitals covering all provincial areas (a decrease by 1 hospital, i.e. Chonprathan Hospital transferred to the Ministry of Education). District level. There are 734 community hospitals, covering 83.6% of all districts, and 284 municipal health centres. Tambon (subdistrict) level. There are 9,768 health centres, covering all subdistricts, several of which have more than one health centre. Village level. There are 151 community health posts, 48,049 rural community primary health care centres, and 3,108 urban community primary health care centres.

Table 6.4 Health facilities in the public sector, 2009

Administrative level Health facility Number Coverage Bangkok Metropolis Medical school hospitals 5 General hospitals 26 MoPH 4 Royal Thai Police 1 Ministry of Justice 4 Ministry of Defence 5 BMA 8 State enterprises 4 Specialized hospitals/institutions 13 Public health centres/branches 68/76 All districts under BMA Regional level and Medical school hospitals 6 branches Regional hospitals 25 Specialized hospitals: 48 Health promotion hospitals 12 Psychiatric hospitals 13

269 Administrative level Health facility Number Coverage Neurological hospital 1 Rajprachasamasai Institute 1 Bamrasnaradura Institute 1 Chest Disease Institute 1 Cancer prevention & control centres 7 Drug dependence treatment centres 6 Mettapracharak Watraikhing Hospital 1 Centre for elderly care 1 Dermatology Institute 1 Dental Institute 1 Sirindhorn National Medical Rehabilitation Centre 1 Thanyarak Institute 1 75 provinces General hospitals 71 100% General hospitals, under MoPH 69 General hospitals, under MoE 2 Military hospitals under the Ministry of Defence 59 Hospital under the Royal Thai Police 1 878 districts Community hospitals 734 83.6% Municipal health centres (2009) 284 7,255 subdistricts Health centres (2009) 9,768 100% 74,954 villages Community health posts 151 Community PHC centres Rural (2007) 48,049 64.1% Urban (2003) 3,108 Sources:1.Bureau of Policy and Strategy, MoPH. 2. Bureau of Health Service System Development, Department of Health Service Support, MoPH. 3. Primary Health Care Division, Department of Health Service Support, MoPH. 4. Department of Provincial Administration, Ministry of Interior. 5. Department of Health, Bangkok Metropolitan Administration (BMA).

270 District-level hospitals are community hospitals, each with 10 to 150 beds, and located in all district towns across the country. For the past several years, community hospitals have been expanded steadily, particularly from 10 beds to 30 beds. In 2009, there were only 37 10-bed hospitals while there were as many as 409 30-bed hospitals among all 734 community hospitals; the proportion of 10-bed hospitals was only 5%, while that for 30-bed hospitals had increased to 55.7% and the proportions of 60-bed, 90-bed, 120-bed, and 150-bed hospitals had also risen (Figure 6.32). Figure 6.32 Proportions of community hospitals by hospital size, 1999›2009

Proportion (%) 120 100 80 60 40 20 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 10 bed 14.33 13.45 11.53 11.45 11.45 7.16 7.16 7.01 4.66 5.04 5.04 30 bed 59.27 58.54 56.94 57.24 57.24 57.44 57.44 57.42 55.89 55.72 55.72 60 bed 17.56 19.05 20.56 20.41 20.41 22.73 22.73 22.80 25.48 25.34 25.34 90 bed 7.30 7.28 8.19 8.14 8.14 8.26 8.26 8.38 8.90 8.99 8.99 120 bed 1.541.68 2.50 2.48 2.48 3.31 3.31 3.30 3.70 3.54 3.54 150 bed 0.000.00 0.28 0.28 0.28 1.10 1.10 1.10 1.37 1.36 1.36

Source: Bureau of Health Service System Development, Department of Health Service Support, MoPH. 2.1.2 Health Facilities in the Private Sector Private health facilities play a significant role in providing health services in urban areas, especially for those with a good economic status. With peopleûs high purchasing power, there are investments in health-care services for the people in the localities. In 2009, there were private health facilities in four categories as follows: (1) Pharmacies or drugstores (3 types): 11,154 modern pharmacies, 4,047 pharma- cies selling only packaged drugs, and 1,986 traditional medicine drugstores. (2) Clinics: 17,671 clinics without inpatient beds. (3) Hospitals: 322 private hospitals with inpatient beds. (4) Health-related business places: 1,268 The number and proportion of private health facilities in Bangkok and the provinces are shown in Table 6.5.

271 Table 6.5 Private health facilities, 2009

Bangkok Provincial areas Health facility Total No. Percent No. Percent 1. Pharmacies 1.1Modern pharmacies 3,757 33.7 7,397 66.3 11,154 1.2Modern pharmacies selling only packaged drugs 433 10.7 3,614 89.3 4,047 1.3Traditional medicine drugstores 400 20.1 1,586 79.9 1,986 Total 4,590 26.7 12,597 73.3 17,187 2. Medical premises without inpatient beds (clinics) 3,878 21.9 13,793 78.1 17,671 3. Medical premises with inpatient beds (private hospitals) - No. of hospitals 96 29.9 226 70.2 322 - No. of beds 13,933 41.7 19,472 58.3 33,405 4. Health-related business places 4.1Spa for health 86 23.7 277 76.3 363 4.2Massage for health 170 20.3 667 79.7 837 4.3Beauty massage 20 29.4 48 70.6 68 Total 276 21.8 992 78.2 1,268 Sources:1.Drug Control Bureau, Food and Drug Administration, MoPH. 2. Bureau of Sanatorium and Art of Healing, Department of Health Service Support, MoPH. 3. Office of Health Business Promotion, Department of Health Service Support, MoPH.

In analyzing the proportions of private clinics in Bangkok and the provinces, it is noted that most clinics (78%) are located in provincial areas and only 22% in Bangkok. Similarly, most private hospitals (70%) are located in provincial areas and the rest (30%) in Bangkok.

For private hospitals, in 2009 most of them were medium-sized hospitals with 51›100 beds, but if the number of all beds was considered, most of the beds were in large hospitals (each with more than 100 beds and 200 beds), see Figure 6.33.

272 Figure 6.33 Proportion of private hospitals by hospital size, 2009

1-10 beds 11-30 beds 31-50 beds Proportion (%) 51-100 beds 101-200 beds >-200 beds 40 35 32.3 32.6 29.3 30 26.8 25 21.4 20 15 10.9 7.7 9.6 10 8.1 7.7 2.8 5 0.8 0 % by no. of hospital % by no. of beds

Source: Bureau of Sanatorium and Art of Healing, Department of Health Service Support, MoPH.

If the numbers of hospitals and beds were classified by hospital size and by region, it was noted that in 2009, most of large hospitals with over 200 beds were located in Bangkok (Table 6.6).

Table 6.6 Number of private hospitals by number of beds and region, 2009

1›10 beds 11 - 30 beds 31 - 50 beds 51 - 100 beds 101 - 200 beds >200 beds Region Hospitals beds Hospitals beds Hospitals beds Hospitals beds Hospitals beds Hospitals beds Bangkok 2 15 12 306 15 643 20 1,759 26 4,158 21 7,052 Central 10 97 11 298 12 539 41 3,575 22 3,623 7 1,895 Northeast 5 67 1 30 14 660 16 1,390 4 560 1 214 North 4 40 6 170 7 337 22 1,800 8 1,104 2 620 South 5 45 5 136 9 413 5 415 9 1,444 - - Total 26 264 35 940 57 2,592 104 8,939 69 10,889 31 9,781 Source: Medical Registration Bureau, Department of Health Service Support, MoPH.

273 Regarding the expansion and closure of private health facilities which are also important issues, based on the data on applications for establishing new facilities (hospitals or sanatoriums with inpatient beds), it was found that the trends were declining while the number of closures were rising during the period 1998›2003 (after the 1997 economic crisis), when as many as 70 hospitals were shut down in 2003. After that period, the number of hospitals closing down was declining to about the same level as that applying for setting up new ones (Figure 6.34). However, since 2007 the number of hospitals closing down has been larger than that for new ones.

Figure 6.34 Number of private hospitals newly established and closed down, 1994›2009

No.of hospitals 80 70 newly established 60 closed down 51 43 42 39 40 37 29 30 25 26 20 14 12 11 11 10 11 10 13 11 11 9 6 5 6 9 66 3 1 1 1 3 0 Year 19941995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Sanatorium and Art of Healing, Department of Health Service Support, MoPH.

Regarding the proportion of hospitals under MoPH, the trend was rising until 1985 but after that the proportion has been stable, while that for private hospitals and other agencies has been declining slightly (Figure 6.35).

274 Figure 6.35 Proportions of hospitals by agency, 1973›2008 Proportion (%) 80 67.4 68.4 68.2 67.4 68.2 70 64.9 65.9 67.1 59.4 60 53.2 50 MoPH. Other ministries Local agencies Private sector 40 39.2 State enterprises 30.1 30 34.6 28.1 27.5 24.7 23.4 23.8 24.9 24.0 23.8 20.1 22.0 20 12.3 8.6 10 6.3 9.0 9.9 4.3 3.4 6.2 6.1 6.1 6.1 6.1 3.1 1.0 1.1 1.1 0.8 0.8 0.9 0.7 0.6 0 Year 1.8 1.1 0.8 0.6 0.7 0.7 0.6 0.8 0.8 0.5 0.4 1973 1977 1981 1985 1989 1993 1997 2001 2005

2007 2008

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. The proportion of beds in MoPH hospitals has been fairly stable, while that for private hospitals has been on the rise and that for other agencies has been declining (Figure 6.36). Figure 6.36 Proportions of hospital beds by agency, 1973›2008

Proportion (%) 80 69.5 67.5 66.9 66.7 70 64.3 65.5 64.8 63.7 65.863.3 60.3 60 MoPH. 50 Other ministries Local agencies 40 Private sector 30 State enterprises 23.3 22.6 21.9 19.2 19.0 21.0 20.1 21.8 20.6 20 17.0 15.6 13.6 12.6 10.4 10.2 10.6 11.8 10.5 10 7.4 9.1 15.2 11.1 1.3 1.0 1.3 1.2 2.6 2.2 1.7 1.8 1.9 1.7 0.8 0 1.8 2.3 2.1 2.1 2.3 2.2 1.8 1.6 1.8 0.6 0.7Year 1973 1997 1981 1985 1989 1993 1997 2001 2005

2007 2008

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

275 A regional comparison revealed that most hospitals in Bangkok are private ones, followed by those under other ministries, whereas in provincial areas, most of them are under MoPH (Figure 6.37). Regarding the proportions of hospital beds by region, they are actually similar to those for hospitals, but the hospitals under other ministries have a higher proportion of hospital beds compared to that for hospitals (Figure 6.38), reflecting the fact that the hospitals under other ministries are large hospitals.

Figure 6.37 Proportions of hospitals by agency and region, 2008

Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

MoPH 11.0 60.3 71.4 74.5 81.9 Other ministries 16.5 10.4 10.0 10.1 7.4 State enterprises 3.3 1.4 0.0 0.0 0.0 Local agencies4.4 0.0 0.4 0.0 0.0 Private sector64.8 27.9 18.1 15.4 10.7

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

276 Figure 6.38 Proportions of hospital beds by agency and region, 2008

Proportion (%) 120 100 80 60 40 20 0 Bangkok Central North South Northeast

MoPH 20.0 66.7 73.8 79.7 83.6 Other ministries 27.2 8.2 10.0 7.4 7.8 State enterprises 1.4 1.6 0.0 0.0 0.0 Local agencies5.3 0.0 0.4 0.0 0.0 Private sector46.1 23.5 16.0 12.8 8.6

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

An analysis of bed-occupancy rates reflects the efficiency in the use of existing beds and the burden on the hospital when admitting as inpatients. Based on the 2009 data, the hospitals under the Ministry of Education had the highest bed-occupancy rate, close to those under MoPH, while those under the Ministry of Defence had the lowest rate (Figure 6.39).

277 Figure 6.39 Bed-occupancy rates by agency, 2006›2009

MoPH Ministry of Education Ministry of Defence Municipalities Private sector Independent agencies 100 82 84 87 80 83 84 82 85 80 71 68 72 71 64 62 54 56 60 54 38 60 50 50 48 49 54 40 20 Bed-occupancy rate (%) 0 Year 2006 2007 2008 2009

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data for 2009 were incomplete. 2.2 Distribution of Health Facilities 2.2.1 Geographical Distribution of Hospitals Trends in the population to hospital bed ratio constantly declined but with regional disparities (Figure 6.40); and during the 1998›2008 period, the ratio dropped slightly in the Northeast (with more beds) except for the rising ratio in 2008, while those for other regions seemed to be stable or rising slightly (Figure 6.40). Figure 6.40 Population/bed ratios by region, 1979›2008 Bangkok Population/bed ratio Central 1,600 1,511 North 1,400 South 1,167 1,172 Northeast 1,200 1,074 980 1,000 875 797 736 780 752 779 800 682 723 665 596 627 600 568 543 453 468 603 509 502 497 492 506 530 478 500 490 500 400 337 310 402 245 395 376 402 386 200 257 312 221 199 210 196 0 Year 1979 1983 1987 1991 1995 1999 2003

2007 2008 Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

278 In addition, the Northeast had the highest bed-occupancy rate (Figure 6.41) reflecting a higher burden of the hospitals in that region, compared with other regions. Figure 6.41 Bed-occupancy rates by region, 2006›2009

Bangkok Central North South Northeast Total

120 100 89 88 87 77 81 83 83 78 79 80 74 73 74 71 76 75 71 76 71 75 76 65 64 61 65 60 40

Bed-occupancy rate (%) 20 0 year 2006 2007 2008 2009 Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

An analysis of bed distribution by province revealed that most provinces in the Northeast had a higher population/bed ratio; compared with that in other provinces in other regions, the distribution of beds was similar to that for health-care providers (Figure 6.42) Figure 6.42 Geographical distribution of population/bed ratios by province, 2007 N

Population per bed 2007 196 - 395 399 - 481 487 - 584 593 - 750 751 - 1,115

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. 279 2.2.2 Geographical Distribution of Health Centres Health centres have been built and distributed to cover all subdistricts (tambons) across the country since the last decade. In 2009, there were 9,769 health centres nationwide. The health centre to population ratio during the last decade had a rising trend in all regions of the country, from 1:10,064 in 1979 to 1:5,218 in 2009. Although health centres were mostly clustered in the Central region in the past, the regional disparities have actually decreased as a result of the policy on health centre distribution and upgrading midwifery centres to health centres implemented since 1982 as shown in Table 6.7. Table 6.7 Distribution of health centres by region in 1979, 1987, 1996›2003, 2006 and 2009 No. of health centres and health centre/population ratio Region 1979 1987 1996 1997 1998 1999 2000 2001 2002 2003 2006 2009 Central 1,219 1,635 2,377 2,471 2,508 2,523 2,524 2,559 2,559 2,549 2,564 2,558 (1:7,781) (1:4,729) (1:3,654) (1:3,554) (1:4,298) (1:4,219) (1:3,681) (1:4,628) (1:4,611) (1:4,629) (1:5,179) (1:5,476) North 914 1,616 1,965 2,151 2,203 2,225 2,231 2,210 2,216 2,220 2,227 2,231 (1:10,748) (1:4,775) (1:4,412) (1:4,103) (1:4,393) (1:4,345) (1:4,093) (1:4,667) (1:4,670) (1:4,662) (1:4,739) (1:4,862) South 688 1,252 1,400 1,488 1,505 1,513 1,516 1,507 1,526 1,521 1,510 1,512 (1:8,230) (1:3,821) (1:3,839) (1:3,653) (1:3,864) (1:3,922) (1:3,872) (1:4,427) (1:4,418) (1:4,433) (1:4,753) (1:4,993) Northeast 1,277 2,489 3,100 3,367 3,398 3,428 3,433 3,462 3,509 3,475 3,461 3,468 (1:12,747) (1:5,818) (1:5,248) (1:4,900) (1:5,063) (1:5,102) (1:4,972) (1:5,427) (1:5,387) (1:5,440) (1:5,442) (1:5,356) Disparity between Northeast 1 : 1.3 1 : 1.2 1 : 1.2 1 : 1.2 1 : 1.1 1 : 1.1 1 : 1.2 1 : 1.1 1 : 1.1 1 : 1.1 1 : 1.1 1 :1.0 and national ratios Total 4,088 6,992 8,842 9,477 9,614 9,689 9,704 9,738 9,810 9,765 9,762 9,769 (1:10,064) (1:4,964) (1:4,411) (1:4,173) (1:4,522) (1:4,514) (1:4,262) (1:4,890) (1:4,872) (1:4,895) (1:5,106) (1:5,218) Sources: Data for 1979›2001 were derived from the Division of Provincial Health, Office of the Permanent Secretary, MoPH. Data for 2002›2006 were derived from the Bureau of Central Administration, Office of the Perma- nent Secretary, MoPH. Data for 2009 were derived from the Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. Notes: 1. The figure in ( ) is the ratio of health centre to population outside municipal areas and sanitary districts. 2. Data on population outside municipal areas for 2001, 2002, 2003 and 2006 were derived from the Bureau of Registration Administration, Department of Provincial Administration, Ministry of Interior. 3. For 2009, data on population outside municipal areas were derived from the Bureau of Policy and Strategy, MoPH. 280 2.2.3 Geographical Distribution of Drugstores The ratio of drugstore to population had an improved trend for the past decade, from 1:4,931 in 1996 to 1:3,628 in 2009. Most drugstores are located in the Central region (including Bangkok) (Table 6.8).

Table 6.8 Distribution of drugstores by region, 1996›2009 No. of drugstores and drugstore/population ratio Region 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Central 6,644 6,690 6,904 7,465 7,534 7,826 7,895 8,821 8,696 8,960 9,088 9,769 9,782 10,394 (1:2,908)(1:2,925)(1:2,869)(1:2,675)(1:2,665)(1:2,590)(1:2,547)(1:2,350)(1:2,373)(1:2,295)(1:2,291)(1:2,154)(1:2,170)(1:2,042) North 1,989 1,958 2,029 2,029 2,045 1,982 1,964 2,087 2,103 2,179 2,179 2,185 2,185 2,332 (1:6,004)(1:6,149)(1:5,976)(1:5,984)(1:5,923)(1:6,111)(1:6,180)(1:5,808)(1:5,690)(1:5,444)(1:5,455)(1:5,438)(1:5,435)(1:5,092) South 1,189 1,152 1,237 1,243 1,273 1,354 1,398 1,510 1,507 1,535 1,535 1,799 1,799 2,035 (1:6,534)(1:6,837)(1:6,472)(1:6,524)(1:6,430)(1:6,104)(1:5,983)(1:5,601)(1:5,618)(1:5,521)(1:5,576)(1:4,796)(1:4,835)(1:4,274) Northeast 2,303 2,396 2,378 2,536 2,253 2,148 2,166 2,566 2,574 2,751 2,668 2,631 2,631 2,663 (1:9,019)(1:8,759)(1:8,923)(1:8,423)(1:9,445)(1:9,986)(1:9,950)(1:8,431)(1:8,339)(1:7,742)(1:8,003)(1:8,127)(1:8,139)(1:8,041) Total 12,125 12,196 12,548 13,273 13,105 13,310 13,423 14,984 14,880 15,425 15,470 16,384 16,397 17,424 (1:4,931)(1:4,958)(1:4,874)(1:4,639)(1:4,713)(1:4,665)(1:4,660)(1:4,200)(1:4,202)(1:4,032)(1:4,048)(1:3,841)(1:3,855)(1:3,628) Source: Food and Drug Administration, MoPH. Note:1.Figures in ( ) are drugstore/population ratios. 2. A drugstore means a modern drugstore, a modern drugstore selling only packaged medicines, or a traditional medicine drugstore. 3. The Central region includes Bangkok.

3. Health Technologies Major health technologies are drugs and medical supplies as well as medical devices for use in the treatment of illnesses. 3.1 Drugs and Medical Supplies The quality of domestically produced drugs has much improved as a result, in part, of the promotion of Good Manufacturing Practices (GMP). In 2003, MoPH issued a rule requiring that all pharma- ceutical manufacturers have a GMP certification. In 2010, 94% of the manufacturers are GMP-certified, while the rest are in the process of applying for GMP certification (Figure 6.43).

281 2.2.3 Geographical Distribution of Drugstores The ratio of drugstore to population had an improved trend for the past decade, from 1:4,931 in 1996 to 1:3,628 in 2009. Most drugstores are located in the Central region (including Bangkok) (Table 6.8).

Table 6.8 Distribution of drugstores by region, 1996›2009 No. of drugstores and drugstore/population ratio Region 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Central 6,644 6,690 6,904 7,465 7,534 7,826 7,895 8,821 8,696 8,960 9,088 9,769 9,782 10,394 (1:2,908)(1:2,925)(1:2,869)(1:2,675)(1:2,665)(1:2,590)(1:2,547)(1:2,350)(1:2,373)(1:2,295)(1:2,291)(1:2,154)(1:2,170)(1:2,042) North 1,989 1,958 2,029 2,029 2,045 1,982 1,964 2,087 2,103 2,179 2,179 2,185 2,185 2,332 (1:6,004)(1:6,149)(1:5,976)(1:5,984)(1:5,923)(1:6,111)(1:6,180)(1:5,808)(1:5,690)(1:5,444)(1:5,455)(1:5,438)(1:5,435)(1:5,092) South 1,189 1,152 1,237 1,243 1,273 1,354 1,398 1,510 1,507 1,535 1,535 1,799 1,799 2,035 (1:6,534)(1:6,837)(1:6,472)(1:6,524)(1:6,430)(1:6,104)(1:5,983)(1:5,601)(1:5,618)(1:5,521)(1:5,576)(1:4,796)(1:4,835)(1:4,274) Northeast 2,303 2,396 2,378 2,536 2,253 2,148 2,166 2,566 2,574 2,751 2,668 2,631 2,631 2,663 (1:9,019)(1:8,759)(1:8,923)(1:8,423)(1:9,445)(1:9,986)(1:9,950)(1:8,431)(1:8,339)(1:7,742)(1:8,003)(1:8,127)(1:8,139)(1:8,041) Total 12,125 12,196 12,548 13,273 13,105 13,310 13,423 14,984 14,880 15,425 15,470 16,384 16,397 17,424 (1:4,931)(1:4,958)(1:4,874)(1:4,639)(1:4,713)(1:4,665)(1:4,660)(1:4,200)(1:4,202)(1:4,032)(1:4,048)(1:3,841)(1:3,855)(1:3,628) Source: Food and Drug Administration, MoPH. Note:1.Figures in ( ) are drugstore/population ratios. 2. A drugstore means a modern drugstore, a modern drugstore selling only packaged medicines, or a traditional medicine drugstore. 3. The Central region includes Bangkok.

3. Health Technologies Major health technologies are drugs and medical supplies as well as medical devices for use in the treatment of illnesses. 3.1 Drugs and Medical Supplies The quality of domestically produced drugs has much improved as a result, in part, of the promotion of Good Manufacturing Practices (GMP). In 2003, MoPH issued a rule requiring that all pharma- ceutical manufacturers have a GMP certification. In 2010, 94% of the manufacturers are GMP-certified, while the rest are in the process of applying for GMP certification (Figure 6.43).

281 Figure 6.43 Percentage of GMP›certified drug manufacturers, 1989›2010

Percentage Legal measures 100 Economic measures 91.0 94.4 90.5 94.0 94.0 94.0 80 82.5 73.8 76.2 77.0 75.6 68.1 72.0 73.8 73.0 60 62.2 65.7 67.8 51.658.3 40 42.0 30.4 20

0 Year 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2010

Source: Drug Control Bureau, Food and Drug Administration, MoPH.

Previously, the drugs used in the country were domestically produced; but during the period 1992›2006, with a high economic growth and new drug marketing monopolies under the Drug Act, the proportion of imported drugs was rising but slowed down during the economic crisis. After the crisis, since 2002, the proportion of imported drugs was rising steadily to 56.3% in 2005 and 64.5% in 2009 (Figure 6.44) due to economic recovery and drug monopolies under the patent system. When considering the values of local production and drug imports, the trends rose steadily, while the import values rose and surpassed the production values for 2005, the difference being nearly 30 billion baht in 2008 (Table 6.9). In addition to producing and dispensing drugs for domestic consumption, some drugs are exported to other countries, the export values rising from 481 million baht in 1989 to 9,184 million baht in 2009 (Figure 6.45).

282 Figure 6.44 Percentages of locally produced and imported drugs (for human use) 1983›2008

Locally produced drugs Percentage Imported drugs 90 Economic Economic recession Bubble economic crisis Economic recovery 80 76.5 72.3 72.0 71.5 69.6 70 73.5 71.7 68.1 68.9 69.6 70.0 63.0 64.5 59.3 60 65.2 57.2 59.3 62.9 53.3 55.7 54.9 56.3 Beginning of monopoly 50.5 50.9 56.2 50 systems for new drugs 46.7 53.6 49.1 43.8 and patenting of 42.8 46.4 49.5 43.7 37.1 44.3 45.1 40 34.8 pharmaceuticals 40.7 40.7 31.1 28.0 30.4 37.0 35.5 30 27.7 31.9 28.5 30.4 30.0 Patented drugs 26.5 28.3 began being 20 23.5 marketed 10 0 Year 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 20072008

Source: Drug Control Bureau, Food and Drug Administration, MoPH.

283 (%)

vernment

percentage of

Retail value as

health spending

Unit: million baht

prices

Constant

Increase (%)

12.9 8.6

prices

Current

prices

Retail

Average, 21 years

value. 2008

prices

Wholesale

Estimated consumption

x 1.8

Estimated retail

value in country

consumption

Estimated local

(wholesale)x1.675

(1)

Local

consumption

Exports

Total

Wholesale values of drugs(current prices as reported)

Values of locally produced and imported drugs (for human use), 1983-2008

The estimated number has to be deducted by the export value (Figure 6.45) Pharmaceutical Organization and narcotics as well as psychotropic drugs.)

Value % Value %

Locally produced Imported

.

Drug Control Bureau, Food and Drug Administration, MoPH.

2. The number from report were 67.5% lower than actuality (underreported by 48% and the report did not include druge from the Go

3. Retail price is approximately 1.8 times the wholesale price.

:

:1

1983 3,777.9 65.2 2,012.0 34.8 5,789.9 255.6 5,534.3 9,270.0 16,686.0 22,718.30 40,893.15 0.0 0.0 40.52 1984 5,453.0 76.5 1,673.0 23.5 7,126.0 284.0 6,842.0 11,460.4 20,628.7 27,837.12 50,106.99 23.6 22.5 39.49 1985 6,651.2 73.5 2,393.1 26.5 9,044.3 315.5 8,728.8 14,620.7 26,317.3 34,692.57 62,446.62 27.6 24.6 44.41 1986 4,678.0 71.5 1,864.5 28.5 6,542.5 350.5 6,192.0 10,371.6 18,668.9 24,190.58 43,543.04 -29.1 -30.3 28.26 1987 5,145.8 68.9 2,325.4 31.1 7,471.2 389.4 7,081.8 11,862.0 21,351.6 27,014.46 48,626.04 14.4 11.7 28.73 1988 6,708.8 72.3 2,571.0 27.7 9,279.8 432.7 8,847.1 14,818.9 26,674.0 32,486.81 58,476.26 24.9 20.3 29.65 1989 8,372.9 71.7 3,307.6 28.3 11,680.5 480.8 11,199.7 18,759.5 33,767.1 38,991.26 70,184.27 26.6 20.0 32.13 1990 8,886.0 72.0 3,449.1 28.0 12,335.1 604.1 11,731.0 19,649.4 35,369.0 38,593.73 69,468.71 4.7 -1.0 28.23 1991 9,657.6 69.6 4,216.4 30.4 13,874.0 784.8 13,089.2 21,924.4 39,463.9 40,677.83 73,220.10 11.6 5.4 28.43 1992 10,696.6 69.6 4,682.6 30.4 15,379.2 1,193.5 14,185.7 23,761.0 42,769.9 42,362.26 76,252.07 8.4 4.1 27.08 1993 11,831.0 70.0 5,075.3 30.0 16,906.3 2,855.3 14,051.0 23,535.4 42,363.8 40,593.66 73,068.59 -0.9 -4.2 23.02 1994 12,969.7 68.1 6,086.6 31.9 19,056.3 1,536.2 17,520.1 29,346.2 52,823.1 48,186.41 86,735.53 24.7 18.7 26.41 1995 15,820.9 63.0 9,276.4 37.0 25,097.3 2,398.5 22,698.8 38,020.5 68,436.9 59,007.23 106,213.01 29.6 22.5 30.09 1996 18,120.4 62.9 10,676.0 37.1 28,796.4 1,784.9 27,011.5 45,244.3 81,439.7 66,449.98 119,609.97 19.0 12.6 31.63 1997 19,608.0 59.3 13,467.1 40.7 33,075.1 2,319.7 30,755.4 51,515.3 92,727.5 71,563.55 128,814.39 13.9 7.7 32.88 1998 16,127.7 53.3 14,146.5 46.7 30,274.2 2,782.3 27,491.9 46,048.9 82,888.1 59,210.92 106,579.66 -10.6 -17.3 30.02 1999 19,033.9 57.2 14,232.3 42.8 33,266.2 3,014.9 30,251.3 50,670.9 91,207.7 65,001.30 117,002.34 10.0 9.8 32.09 2000 20,995.9 55.7 16,700.4 44.3 37,696.3 3,732.7 33,963.6 56,889.0 102,400.2 71,799.99 129,299.91 12.3 10.5 34.16 2001 23,087.9 53.6 19,967.6 46.4 43,055.5 4,326.9 38,728.6 64,870.4 116,766.7 80,572.77 145,030.95 14.0 12.2 36.35 2002 24,144.6 54.9 19,867.9 45.1 44,012.5 4,115.5 39,897.0 66,827.5 120,289.5 82,504.30 148,507.79 3.0 2.4 35.87 2003 26,586.1 50.5 26,024.9 49.5 52,611.0 4,821.5 47,789.5 80,047.4 144,085.3 97,002.04 174,603.68 19.8 17.6 38.72 2004 31,707.6 50.9 30,545.5 49.1 62,253.1 4,961.6 57,291.5 95,963.3 172,734.0 113,116.86 203,610.35 19.9 16.6 43.73 2005 29,704.8 43.7 38,293.4 56.3 67,998.2 6,196.9 61,801.3 103,517.1 186,330.8 116,821.39 210,278.50 7.9 3.3 42.61 2006 30,910.9 40.7 45,004.6 59.3 75,915.5 6,958.3 68,957.2 115,503.3 207,906.0 124,528.19 224,150.74 11.6 6.6 41.82 2007 41,232.4 43.8 53,000.1 56.2 94,232.5 7,409.9 86,822.6 145,427.9 261,770.1 153,268.64 275,883.55 25.9 23.1 48.08 2008 35,322.9 35.5 64,148.1 64.5 99,471.0 8,976.5 90,494.5 151,578.3 272,840.9 151,578.29 272,840.92 4.2 -1.1 46.39

Year

Table 6.9

Note

Source

284 Figure 6.45 Values of drugs exported from Thailland (current prices), 1989-2009 Million baht 10,000 9,184.0 8,976.5 8,000 7,409.9 6,958.3 6,000 6,196.9 4,326.90 4,961.6 4,821.90 4,000 4,155.50 2,855.30 2,782.30 3,723.60 2,398.50 3,014.90 2,000 2,319.70 480.0 1,193.50 1,536.20 1,784.90 784.80 0 604.10 Year 1989 1991 1993 1995 1997 1999 2001 2002 2005 2007 2009 Sources: Food and Administration, MoPH. Note: Data for 1989-2009 were derived from the Customs Department, Ministry of Finance. 3.2 Medical and Health Technologies High-technology medical devices are on a rising trend, but most of them are clustered in large cities and in the private sector rather than the public sector, except that extracorporeal shortwave lithotripters (ESWL) and ultrasound devices are more abundant in the public sector than in the private sector (Table 6.10). Table 6.10 Number and distribution of important medical devices

Number of devices Number by sector Device Total In Bangkok: In provinces: Remarks No. (%) No. (%) Public(%) Private(%) 1.CT scanners(1) 399 128 (32.1) 271 (67.9) 145 254 2009 (36.3) (63.7) 2.Magnetic resonance 51 17 (33.3) 34 (66.7) 23 28 2008 imaging devices (MRI) (1) (45.1) (54.9) 3.Lithotripters(2) 74 9 (12.2) 65 (87.8) 48 26 2008 (64.9) (35.1) 4.Mammography devices (1) 215 117 (54.4) 98 (45.6) 85 130 2009 (39.5) (60.5) 5.Ultrasound devices(2) 2,158 323 (15.0) 1,835 (85.0) 1,624 534 2009 (75.3) (24.7) Sources: (1) Bureau of Radiology and Medical Devices, Department of Medical Services, MoPH. (2) Report on Health Resources Survey, Bureau of Policy and Strategy, MoPH.

285 The use of high-tech medical devices is on the rise in Thailand the number of subdevices, such as MRI devices, has been rising in both public and private sectors (Figure 6.46).

Figure 6.46 Number of MRI devices in the private and public sectors in Thailand

No. of devices Total operating 35 60 54 30 51 30 private 28 28 50 public 25 26 26 25 45 43 23 total operating 40 20 31 38 17 17 16 26 16 16 26 19 30 15 25 15 25 26 15 12 13 10 10 11 20 10 8 8 8 9 9 9 7 12 13 15 5 6 5 5 10 5 3 4 7 8 5 6 0 3 0 Year

1988 1989 1991 1993 2001 1990 2002 1995

1992 1997

1994 1999

1996

1998 2003

2000 2005

2007 2008 2004

2006

Sources: Data for 1988-2000 were derived from Piya Hanvoravongchai, 1999. Data for 2003-2005 were derived from the Radiology and Medical Devices Division, Department of Medical Sciences, MoPH, 2006. Data for 2006›2008 were derived from the Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH. Note: The number for each year is as recorded at the end of the year.

The values of imported medical equipment rose by 13.04% annually between 1991 and 2009. At the beginning of the economic crisis, the import values were decreasing, but increased by as much as 19.2% in 2003, whereas the values of exports have been rising since 1997. Since 2004, the import values have been markedly greater than the export values (Figure 6.47).

286 Figure 6.47 Values of imported and exported medical devices, Thailand, 1991›2009

million baht 24,000 22,654.3 22,000 imported values 20,000 exported values 20,492.2 18,255.3 18,648.5 18,000 16,750.2 15,799.1 16,241.7 15,857.3 16,000 14,930.1 16,478.0 16,859.1 14,000 15,035.3 11,934.5 12,000 10,860.5 13,055.1 11,973.1 10,000 9,542.5 9,334.8 8,842.0 7,670.1 10,090.2 8,000 6,750.8 8,953.2 8,461.9 5,893.4 5,860.2 7,009.3 6,000 5,144.1 5,601.8 4,000 3,417.8 4,728.1 5,141.8 5,457.6 5,188.7 2,493.2 4,395.6 2,000 3,245.5 1,881.1 0 Year 1991 1992 19931994 1995 1996 1997 1998 1999 2000 2001 20022003 2004 2005 2006 2007 2008 2009

Source: Department of Customs, Ministry of Finance.

The increase in values of technology imports was partly due to the imports of high-cost devices, particularly CT scanners, MRI devices, lithotripters and mammography devices (Figure 6.48).

287 Figure 6.48 Numbers of high-cost medical technologies, Thailand, 1976›2009

No. of devices 399 400 375 350 343 314 CT scanners 307 300 Mammography devices 272 260 266 250 ESWL 232 242 215 MRI devices 202 198 200 152 150 137 130139 112 113 99 97102 101 90 100 79 75 75 75 76 74 74 57 58 54 39 38 38 45 43 51 50 32 39 24 32 26 30 34 38 31 6 8 9 15 17 12 16 16 19 1 23 5 3 6 9 14 15 15 25 26 25 26 0 3 5 6 7812 13 Year

1976

1979

1985

1988

1991

1994

1997

2003

2006 2007 2000 2008 2009

Sources:- Wongduern Jindawatthana et al. High-cost Medical Devices in Thailand: Distribution, Utilization and Accessibility, 1999. - For 2002-2009, data were derived from reports on health resources of the Bureau of Policy and Strategy, Office of the Permanent Secretary, and the Bureau of Radiology and Medical Devices, Department of Medical Sciences, MoPH.

The problem of inequalities in high-technology diffusion, especially CT scanners, MRI devices, ESWL and mammography devices, can be considered based on the device-to-population ratios (number of devices per 1 million population). For Bangkok, the ratios are highest for CT scanners, MRI, ESWL and mammography devices. But when using the discrepancy index, for Bangkok, the indices for all 4 types of devices ranged from 1.3 to 6.0 (compared with the national average), and for provincial areas the indices ranged from 0.4 to 1.3 (Table 6.11). For CT scanners, the discrepancy index has been rising (Table 6.12); the Bangkok/Northeast discrepancy rose to 9-fold in 2009. This has shown that, even though the economic crisis is over, inequalities in medical device diffusion have increased.

288 Table 6.11 Ratio of high-cost medical technologies to population and discrepancy index by region, 2009

Region Ratio of medical devices per 1 million population Discrepancy index ESWL CT MRI Mammography ESWL CT MRI Mammography Bangkok 1.6 22.5 3.0 20.5 1.3 3.6 3.7 6.0 Metropolis Provincial 1.1 4.7 0.6 1.7 0.9 0.7 0.7 0.5 areas Central 1.3 8.3 0.8 3.1 1.1 1.3 1.0 0.9 North 1.5 4.7 0.5 1.0 1.3 0.7 0.6 0.3 Northeast 0.7 2.3 0.4 1.2 0.6 0.4 0.5 0.4 South 1.4 4.1 0.8 1.3 1.2 0.7 1.0 0.4 Nationwide 1.2 6.3 0.8 3.4 1.0 1.0 1.0 1.0 Sources:- Report on Health Resources, Bureau of Policy and Strategy, MoPH (ESWL data for 2008). - Bureau of Radiology and Medical Devices, Department of Medical Sciences (data on CT, MRI and mammography devices, 2009). Table 6.12 Ratio of CT Scanners to population and discrepancy index by region, 1999›2009 No. of CT scanners Ratio of CT scanners Discrepancy Index Region per 1 million population 1999 2003 2006 2008 2009 1999 2003 2006 2008 2009 1999 2003 2006 2008 2009 Bangkok 89 89 115 118 128 15.9 13.3 20.5 20.7 22.5 3.5 3.2 3.7 3.5 3.6 Metropolis Provincial 183 177 228 257 271 3.3 3.1 4.0 4.5 4.7 0.7 0.7 0.7 0.8 0.7 areas Central 74 80 110 119 129 5.2 5.3 7.4 7.7 8.3 1.2 1.3 1.3 1.3 1.3 North 41 37 48 54 56 3.4 3.2 4.0 4.5 4.7 0.8 0.8 0.7 0.8 0.7 Northeast 46 38 46 49 50 2.2 1.7 2.2 2.3 2.3 0.5 0.4 0.4 0.4 0.4 South 22 22 24 35 36 2.8 2.5 2.9 4.0 4.1 0.6 0.6 0.5 0.7 0.7 Nationwide 272 266 343 375 399 4.5 4.2 5.5 5.9 6.3 1.0 1.0 1.0 1.0 1.0 Sources: For 2003›2009, data were derived from the Bureau of Radiology and Medical Devices, Department of Medical Sciences, MoPH. For 1999, data were derived from Wongduern Jindawatthana et al. High-cost Medical Devices in Thailand: Distribution, Utilization and Accessibility, 1999.

289 4. Health Expenditure 4.1 Trends in Overall Health Expenditure During the past decades, health expenditure in Thailand was on a rapidly upward trend, rising from 25,315 million baht in 1980 to 588,154 million baht in 2008 (Figure 6.49), a more than 20›fold increase. Per-capita health spending rose from 545 baht in 1980 to 9,304 baht in 2008 (Table 6.13) an almost 17-fold increase in current prices.

Figure 6.49 Overall, public and private health expenditures, 1995›2008

700 600 Public expenditure 588.1 544.4 Private expenditure 500 497.1 Overall expenditure 437.2 400 372.1 395.0 335.3 338.8 299.7 321.2 308.7 321.2 300 282.0 276.1 284.2 265.5 290.4 257.5 243.6 248.3 227.5 200.9 215.3 219.6 187.5 222.3 200 170.0 175.3 176.7 188.5 146.0 156.5 127.9 127.9 87.5 106.6 99.3 95.7 98.8 105.7 115.4 Health expenditure (billion bath) 100 70.9 0 Year 1995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007 2008

Source: Table 6.13.

As a percentage of GDP, the national health expenditure rose from 3.8% in 1980 to 6.4% in 2008 (Figure 6.50), the growth rising at the rate faster than that for GDP, i.e. an average of 7.6% in real terms while the average GDP growth was only 5.6% annually (Table 6.14). Most of health spending was on curative care as evidenced by the fact that the proportion of pharmaceutical spending rose to 46.4% of overall health spending in 2008 (Table 6.14 and Figure 6.50).

290 Figure 6.50 Overall health and drug expenditures and proportion of drug expenditure to health expenditure, all in relation to GDP, 1995›2008

50 48.08 6.48 7 6.26 6.29 6.17 6.33 5.96 5.97 6.13 6.09 6.15 43.73 46.39 6.38 6 5.58 % Health expenditure and drug 40 5.43 38.72 6.09 42.61 41.82 34.16 36.35 35.87 32.88 32.09 5 expenditure(%GDP) 31.63 30.02 30 30.08 4 3.07 3.01 2.66 2.63 2.65 3 20 2.27 2.43 1.98 1.98 2.08 2.21 1.63 1.77 1.82 2 10 Health expenditure (% of GDP) Drug expenditure (% of health expenditure) 1 % Drug expenditure / health expenditure Drug expenditure (% of GDP) 0 0 1995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Source: Table 6.14.

Regarding sources of health expenditure, a higher proportion was from the private including house- hold sector (57.6% of overall health spending in 2008), whereas the state health spending was 42.2% of total health spending (Figure 6.51). Since the launching of the universal health-care system (2002) with universal access to antiretroviral therapy and renal replacement therapy, the state health spending has substantially risen.

291 Figure 6.51 Proportions of public and private health expenditures, 1980›2008

Private expenditure Percentage Public expenditure 90

80.07

78.81

78.89

76.63

76.28

80 75.03

74.27

73.06

72.45

71.63

69.19

68.79

67.55

67.75

68.63

67.22

67.03

67.03

67.18

66.41

66.01

66.33

65.48 70 65.45

63.99

62.10

62.16

58.99 60 57.6 50

42.23

40.84

37.80

37.73 40 35.98

33.97

34.41 34.37

33.66

32.95

33.41

32.91

32.38

31.73

31.17

31.5

30.73

29.93

29.66

27.61

27.39

26.18

24.75

30 24.96

23.52

22.7

20.96

20.83 20 19.69 10 UC ARV Economic crisis UC UC RRT 0 Year 1980 1982 1984 1986 19881990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Source: Table 6.13. Notes:UC=universal coverage of health care ARV = antiretroviral drugs RRT = renal replacement therapy

292 of GDP

percentage

Total health expenditure

Amount Per capita As

financial aid

Internetional

Total Percent

Total Percent

Private sector

House-

holds &

employers

health

Private

insurance

Total Percent

state

agencies

Indepen-

dent and

supervised

Social

security

Workersû

tion fund

compensa-

Public sector

state

benefit

scheme

enterprise

Civil

benefit

servant

scheme

Other

ministeries

Health expenditure at current prices, 1980-2008(million baht)

NESDB, Thailandûs National Income, 1951-2008

.

MoPH

2. Viroj Tangcharoensathien. Sufferings and Causes in Health System, 1996 3. Charles Myers, Financing Health Services and Medical Care in Thailand, 1985 4. International Health Policy Program, MoPH. Thai National Health Accounts 2006-2008.

:1

1980 4,495 2,210 660 111 100 - - 7,576 29.93 224 17,150 17,374 68.63 365 1.44 25,315 544.94 3.82 1981 5,572 2,535 995 167 149 - - 9,418 29.66 284 21,229 21,513 67.75 824 2.59 31,755 668.70 4.18 1982 6,652 2,838 1,219 204 153 - - 11,066 31.73 318 23,109 23,427 67.18 380 1.09 34,873 719.16 4.14 1983 7,092 3,134 1,482 248 205 - - 12,971 31.50 350 27,469 27,819 67.55 391 0.95 41,181 832.63 4.47 1984 8,618 3,467 1,791 300 250 - - 14,426 27.61 469 36,951 37,420 71.63 395 0.76 52,241 1,036.61 5.29 1985 9,044 3,716 2,157 362 236 - - 15,515 26.18 547 42,751 43,298 73.06 452 0.76 59,265 1,146.75 5.61 1986 9,275 3,965 2,594 435 221 - - 16,490 24.96 630 48,432 49,062 74.27 508 0.77 66,060 1,254.78 5.83 1987 9,525 4,082 2,828 474 274 - - 17,183 22.70 756 57,258 58,014 76.63 507 0.67 75,704 1,439.10 5.82 1988 10,373 4,338 3,156 529 347 - - 18,743 20.83 951 69,955 70,906 78.81 319 0.35 89,968 1,649.70 5.77 1989 11,733 4,448 3,521 590 397 - - 20,689 19.69 1,162 82,988 84,150 80.07 252 0.24 105,091 1,895.31 5.66 1990 16,225 4,558 4,316 723 443 - - 26,265 20.96 1,403 97,450 98,853 78.89 184 0.15 125,302 2,224.04 5.74 1991 20,569 4,699 5,127 859 624 778 - 32,656 23.52 1,544 104,348 105,892 76.28 270 0.19 138,818 2,449.93 5.54 1992 24,604 4,840 5,854 981 753 2,057 - 39,089 24.75 1,775 116,745 118,520 75.03 356 0.23 157,965 2,753.20 5.58 1993 32,898 4,928 7,906 1,291 927 2,473 - 50,423 27.39 2,061 131,297 133,358 72.45 281 0.15 184,062 3,141.85 5.81 1994 39,319 5,558 9,954 1,668 1,169 3,773 - 61,441 30.73 2,307 136,047 138,354 69.19 154 0.08 199,949 3,405.40 5.51 1995 45,833 6,677 11,156 1,869 1,370 3,991 - 70,896 31.17 4,984 151,508 156,492 68.79 89 0.04 227,477 3,837.50 5.43 1996 55,861 7,768 13,587 2,418 1,610 6,239 - 87,483 33.97 6,296 163,693 169,989 66.01 35 0.01 257,507 4,307.00 5.58 1997 68,934 7,1,82 15,503 2,756 1,987 10,245 - 106,607 37.80 7,518 167,780 175,298 62.16 96 0.03 282,001 4,663.80 5.96 1998 65,065 5,740 16,440 2,817 1,630 7,637 - 99,329 35.98 7,803 168,876 176,679 63.99 82 0.03 276,090 4,514.50 5.97 1999 62,787 6,087 15,174 2,539 1,404 7,676 - 95,667 33.66 8,171 180,356 188,527 66.33 41 0.01 284,235 4,615.90 6.13 2000 63,001 6,195 17,062 1,622 1,257 9,623 - 98,760 32.95 7,291 193,634 200,925 67.03 72 0.02 299,757 4,852.80 6.09 2001 61,563 7,134 19,180 3,013 1,277 13,543 - 105,710 32.91 8,400 206,942 215,342 67.03 187 0.06 321,239 5,173.40 6.26 2002 70,923 6,884 20,475 3,081 1,220 11,223 1,595 115,401 34.41 9,734 209,886 219,620 65.48 372 0.11 335,393 5,361.61 6.15 2003 74,134 8,579 22,679 3,971 1,480 15,113 1,954 127,910 34.37 11,128 232,457 243,585 65.45 665 0.18 372,160 6,912.95 6.29 2004 77,721 7,056 19,798 4,101 1,490 15,533 2,189 127,900 32.28 12,581 252,956 265,537 67.22 1,573 0.40 395,018 6,317.59 6.09 2005 85,914 6,070 28,951 3,741 1,507 17,592 2,301 146,076 33.41 13,861 276,547 290,408 66.41 791 0.18 437,275 7,030.62 6.17 2006 107,101 8,919 37,037 8,068 1,684 21,029 3,736 187,574 37.73 10,258 298,433 308,691 62.10 837 0.17 497,102 7,937.96 6.33 2007 129,683 10,343 46,514 8,882 1,735 21,686 3,531 222,374 40.84 11,099 310,088 321,187 58.99 890 0.16 544,451 8,651.21 6.38 2008 142,114 11,820 54,937 9,780 1,688 23,767 4,255 268,287 42.23 13,507 325,295 338,802 57.60 991 0.17 588,154 9,304.17 6.48

Year

Table 6.13

Source

293 of health

expenditure

As percentage

As

of GDP

percentage

Increase

(percent)

Drug expenditure

prices

Value in 1988

Actual value

of GDP

As percentage

Increase

(percent)

prices

Health expenditure

Value in 1988

Actual value

Increase

(percent)

GDP

Average 5.56 7.57 7.01

prices

Value in 1988

Actual value

Health and drug expenditures as percentage of GDP, 1980-2008 (million baht)

Tables 6.9 and 6.13

:

Year

1980 662,482 910,457 - 25,315 34,791 - 3.82 - - - - - 1981 760,356 927,535 1.88 31,755 38,737 11.34 4.18 - - - - - 1982 841,569 977,264 5.36 34,873 40,496 4.54 4.14 - - - - - 1983 920,989 1,029,583 5.35 41,181 46,037 13.68 4.47 16,686 18,653 - 1.81 40.52 1984 988,070 1,094,770 6.33 52,241 57,882 25.73 5.29 20,629 22,857 22.53 2.09 39.49 1985 1,056,496 1,143,520 4.45 59,265 64,147 10.82 5.61 26,317 28,485 24.62 2.49 44.41 1986 1,133,397 1,205,844 5.45 66,060 70,283 9.57 5.83 18,669 19,862 -30.27 1.65 28.26 1987 1,299,913 1,350,395 11.99 75,704 78,644 11.90 5.82 21,181 22,181 11.67 1.67 28.73 1988 1,559,804 1,559,804 15.51 89,968 89,968 1440 5.77 26,674 26,674 20.25 1.71 29.65 1989 1,856,992 1,760,616 12.87 105,091 99,637 10.75 5.66 33,763 32,011 20.01 1.82 32.13 1990 2,183,545 1,956,310 11.12 125,302 112,262 12.67 5.74 35,369 31,688 -1.01 1.62 28.23 1991 2,506,635 2,121,435 8.44 138,818 117,486 4.65 5.54 39,464 33,399 5.40 1.57 28.43 1992 2,830,914 2,302,231 8.52 157,965 128,464 9.34 5.58 42,770 34,783 4.14 1.51 27.08 1993 3,170,258 2,494,247 8.34 184,062 144,813 12.73 5.81 42,364 33,331 -4.17 1.34 23.02 1994 3,629,341 2,718,376 8.99 199,949 149,762 3.42 5.51 52,823 39,564 18.70 1.45 26.41 1995 4,186,212 2,963,585 9.02 227,477 161,040 7.53 5.43 68,437 48,449 22.46 1.63 30.08 1996 4,611,041 3,089,150 4.24 257,507 172,516 7.13 5.58 81,440 54,560 12.61 1.77 31.63 1997 4,732,610 2,998,921 -2.92 282,001 178,696 3.58 5.96 92,728 58,759 7.70 1.98 32.88 1998 4,626,447 2,713,554 -9.52 276,090 161,935 -938 5.97 82,888 48,616 -17.26 1.82 30.02 1999 4,637,079 2,713,416 -0.01 284,235 166,322 2.71 6.13 91,208 53,371 9.78 1.98 32.09 2000 4,923,263 2,834,377 4.46 299,757 172,573 3.76 6.09 102,400 58,953 10.46 2.08 34.16 2001 5,133,836 2,908,656 2.62 321,239 182,003 5.46 6.26 116,767 66,156 12.22 2.27 36.35 2002 5,451,854 3,070,255 5.56 335,393 188,879 3.78 6.15 120,290 67,742 2.40 2.21 35.87 2003 5,917,368 3,270,929 6.68 372,160 205,718 8.92 6.29 144,085 79,646 17.57 2.43 38.72 2004 6,489,847 3,489,516 6.54 395,018 212,397 3.25 6.09 172,734 92,877 16.61 2.66 43.73 2005 7,087,660 3,648,562 4.56 437,275 225,099 5.98 6.17 186,331 95,919 3.28 2.63 42.61 2006 7,850,193 3,860,666 5.81 497,102 244,471 8.61 6.33 207,906 102,247 6.60 2.65 41.82 2007 8,529,836 4,100,672 6.22 544,451 261,742 7.06 6.38 261,770 125,844 23.08 3.07 48.08 2008 9,075,493 4,139,796 0.95 588,154 268,287 2.50 6.48 272,841 124,457 -1.10 3.01 46.39

Note

Table 6.14

294 1

.34

0.48 0.53 0.55 0.53 0.75 0.65 0.72

-

--

--

---

--

--

--

2.61 3.93 3.51 3.35 3.69 3.71 4.98 4.90 5.28 5.50 5.95 5.34 5.69 5.97 6.10 6.09 5.01 6.62 7.45 8.54 9.41 0.44 0.66 0.59 0.56 0.62 0.62 0.83 0.82 0.94 0.98 1.02 0.89 0.54 0.94 0.92 1.07 1.04 0.86 1.62 1.63 1.67 0.40 0.33 0.39 0.38 0.45 0.48 0.58 0.60 0.63 0.70 0.59 0.49 0.42 0.40 0.36 0.40 0.38 0.34 0.34 0.32 0.29

1980 1986 1988 1989 1991 1992 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Proportions of health spending as a percentage of overall health expenditure in Thailand by funding source, 1980-2008

Table 6.13

:

Ministry of Public Health 17.76 14.04 11.53 11.16 14.28 15.58 19.66 20.15 21.69 24.44 23.57 22.09 21.02 19.16 21.15 19.92 19.68 19.65 21.55 23.82 24 Other ministries 8.73 6.00 4.82 4.23 3.39 3.06 2.78 2.94 3.02 2.55 2.08 2.14 2.07 2.22 2.05 2.31 1.79 1.39 1.79 1.90 2.02 Civil servants benefit scheme State enterprise benefit scheme Workersû compensation fund Social security 0.00 0.00 0.00 0.00 0.56 1.30 1.89 1.75 2.42 3.63 2.77 2.70 3.21 4.22 3.35 4.06 3.94 4.02 4.23 3.98 4.04

agencies Independent and state-supervised Total 29.93 24.96 20.83 19.69 23.52 24.75 30.73 31.17 33.97 37.80 35.98 33.66 32.95 32.91 34.41 34.37 32.38 33.41 37.73 40.84 42.23

Private health insurance 0.88 0.95 1.06 1.11 1.11 1.12 1.15 2.19 2.44 2.66 2.82 2.88 2.43 2.61 2.90 2.99 3.18 3.17 2.06 2.04 2.30 Household and employers 67.75 73.32 77.76 78.97 75.17 73.91 68.04 66.60 63.57 59.50 61.17 63.45 64.60 64.42 62.58 62.47 64.04 63.24 60.03 56.95 55.3 Total 68.63 74.27 78.81 80.07 76.28 75.03 69.19 68.79 66.01 62.16 63.99 66.33 67.03 67.03 65.48 65.45 67.22 66.41 62.10 58.99 57.60 Other International financial aid 1.44 0.77 0.35 0.24 0.19 0.23 0.08 0.04 0.01 0.03 0.03 0.01 0.02 0.06 0.11 0.18 0.40 0.18 0.17 0.16 0.17 Total 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

1. Public sector

2. Private sector

3.

Source

Table 6.15

295 In comparison with other Asian countries (Table 6.16), although Thailandûs per capita health expenditure is not so high, its spending as a percentage of GDP is higher than those for other countries; and its proportion of public health spending is lower than that of private health spending, the people bearing a greater share of health-care spending for themselves. Table 6.16 Comparison of health expenditures among some Asian countries

Health expenditure Country Per capita (USD) As percentage of GDP Proportion, govt.: household Indonesia 81 2.2 54.5 : 45.5 Philippines 130 3.9 34.7 : 65.3 Sri Lanka 179 4.2 47.5 : 52.5 Malaysia 604 4.4 44.4 : 55.6 Thailand (2008) 282 6.4 42.4 : 57.6 Singapore 1,643 3.1 32.6 : 67.4 South Korea 1,688 6.3 54.9 : 45.1 Source: The World Health Report, 2010 (data for 2007). Note: For 2008, based on the exchange rate of 33 baht to a US dollar. 4.2 Public Health Expenditure The major source of public expenditure on health is the government budget, especially through MoPH which is a central administration agency. During the 1980›1989 decade, the proportion of public spending on health dropped from 29.9% to 19.7%, but after 1989, the proportion had a rising trend to 37.8% in 1997, during the period of rapid economic recovery and continuous growth. So, after the economic crisis the government had to adjust the national budget downwards, resulting in a drop to 32.9% in 2001, but it rose again in 2008 to 42.2%, probably due to the launch of the universal health-care policy and the substantial increase in civil servantsû health benefit spending. An analysis of the sources of public health spending revealed that the proportion from MoPH had a falling trend from 24.4% in 1997 to 19.7% in 2005 and to 24.3% in 2008, while the proportion of health expenditure under the civil servants medical benefits scheme rose from 5.5% in 1997 to 9.4% in 2008; similarly, the proportion of health expenditure under the social security scheme also rose from 3.6% in 1997 to 4% in 2008 (Table 6.15). Regarding the MoPH budget, the proportion in relation to the national budget rose from 6.7% in 2001 to 9.1% in 2011 (Figure 6.52), reflecting the continuous importance accorded by the government to the health service system.

296 Figure 6.52 The national health budget and MoPH budget, 1984›2011

MoPH budget National health budget Baht(in millions) MoPH budget as a percentage of national budget percentage

9.5 10 200,000 208,093.4

8.6 9

9.1 180,000 169,633.2 8.3 188,625.4

7.9

7.7 7.8

7.6 8

160,000 7.4

7.3 178,852.7

7.2

7.1 154,140.4

6.9

6.9

6.7 6.7 148,739.6 7 140,000 6.4

6.3

5.8 6

120,000 5.4

5.3

161,530.4

117,005.3

153,133.8 100,000 4.8 5

4.5

4.4

4.3

142,113.6

4.3

4.2

4.2

129,683.3

89,163.7

83,786.6

80,000 78,224.2 4

72,406.00

72,769.7

66,455.20

66,254.30

65,209.90

63,452.20

62,546.30

60,000 107,100.8 3

52,372.70

44,335.00

85,914.4

36,549.60

40,000 77,720.7 2

74,133.9

70,923.2

27,238.20

22,705.90

67,574.3

18,046.80

63,705.10

61,097.20

60,640.90

55,861.2

12,447.90 20,000 59,227.30

10,959.50

9,537.50

9,762.30

10,051.10 1

9,039.10 45,832.6

8,617.60 39,318.7

0 32,989.1 0 Year

24,640.4

20,568.6

16,225.10

9,044.30

9,525.10

9,274.70

11,733.10

10,272.50

1984 2011

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Bureau of the Budget. Note: For 1995-2010, the MoPH budget includes the health insurance revolving funds (previously known as health card revolving funds).

297 4.3 Private and Household Health Expenditure The private sector has households as the largest source of funds for health care since the people sometimes have to make an out-of-pocket payment for the services, according to their behaviour of buying drugs for self-medication, or whenever they are not entitled to health insurance coverage at a private clinic or private hospital, or when they do not follow the steps or procedures of the state health-care scheme, in the designated area, or at the health facility. Therefore, the household financing plays a very significant role in health-care delivery. The proportion of household spending has always been more than 60% (Table 6.15). In 1980, such a proportion was as high as 68.6% and rose to 80.1% in 1989 due to the decrease in government budget, resulting in the households bearing a greater share of health-care costs. After 1989 until 1997 with the economic crisis, the household spending proportion steadily dropped to 62.2%, but rose again to 67.03% in 2000 with a decreased state budget. Beginning in 2005, the proportion slightly dropped to 62.1% in 2006 and 57.6% in 2008, reflecting the decreased family burden resulting from the universal health-care policy. This situation has shown that the use of services that are not covered by the universal health-care scheme is still high, particularly drug purchasing for self-care, attending a private clinic, and bypassing the steps required when using state health services, attending a health facility in another area; and in such instances, the people have to pay for their own services. In analyzing the sources of private health expenditure, it has been found that the major source is the households and employers rather than private health insurance. The proportion of private health insurance is only 2% to 3%, which is very little compared with that from the households and employers. The pattern of household health expenditure derived from the household income and expenditure survey conducted by the National Statistical Office during 1981›1996 revealed a rather stable rate of 3.6% to 3.9% of overall family spending each month. The proportion declined to 3.2% during the economic crisis and dropped further to 2.6% in 2002 and 2.2% in 2009. Significant observations are as follows: 1) Household health expenditure for self-medication had a declining trend from 31.9% in 1981 to 11.9% in 1996. On the contrary, the proportion of services purchased at health facilities (including drug consumption and services at private clinics, and state and private hospitals) had a rising trend from 68.1% to 88.0% for the same period. There was a change in the trend when the economic crisis occurred in 1997 as more people turned to purchasing drugs for self-medication, the proportion of self-care rising to 18.6% in 2000, with a declining trend in attending health facilities. When the economy recovered in 2002, the propor- tion of self-medication dropped to 13.9%. But during 2007›2009, the self-medication spending rose again to 23.3% in 2009, whereas the health-care spending at private hospitals dropped to 76.7% in the same year (Figure 6.53 and Table 6.17).

298 Figure 6.53 Household health expenditure, 1981›2009

Baht/month Health expenditure Self-medication Health facilities 400 343 350 313 287 302 282 300 262 262 279 302 263 252 250 226 236 240 239 249 200 185 223 214 217 222 223 143 150 132 187 113 150 100 112 73 97 48 49 53 59 50 77 35 31 35 39 39 41 35 40 43 36 0 Year 1981 1983 1985 1987 19891991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Source: Report on Household Socio-Economic Survey. National Statistical Office. Note: The estimates are expected to be lower than reality as the survey coverage often missed high- income families.

2) Health expenditure when attending health facilities had a rising proportion for private facilities, but declining for state facilities. As shown in Figure 6.54, household spending at private health facilities (clinics and hospitals) had a rising trend from 40% in 1986 to 52.5% in 1994. On the contrary, household spending at public hospitals and health centres declined from 50% to 38.1% for the same period. At the beginning of the economic crisis period, more people attended public hospitals and health centres and fewer people went to private hospitals and clinics. For other services, such as dental care and opticiansû services, the spending proportion was 8% to 10% of household health spending. It is noteworthy that since 2002, the beginning of economic recovery and the universal health care, the household spending on health care at private hospitals/clinics increased to 58% in 2004 and 61.7% in 2009, while such spending at state health facilities dropped to 25.4% for the same year, whereas the spending at other health facilities rose to 12.9%, probably due to attending state health facilities under the universal health-care system, making the people spend less at such places.

299 Figure 6.54 Proportion of household health spending when attending health facilities, 1986›2009

Public hospital & health centres Private hospital/clinics Other Percentage 70 61.4 61.7 60 58.1 57.7 55.5 51.3 52.5 53.4 50 50.0 49.0 50.5 50 46.0 48.1 46.0 44.4 44.8 40 42.5 40.0 41.3 40.6 40.1 40.1 38.1 37.8 30 33.5 26.5 25.4 20 12.1 12.9 10.0 9.4 11 10 8.0 8.7 8.0 6.6 7.1 7.0 8.8 1.8 2.2 0 Year 1986 1988 1990 19921994 1996 1998 2000 2002 2004 2006 2008 2009

Source: Report on Household Socio-Economic Survey. National Statistical Office.

300 .7

Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht % Baht %

%

1981 1986 1988 1990 1992 1994 1996 1998 2000 2001 2002 2004 2006 2007 2008 2009

Household health spending pattern (baht/month), 1981-2009

Baht % Baht

Report on Household Socio-Economic Servey. National Statistical Office.

Pattern of

expenditure

Public hospitals & - - 48 50.0 52 46 62 41.3 76 40.6 85 38.1 148 49.0 107 44.8 91 42.5 98 45.0 87 40.1 89 40.1 94 37.8 79 33.5 59 26.5 61 25.4 health centres Private hospitals/ - - 39 40.0 51 46 75 50.0 96 51.3 117 52.5 134 44.4 115 48.1 108 50.5 110 50.4 126 58.1 128 57.7 133 53.4 131 55.5 137 61.4 148 61.7 clinics Other - - 10 10 9 8 13 8.7 15 8.0 21 9.4 20 6.6 17 7.1 15 7.0 10 4.6 4 1.8 5 2.2 22 8.8 26 11.0 27 12.1 31 12.9

Family size (persons) 4.5 - 4.3 - 4.0 - 4.1 - 3.9 - 3.8 - 3.7 - 3.7 - 3.6 - 3.6 - 3.5 - 3.4 - 3.3 - 3.3 - 3.3 - 3.3 - Total expenditure per 3,374 - 3,783 - 4,161 - 5,437 - 6,529 - 7,567 - 9,190 - 10,389 - 9,848 - 10,025 - 10,889 - 12,297 - 14,311 - 14,500 - 15,942 - 16,205 - month Consumption 3,161 - 3,486 - 3,804 - 4,942 - 5,892 - 6,787 - 8,072 - 8,966 - 8,558 - 8,758 - 9,601 - 10,885 - 12,701 - 12,735 - 14,087 - 14,244 - expenditure per month Health expenditure 113 3.6 132 3.8 143 3.9 185 3.7 226 3.8 262 3.9 343 4.2 287 3.2 263 3.1 264 3.0 252 2.6 262 2.4 302 2.4 279 2.2 282 2.0 313 2.2 per month Self-medication 36 31.9 35 26.5 31 21.7 35 18.9 39 17.3 39 14.9 41 11.9 48 16.7 49 18.6 46 17.4 35 13.9 40 15.3 53 17.5 43 15.4 59 20.9 73 23.3 expenditure Spending at health 77 68.1 97 73.5 112 78.3 150 81.1 187 82.7 22.3 85.1 302 88.0 239 83.3 214 81.4 218 82.6 217 86.1 222 84.7 249 82.5 236 84.6 223 79.1 240 76 facilities -

-

-

Source:

Table 6.17

301 5. Accessibility of Health Services 5.1 Coverage of Health Security Thailand has been expanding health security or insurance coverage to all the people under major schemes: civil servants medical benefits (also for state enterprise employees), social security, medical services for the poor and society-supported groups, voluntary health insurance project, private health insur- ance, and vehicle accident victims protection. In 2001, all the schemes could cover 71.0% of the population. Since 2001, under the universal health-care policy, the coverage of health security had risen to 97.4% by 2009 (76.1% under the universal coverage scheme), leaving 2.6% without any health insurance (Table 6.18).

Table 6.18 Percentage of Thai people with health security, 1991, 1996, 2001 and 2003-2009 Before the launch After the launch of the UC of the UC health-care scheme Health insurance scheme health-care scheme 1991 1996 2001 2003 2004 2005 2006 2007 2009 1.Universal coverage health care - - 0.9 74.7 73.5 72.2 74.3 73.6 76.1 - Gold card with Tor (not paying 30 - - - 30.6 28.1 28.6 42.8 baht/visit) 74.7 76.1 - Gold card without Tor (paying 30 - - 0.9} 42.9 44.1 45.7 30.9 } baht/visit) 2.Medical welfare for the poor 12.7 12.6 31.5 ------(Sor Por Ror) 3.Medical benefits for civil servants and 15.3 10.2 8.5 8.9 9.4 9.8 8.9 9.1 7.7 state enterprise employees - Civil servants 13.2 9.0 7.5 8.9 9.4 9.8 8.9 9.1 7.7 - State enterprise employees 2.1 1.2 1.0 } }} 4.Social security and workersû compensation - 5.6 7.2 9.6 10.7 11.0 11.4 12.1 12.3 fund 5.Voluntary health insurance 4.5 16.1 22.1 1.7 0.8 1.0 0.7 1.1 0.9 - Health card, MoPH 1.4 15.3 20.8 ------Private insurance 3.1 0.8 1.3 1.7 0.8 1.0 0.7 1.1 0.9 6.Others 0.9 1.0 0.8 - - 1.1 0.7 0.5 0.4 Population with health insurance 33.5 45.5 71.0 94.9 94.3 95.1 96.0 96.3 97.4 Population without health insurance 66.5 54.5 29.0 5.1 5.7 4.9 4.0 3.7 2.6

Sources: 1. Reports on Health and Welfare Surveys, 1991, 1996, 2001, 2003, 2004, 2007 and 2009. National Statistical Office. 2. Viroj Tangcharoensathien, et al. An analysis of data from the Reports on Health andWelfare Surveys, 2003-2009. National Statistical Office. Note: The number of insured persons with private health insurance companies in 2004 was 2.88 million, or 4.4% of total population, but some of them had coverage from more than one scheme.

302 In addition, it was found that, in 2009, the proportion of rural residents with universal health- care cards was higher than that for urban residents. But more urban residents had health-care coverage under the social security scheme and the medical benefits scheme for civil servants than did rural residents (Table 6.19). Table 6.19 Percentage of people with health insurance coverage in municipal and non-municipal areas, 1991, 1996, 2001, 2003, 2004, 2006, 2007 and 2009

Health insurance Municipal areas Non-municipal areas coverage 1991 1996 2001 2003 2004 2006 2007 2009 1991 1996 2001 2003 2004 2006 2007 2009 No insurance 65 58 42 9 10.1 7.7 7.3 5.3 68 52 22 3 3.5 2.5 2.1 1.4 Civil servants and state 22 17 16 15 15.3 14.1 14.6 12.1 6 7 9 6 6.5 6.6 6.6 5.8 enterprise employees Universal health care - - - 56 54.6 56.3 55.3 60.3 - - - 84 82.8 82.1 81.6 83.1 Social security - 11 13 18 18.2 19.8 20.2 19.7 - 3 4 6 7.0 7.7 8.6 9.1 Medical welfare for 7 5 15 - - - - - 21 16 39 - - - - - the poor Health card 1 6 10 - - - - - 2 20 27 - - - - - Private health insurance 5 2 3 3 1.8 1.6 2.5 2.1 1 1 1 1 0.3 0.3 0.5 0.2 Others 1 1 1 - - 0.6 0.2 0.5 1 1 1 - - 0.7 0.6 0.4 Sources:1.Reports on Health and Welfare Surveys, 1991, 1996, 2001, 2003, 2006, 2007 and 2009. National Statistical Office. 2. Viroj Tangcharoensathien et al. An analysis of data from the Reports on Health and Welfare Surveys, 2003, 2004, 2006, 2007 and 2009. National Statistical Office. Note: The number of insured persons with private health insurance companies in 2004 was 2.88 million, or 4.4% of total population, but some of them had coverage from more than one scheme.

5.2 Rate of Health Service Utilization The utilization of health services at hospitals (health facilities with inpatient beds) is on the rise; the rate of service utilization at hospitals (visits/person/year) rose from 1.8 in 2001 to 3.4 in 2009, the rate being highest in Bangkok (4›6 visits) and lowest in the Northeast (1.2›3 visits). That reflects the rate of access to outpatient services being highest in Bangkok (including for outpatients coming from other provinces) (Figure 6.20). Similarly, the rate of hospitalizations or inpatient service utilization also rose from 10% in 1995 to 14.7% in 2007, but dropped slightly in 2009 due to incomplete survey coverage, the rate being highest in Bangkok and lowest in the Northeast (Figure 6.21).

303 An analysis of the relationship between service utilization and provincial health resources reveals that the outpatient service rate is associated with the population/doctor ratio and the inpatient service rate and the population/bed ratio (Figure 6.55 and Figure 6.56). This reflects the fact that the provinces with a lot of health resources (low population/doctor and population/bed ratios) will have higher utilization rates, and confirms the influence of health resources on the chances of peopleûs service utilization.

Table 6.20 Rate of outpatient service utilization by region, 2001›2009 Utilization rate (visits/person/year) Region 2001 2002 2003 2004 2005 2006 2007 2008 2009 Bangkok 4.0 3.9 4.4 4.4 5.1 5.4 6.4 4.1 3.7 Central 2.0 2.1 2.3 2.3 2.5 2.7 2.9 3.3 4.2 North 1.6 1.6 1.7 1.8 2.0 2.0 2.1 2.2 3.1 Northeast 1.2 1.3 1.3 1.3 1.4 1.5 1.6 1.5 3.1 South 1.7 1.7 1.7 1.8 1.9 1.9 2.1 2.1 3.2 Total 1.8 1.8 1.9 2.0 2.2 2.3 2.5 2.4 3.4

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Incomplete survey courage.

Table 6.21 Rate of inpatient service utilization by region, 1995›2009

Utilization rate (visits/person/year) Region 1995 1997 1999 2001 2003 2005 2006 2007 2008 2009 Bangkok 11.6 15.5 19.9 22.3 20.3 21.7 20.1 26.2 14.4 11.0 Central 12.4 13.8 15.0 15.7 14.4 15.6 16.1 15.9 15.3 15.2 North 9.4 11.9 12.7 15.0 13.1 12.8 13.3 13.5 13.2 10.9 Northeast 8.4 11.0 10.4 10.7 10.7 10.6 10.9 11.3 11.2 11.3 South 10.7 12.3 12.0 13.9 13.5 13.8 14.6 15.0 16.6 15.7 Total 10.1 12.4 13.0 14.2 13.3 13.7 14.0 14.7 13.6 12.8

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Incomplete survey courage.

304 Figure 6.55 Relationship between the rate of outpatient service utilization and population/doctor ratio at provincial level, 2007

7

6 5 4

3 2

1

Outpatient utilization rate (visits/person/yr) 0 0 2,000 4,000 6,000 8,000 10,000 Population/doctor ratio Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

Figure 6.56 Relationship between the rate of inpatient service utilization and population/bed ratio at provin- cial level, 2007

inpatient utilization ratio (% of pop.) 30

25

20

15

10

inpatient utilization rate (% of pop.)

0 0 200 400 600 800 1,000 1,200 Population/bed ratio Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

305 A geographical distribution analysis of service utilization rates at provincial level reveals that the provinces that are the centres of regions and the provinces in the Central region have a high utilization rate, while most provinces in the Northeast have a lower utilization rate than other provinces (Figure 6.57).

Figure 6.57 Geographical distribution of outpatient (OPD) service utilization rates and inpatient service (admission) rates at provincial level, 2007

NN

OPD utilization rate 2007 Admission rate (%) 2007 1.2 - 1.5 8.3 - 11.2 1.5 - 1.8 11.2 - 12.7 1.8 - 2.2 12.7 - 14 2.2 - 2.6 14 - 15.8 2.6 - 6.4 15.8 - 27.6

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

5.3 Utilization of Health Services by Agency and Service Level During the last seven-year period (2002›2009), the proportion of outpatients by agency of hospitals was highest for hospitals under MoPH or about two-thirds (65%) of all patients, followed by private hospitals with about one-fifth (24%) of all patients, and university hospitals (4%) (Figure 6.58). Similarly, the proportion of inpatients or admissions, for the same period, was highest in MoPH hospitals (73%), followed by private hospitals (20%) and university hospitals (3%) (Figure 6.59).

306 Figure 6.58 Proportions of outpatients (visits) by agency of hospitals, 2002›2009 80

70 67.1 68.1 67.3 64.8 64.7 63.2 62.0 60.5 60

50 MoPH Municpalities Ministry of Education Private 40 Ministry of Defence Indendent agencies

Proportion (%) 30 25.3 26.0 25.3 27.3 23.6 23.9 22.6 21.0 20

10 6.2 6.1 5.2 5.8 4.1 3.8 3.3 3.1 2.8 3.2 3.1 3.5 3.7 3.5 3.3 1.9 1.3 1.7 1.9 1.9 1.9 1.7 0.9 1.4 0 0.8 0.5 0.4 1.4 1.3 0.5 0.5 0.5Year 2002 2003 20042005 2006 2007 2008 2009 Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete. Figure 6.59 Proportions of inpatients by agency of hospitals, 1995›2009 Proportion (%) 90 80 76.9 75.3 70.5 71.9 72.9 72.8 71.0 73.3 70 68.3 60 MoPH Ministry of Education 50 Ministry of Defence Municpalities Private Indendent agencies 40 30 24.2 22.3 19.9 20.9 19.6 20 16.2 18.5 19.3 18.9 2.3 3.0 2.4 3.2 3.2 3.6 3.2 2.1 10 2.2 2.8 2.4 2.2 2.2 1.9 2.6 1.5 1.1 2.0 1.3 1.3 1.3 1.3 1.3 1.5 1.2 0.8 0 Year 2.3 1.0 1.0 1.1 0.4 0.9 0.4 0.4 0.0 1995 1997 19992001 2003 2005 2007 2008 2009 Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete.

307 In analyzing the proportions of outpatient service utilization, including the services at subdis- trict health centres, only in MoPH hospitals (community, general and regional hospitals) to see the trends in service utilization by level of health facilities, it was found that the major change that had occurred was the rising trend in the number of outpatient visits at the aforementioned hospitals, especially the increase rate was highest for subdistrict and community health centres followed by community hospitals. The increase was lowest for regional hospitals. So, the structure of patients is gradually changing from an inverted triangle to a regular triangle (Figures 6.60 and 6.61).

Figure 6.60 Proportions of outpatients by level of MoPH health facilities, 1977›2009

46.2 % Regional/general hospitals 32.4 %

24.4 % Community hospitals 35.9 %

29.4 % Health centres 31.7 %

1977 1985

21.2 % Regional/general hospitals 18.2 %

37.2 % Community hospitals 35.7 %

41.6 % Health centres 46.1 % 1993 2000

17.8 % Regional/general hospitals

36.9 % Community hospitals

45.3 % Health centres

2009

Source: Bureau of Policy and Strategy, MoPH.

308 Figure 6.61 Numbers of outpatients (OPD visits) by level of MoPH health facilities,1995›2009

No. of visits (in millions) 80 85.8 Health centres/community health posts 72.2 70 Community hospital 63.9 60 Regional/general hospital 62.4 60.4 60.2 60.9 65.2 69.9 50 51.8 58.9 57.4 61.3 44.5 46.9 55.6 40 41.5 32.4 35.4 43.7 30 36.7 40.2 33.9 33.3 33.7 28.0 29.6 29.3 29.8 30.6 20 26.1 23.0 27.1 19.4 20.4 10 14.6 15.5 16.8 18.1 0 Year 1995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources: Bureau of Policy and Strategy and Bureau of Health Service System Development, MoPH.

6. Efficiency and Quality of Health Service Delivery 6.1 Hospitalization When analyzing the efficiency of hospitalization, or admission for inpatient care, if each patient has an equal health need, a greater number of admissions will reflect a lower level of efficiency as inpatient care will require more resources and higher health-care costs. However, the severity of the outpatient will have to be taken into account and it is associated with the access to health care. A good access to health care will make outpatients less severe and there will be fewer admissions. The health resources survey reveals that MoPH hospitals have the highest inpatient/outpa- tient rate (7%), while the hospitals under other agencies have similar inpatient/outpatient rates (4%›5.5%), as shown in Table 6.22; and by region, it has been found that the Northeast and the South have the highest inpatient/outpatient rate (7.5%›7.8%), whereas Bangkok has the lowest rate (4.3%) (Table 6.23).

309 Figure 6.61 Numbers of outpatients (OPD visits) by level of MoPH health facilities,1995›2009

No. of visits (in millions) 80 85.8 Health centres/community health posts 72.2 70 Community hospital 63.9 60 Regional/general hospital 62.4 60.4 60.2 60.9 65.2 69.9 50 51.8 58.9 57.4 61.3 44.5 46.9 55.6 40 41.5 32.4 35.4 43.7 30 36.7 40.2 33.9 33.3 33.7 28.0 29.6 29.3 29.8 30.6 20 26.1 23.0 27.1 19.4 20.4 10 14.6 15.5 16.8 18.1 0 Year 1995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Sources: Bureau of Policy and Strategy and Bureau of Health Service System Development, MoPH.

6. Efficiency and Quality of Health Service Delivery 6.1 Hospitalization When analyzing the efficiency of hospitalization, or admission for inpatient care, if each patient has an equal health need, a greater number of admissions will reflect a lower level of efficiency as inpatient care will require more resources and higher health-care costs. However, the severity of the outpatient will have to be taken into account and it is associated with the access to health care. A good access to health care will make outpatients less severe and there will be fewer admissions. The health resources survey reveals that MoPH hospitals have the highest inpatient/outpa- tient rate (7%), while the hospitals under other agencies have similar inpatient/outpatient rates (4%›5.5%), as shown in Table 6.22; and by region, it has been found that the Northeast and the South have the highest inpatient/outpatient rate (7.5%›7.8%), whereas Bangkok has the lowest rate (4.3%) (Table 6.23).

309 Table 6.22 Rate of admissions (inpatients/outpatients) by agency of hospitals, 2002›2009

Admission rate (percentage of inpatients in relation to outpatients) Agency 2002 2003 2004 2005 2006 2007 2008 2009 MoPH 7.9 7.7 7.5 7.1 7.0 6.7 6.2 6.3 Ministry of Education 4.2 5.4 4.5 5.2 4.0 3.7 5.5 6.4 Ministry of Defence 8.6 4.7 4.7 4.0 3.2 3.2 4.4 2.7 Other ministries 4.6 4.4 9.7 7.1 3.0 2.4 2.7 3.2 Municipalities 5.4 4.7 4.7 5.2 4.1 4.3 3.8 0.3 Private sector 6.3 5.4 5.5 5.1 5.1 5.2 4.6 4.8 Independent agencies 4.2 5.1 5.6 4.3 4.2 4.9 3.7 3.4

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete.

Regarding efficiency, a high admission rate may be interpreted as low efficiency. But actually, such a high rate may result from differences in access to health care, which means that the outpatients at hospitals in the Northeast and the South may be more seriously ill than those in other regions. So they will need a longer hospital stay resulting from their lower accessibility compared to other regions.

Table 6.23 Rate of admissions (inpatients/outpatients) by region, 2001›2009 Admission rate (percentage of inpatients in relation to outpatients) Region 2001 2002 2003 2004 2005 2006 2007 2008 2009 Bangkok 5.6 5.2 4.6 4.4 4.3 3.7 4.1 3.5 3.2 Central 7.9 7.3 6.3 6.6 6.2 5.9 5.5 4.6 5.2 North 9.3 7.9 7.8 7.3 6.6 6.8 6.4 6.1 6.0 South 8.2 8.1 7.8 7.0 7.4 7.6 7.2 7.7 7.2 Northeast 9.2 8.1 8.2 8.2 7.7 7.4 7.3 7.3 6.8 Total 8.0 7.3 6.8 6.7 6.3 6.1 5.9 5.7 5.7 Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete.

310 6.2 Average Length of Stay of Inpatients An analysis of the average length of stay of inpatients may help reflect the efficiency of inpatient care to a certain extent. If all patients have an equal severity of illness, a long length of stay will result in a higher treatment cost, meaning less efficient treatment. Data from the 1995›2009 health resources surveys revealed that private hospitals had the shortest average length of stay of 3 days, while those under universities and the Ministry of Defence had the longest, approximately 6.3›6.7 days (Figure 6.62). Such characteristics might result from the severity of patients; hospitals with a high level of efficiency tend to admit patients with complex illnesses resulting in a longer length of stay, especially in university hospitals.

Figure 6.62 Average length of stay of inpatients by agency of hospitals, 1995›2009

Length of stay (days) 10 8 6 4 2

0 1995 1997 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year MoPH 4.9 4.6 4.3 4.3 4.3 4.3 4.3 4.3 4.2 4.4 4.1 4.1 Ministry of Education 4.7 8.6 7.9 8.1 7.1 6.9 8.0 6.4 6.7 7.0 5.5 5.7 Ministry of Defence 6.2 8.0 5.6 6.5 4.5 5.7 8.3 6.7 7.0 7.1 5.0 6.4 Municipalities7.5 6.8 6.0 5.7 6.1 5.7 5.5 4.8 7.3 6.1 5.6 NA Private 4.0 3.1 3.1 2.8 2.5 3.1 2.9 3.0 2.8 2.8 3.4 3.1 Independent agencies 7.3 7.1 6.0 5.9 4.7 5.2 4.8 6.9 7.1 4.7 5.3 6.3

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete.

311 A regional analysis reveals that the length of stay for Bangkok is longest (5.5 days), while it is shortest (3.7 days) for the Northeast (Figure 6.63). Factors related to hospital capacity might make high-capacity hospitals in Bangkok admit patients with complex illnesses and longer hospitalization. The same is true for the provinces that are the centres of regions and some provinces in the Central region, the North and the South (Figure 6.64).

Figure 6.63 Average length of stay of inpatients by region 1995-2009

Length of stay (days) 9 8 7 6 5 4 3 2 1 1995 1997 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Bangkok 7.6 6.3 5.2 4.8 4.8 5.1 6.0 5.1 5.4 4.6 4.9 5.7 Central 5.2 4.6 4.3 4.6 4.1 4.4 4.4 4.3 4.2 4.2 4.5 4.1 North 4.44.3 4.2 3.7 4.2 4.1 4.1 4.3 4.1 4.6 3.9 3.7 South 5.0 4.6 4.6 4.3 4.1 4.0 4.1 4.1 3.9 4.3 3.5 3.7 Northeast 3.7 3.6 3.6 3.7 3.7 3.7 3.6 3.7 3.7 3.7 3.7 3.8 Total 4.9 4.4 4.2 4.2 4.1 4.2 4.3 4.2 4.2 4.2 4.0 4.0

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH. Note: Data on coverage was incomplete.

312 Figure 6.64 Geographical illustration of average length of stay by province, 2007

N

Average length of stay 2007 2.8 - 3.4 3.4 - 3.7 3.7 - 4 4 - 4.4 4.4 - 7.7

Source: Report on Health Resources, Bureau of Policy and Strategy, MoPH.

6.3 Inpatient Mortality Rate The mortality rate of inpatients is, to a certain extent, an indicator of inpatient care quality. If there is an assumption that the level of patient severity does not change, the better quality of care will help improve the treatment outcome, i.e. a drop in patient mortality. According to the inpatient database of the National Health Security Office, between 2005 and 2010, the mortality rate decreased for most patients with chronic diseases such as ischemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, reflecting a better access to and better medical care which results in a lower chance of dying (Figure 6.65).

313 Figure 6.65 Mortality rates of inpatients with diabetes, hypertension, cerebrovascular disease, ischemic heart disease, COPD, asthma and tuberculosis, 2005›2010

Diabetes Asthma in adults COPD Hypertension Cerebrovascular Tuberculosis, all organs Acute ischemic heart 25

21.7 20.9 20 19.1 18.0 16.8 16.9 16.3 15.7 15.9 15.5 15.1 15 14.9

10

Inpatients Mortality rate (%) 6.3 6.7 6.6 7.0 6.0 6.2 5.1 5.6 6.3 5.2 5 5.3 5.5 4.8 4.8 4.8 4.6 4.7 4.8 1.9 1.5 1.3 1.2 1.2 1.2 0 0.7 0.6 0.8 0.9 0.6 0.7 2005 2006 2007 2008 2009 2010 Year Source: Inpatient database, National Health Security Office, 2005›2010.

However, for cancer, the inpatient mortality rate has been on a rising trend from 12.9% in 2005 to 15.0% in 2010, probably due to disease severity and the trend in getting hospitalization or home care for terminally ill patients. But the rates for cardiovascular disease and head injuries slightly decreased (Figure 6.66), reflecting the quality of medical care which can be further improved in parallel with the quality of disease prevention and control to prevent the illnesses from getting more severe, which will help improve the chance of survival.

314 Figure 6.66 Mortality rates of inpatients with head injuries, cardiovascular disease and cancer, 2005›2010

Head injuries Cardiovascular disease cancer, all organs 20

15 14.6 15.0 12.9 13.6 13.9 14.3 10 9.7 9.7 9.6 9.2 8.9 8.9 5 3.8 Inpatients mortality rate (%) 3.6 3.5 3.6 3.6 3.7 0 2005 2006 2007 2008 2009 2010

Source: Inpatient database, National Health Security Office, 2005›2010.

7. Equities in Health Services 7.1 Equities in Health Service Utilization Chances of choosing health services for people are different depending on their socio-eco- nomic status. The 2009 health and welfare survey revealed that, only for services at subdistrict health centres, community hospitals, regional/general hospitals, and private hospitals, the poorest group attended health centres the most (34%), while the richest group chose private hospitals the most (33.9%). That reflects the chances of choosing services; private hospitals are attended mostly by the high-income group and so are general/regional hospitals (Figure 6.67). The differences in the health service selection opportunity might affect the quality of services according to the capacity of health facilities, especially if the illness needs to be treated at a high-capacity facility.

315 Figure 6.66 Mortality rates of inpatients with head injuries, cardiovascular disease and cancer, 2005›2010

Head injuries Cardiovascular disease cancer, all organs 20

15 14.6 15.0 12.9 13.6 13.9 14.3 10 9.7 9.7 9.6 9.2 8.9 8.9 5 3.8 Inpatients mortality rate (%) 3.6 3.5 3.6 3.6 3.7 0 2005 2006 2007 2008 2009 2010

Source: Inpatient database, National Health Security Office, 2005›2010.

7. Equities in Health Services 7.1 Equities in Health Service Utilization Chances of choosing health services for people are different depending on their socio-eco- nomic status. The 2009 health and welfare survey revealed that, only for services at subdistrict health centres, community hospitals, regional/general hospitals, and private hospitals, the poorest group attended health centres the most (34%), while the richest group chose private hospitals the most (33.9%). That reflects the chances of choosing services; private hospitals are attended mostly by the high-income group and so are general/regional hospitals (Figure 6.67). The differences in the health service selection opportunity might affect the quality of services according to the capacity of health facilities, especially if the illness needs to be treated at a high-capacity facility.

315 Figure 6.67 Percentage of health facility selection when ill by level of householdûs average monthly income, 2009

Percentage 120 100 80 60 40 20 0 Poorest Poor Middle income Rich Richest Private hospitals 15.1 15.3 19.2 23.9 33.9 Other state hospitals 17.9 18.4 22.6 24.9 35.3 Community hospitals 32.6 31.7 29.0 27.4 17.2 Health Centres 34.4 34.7 29.1 23.8 13.6

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from Health and Welfare Survey, 2009. National Statistical Office.

For cases requiring hospitalization, the characteristics are similar, i.e. the poorest group would be admitted to community hospitals the most (48.4%), while the richest group would have the highest chance of being admitted to a private hospital (33.7%), compared with other income groups. However, hospitalization at general and regional hospitals is not much different; all income groups have a 46% to 50% chance of being hospitalized (Figure 6.68), indicating that the poorest group still has a rather high chance of getting admitted to high-capacity hospitals although their chance of getting hospitalized in private hospitals is smallest.

316 Figure 6.68 Percentage of health facility selection when hospitalized by level of householdûs average monthly income, 2009

Percentage 120 100 80 60 40 20 0 Middle Poorest Poor income Rich Richest

Private hospitals 4.4 10.0 9.4 12.9 33.7 Other state hospitals 47.2 47.7 50.3 49.9 45.6 Community hospitals 48.4 42.3 40.3 37.2 20.8

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from Health and Welfare Survey, 2009. National Statistical Office.

Besides, a comparison of health service utilization according to patientsû entitlement reveals that the implementation of the universal health-care policy has resulted in the peopleûs access to and atten- dance of health facilities when ill increasing from 49% in 1991 to 75.3% in 2005 and 68.5% in 2009. For the group without any health insurance, their chance of utilizing health facilities has increased from 47% in 1991 to 66.6% in 2005 and 55.1% in 2009; and, for the groups with civil servants benefits and universal health-care coverage, their utilization of health facilities when ill is highest, compared with other groups (Table 6.24).

317 Table 6.24 Morbidity rates and proportions of utilization of health facilities by type of medical welfare scheme, 1991, 1996, 2001, 2003›2007 and 2009

Morbidity rate (episodes/person/yr) Percentage of utilizing health facilities Welfare scheme 1991 1996 2001200320042005 200620072009 199119962001 200320042005200620072009 No health insurance 5.7 3.5 3.3 4.2 3.2 3.4 2.6 2.5 4.2 47 62 61 56 60.6 66.6 55.1 56.5 55.1 Universal (30-baht) - - 3.4 5.0 5.1 4.8 3.4 3.4 5.8 - - 62 72 72.8 76.5 72.1 68.5 68.6 health-care scheme Medical care for 7.2 6.9 5.3 ------50 67 74 ------the poor Health card, MoPH 7.0 4.5 3.7 ------55 68 71 ------Welfare for civil 5.4 3.7 3.6 4.9 4.8 4.5 4.1 3.9 6.2 60 71 75 71 73.1 75.1 75.8 71.4 77.6 servants and state enterprise employees Social security - 2.5 2.5 3.0 3.0 2.7 1.9 1.8 3.8 - 58 66 67 63.0 68.6 66.8 62.7 61.9 Private insurance 4.4 3.5 3.0 3.5 1.9 2.1 2.4 2.1 3.8 42 72 65 67 60.2 77.0 50.6 65.3 52.7 Total 5.9 4.0 3.9 4.7 4.7 4.4 3.3 3.2 5.6 49 65 70 71 71.6 75.3 71.3 68.068.5 Sources: Viroj Tangcharoensathien et al. An analysis of data from the Reports on Health and Welfare Surveys, 1991, 1996 and 2001›2009. National Statistical Office.

7.2 Equity in Health-care Spending Household health spending according to householdsû socio-economic status should be equi- table, i.e. a poor household should pay less to the system than a rich household in an amount proportional to their household incomes. As a result of the universal health-care policy, household health spending has decreased; health spending among the poor (1st›4th decile groups) dropped by 3›27%. However, it is noteworthy that, for the richest (10th decile) group, their health spending decreased by 10% (Figure 6.69).

318 Figure 6.69 Comparison of average household health spending in 10 decile groups of households before and after the launch of the universal health-care scheme

Health spending (baht) 1,400 1,200 1,000 800 600 400 200 0 1 2 3 4 5 6 7 8 9 10 Decile 1996 65 90 132 135 164 191 241 274 384 1,380 group 2000 65 88 117 139 155 219 255 300 382 913 2002 45 67 93 105 139 192 217 267 373 1,024 200452 68 89 125 144 200 213 318 369 1,044 2007 44 67 97 136 161 184 224 278 457 1,190 2009 47 79 104 138 200 215 267 366 479 1,248

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from householdsû socio- economic survey, 1996›2009. National Statistical Office.

According to an analysis of the proportions of household health spending by income group, the burden of peopleûs health spending is not in accordance with their ability to pay. When comparing the proportion of health spending of each income group, low-income people have a higher proportion of health spending than high-income people (Figure 6.70). After the government launched the health insurance scheme for various groups of underprivileged people and the universal health-care scheme, it was found that the differences in burden of health spending between the rich and the poor had a declining trend, from 6.4-fold in 1992 to 0.9-fold in 2008

319 Figure 6.70 Percentage of health spending in relation to household income by decile group of income, 1992, 1996, 2002, 2004 and 2008 Percentage 10

8

6

4

2

0 1st-10th 1 2 3 4 5 6 7 8 9 10 Decile difference 1992 8.17 4.82 3.74 3.65 2.87 2.57 2.45 1.99 1.64 1.27 6.4 1996 5.46 4.58 3.32 3.16 2.93 2.52 2.36 1.97 1.57 1.10 5.0 20022.77 2.59 2.14 1.90 2.20 1.98 1.74 1.92 1.83 1.71 1.6 2004 2.23 1.77 1.75 1.62 1.40 1.37 1.32 1.35 1.15 1.07 2.1 2008 2.05 1.95 1.69 1.60 1.74 1.68 1.66 1.83 1.74 2.18 0.9

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from householdsû socio- economic survey, 1992›2009. National Statistical Office.

However, an recent analysis of the differences of peopleûs groups by their socio›economic status was undertaken based on the household spending rather than household income and a comparison was made on the proportion of their health spending with household income, i.e. the proportion of health spending in relation to household spending, rather than health spending in relation to household income. Such a method of calculation will be a comparison of the burden of health spending in relation to overall household spending. It was found that the poorest groupûs burden of health spending in relation to household spending was 2.3% in 1996, which decreased steadily to 1% in 2009. Similar downward trends were noted for other income groups, i.e. the richest group had a decline of health spending in relation household spending from by 4% in 1996 to 2.3% in 2009 (Figure 6.71 and Table 6.25); and the rich group had a higher proportion of health/household spending, reflecting the fact that the universal health-care scheme has created equity in spending by protecting the poor, especially when attending a health facility without a too-high health spending burden.

320 Figure 6.71 Percentage of health spending in relation to household spending by decile group, 1996, 2002, 2004, 2007 and 2009

Percentage 4.5 4 3.5 3 2.5 2 1.5 1 Decile 1 2 3 4 5 6 7 8 9 10 1996 2.3 2.5 3.0 2.6 2.7 2.7 2.6 2.6 2.6 4.0 2002 1.3 1.5 1.7 1.8 1.8 2.1 1.8 2.1 2.0 2.7 20041.5 1.4 1.5 1.9 1.8 2.1 1.8 2.1 2.0 2.7 2007 1.0 1.1 1.3 1.6 1.6 1.5 1.5 1.5 1.9 2.5 2009 1.0 1.1 1.3 1.5 1.8 1.5 1.7 1.8 1.7 2.3

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from householdsû socio- economic survey, 1996›2009. National Statistical Office. Table 6.25 Proportion of health spending in relation to household income, based on household spending, by decile group, 1996›2009 Proportion of spending in various income decile group (based on household spending) 1st›10th decile Year 12345678910group difference 1996 2.3 2.5 3.0 2.6 2.7 2.7 2.6 2.6 2.6 4.0 0.6 1998 1.5 1.7 2.0 2.3 2.4 2.4 2.6 2.5 3.0 2.6 0.6 2000 2.1 2.2 2.5 2.6 2.5 2.9 2.7 2.6 2.4 2.7 0.8 2002 1.3 1.5 1.7 1.8 1.8 2.1 2.0 2.0 2.1 2.9 0.4 2004 1.5 1.4 1.5 1.9 1.8 2.1 1.8 2.1 2.0 2.7 0.6 2006 1.1 1.6 1.5 1.6 1.8 1.8 1.8 1.6 2.2 2.7 0.4 2007 1.0 1.1 1.3 1.6 1.6 1.5 1.5 1.5 1.9 2.5 0.4 2008 1.0 1.1 1.3 1.5 1.4 1.6 1.4 1.5 1.6 2.2 0.5 2009 1.0 1.1 1.3 1.5 1.8 1.5 1.7 1.8 1.7 2.3 0.4 Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from householdsû socio- economic survey, 1996›2009. National Statistical Office.

321 In addition, it was found that, in 2004, most people including the low-income group had a low proportion of health spending in relation to household income, i.e. 82% of the poorest had a health spending lower than 5% of their household income and 94% of the richest also had a health spending lower than 5% of their household income. In 2008, a larger proportion of the poorest had the health spending lower than 5%, while a smaller proportion of the richest had the health spending lower than 5%. That means the poor had a lower burden of spending; in other words, the proportion of people spending less than 5% increased and such a proportion was close to that of the richest, i.e. 90% of households in each group (Table 6.26). Table 6.26 Percentage of households classified by percentage of household health spending in 10 decile groups, 2004 and 2008

Decile Health spending as percentage of household income 0 - 5 % 6 - 10 % 11 - 20 % 21 - 30 % 31 - 40 % 41 - 50 % Over 50 % 2004 2008 2004 2008 2004 2008 2004 2008 2004 2008 2004 2008 2004 2008 1 82.2 89.1 7.3 4.5 4.7 3.7 1.2 1.4 0.3 0.7 1.0 0.3 0.8 0.3 2 91.4 89.6 5.2 5.6 1.9 2.7 0.7 1.3 0.3 0.4 0.4 0.2 0.4 0.1 3 92.2 90.9 4.6 5.2 2.2 2.7 0.3 0.6 0.1 0.5 0.1 0.1 0.5 0.0 4 92.2 90.1 5.0 6.2 1.7 2.4 0.4 0.7 0.3 0.3 0.2 0.2 0.2 0.1 5 92.2 89.7 4.8 5.8 1.9 2.2 0.4 1.2 0.3 0.5 0.2 0.3 0.2 0.2 6 92.5 91.2 4.7 5.0 1.8 2.4 0.6 0.8 0.2 0.3 0.04 0.1 0.1 0.1 7 94.2 92.3 3.1 4.2 1.7 1.7 0.4 1.1 0.2 0.5 0.03 0.2 0.4 0.2 8 94.6 91.2 2.9 5.0 2.0 2.4 0.3 0.5 0.1 0.6 0.1 0.1 0.03 0.3 9 94.5 91.0 2.8 5.1 1.6 2.8 1.0 0.5 0.02 0.3 0.0 0.2 0.1 0.2 10 94.0 89.2 3.9 5.9 1.5 2.6 0.4 0.8 0.01 0.7 0.0 0.3 0.1 0.4 Total 92.0 90.4 4.4 5.3 2.1 2.6 0.6 0.9 0.2 0.5 0.1 0.2 0.3 0.2

Source: Suphon Limwattananond and Vuthiphan Vongmongkol. Analysis of data from householdsû socio- economic survey, 1996›2009. National Statistical Office.

When considering the proportion of households facing catastrophic health spending (health spending more than 10% of overall household spending), it was found that, before the launch of the universal health-care scheme, such a proportion had a rising trend, but with the universal health care, such a proportion dropped from 5.97% in 1996 to 3.29% in 2009, and the disparity between the richest and the poorest households declined from 0.57-fold in 1996 to 0.25-fold in 2009 (Figure 6.72 and Table 6.27).

322 Figure 6.72 Proportion of households facing catastrophic health spending, 1996›2009

Percentage 10

8 5.97 5.75 6 5.31 4.06 4.08 3.85 4 3.24 3.13 3.29

2

0 Year 1996 19971998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Vuthiphan Vongmongkol. Analysis of data from householdsû socio-economic survey, 1996›2009. National Statistical Office. Note:A household facing catastrophic health spending means a household that has a health spending of 10% or more of the health household spending. Table 6.27 Proportion of households facing catastrophic health spending based on household spending by decile group, 1996›2009 Income decile (based on household spending) 1st›10th decile Year 12345678910Total group difference 1996 4.62 5.28 7.27 5.15 6.06 5.63 5.85 5.92 5.72 8.07 5.90 0.57 1998 3.01 3.00 4.28 4.48 4.95 5.52 6.37 6.13 8.52 6.80 5.31 0.44 2000 5.19 4.57 5.52 5.99 5.61 6.40 6.03 6.26 4.85 7.06 5.75 0.74 2002 1.93 2.33 3.13 3.10 4.06 4.68 4.60 4.82 5.00 6.99 4.06 0.28 2004 2.87 2.25 2.53 4.23 3.75 4.59 3.74 4.54 5.14 7.17 4.08 0.40 2006 1.62 3.32 2.57 3.22 4.01 3.68 4.54 3.79 4.97 6.81 3.85 0.24 2007 1.88 1.66 2.20 2.76 3.74 3.21 3.19 3.32 4.53 5.87 3.24 0.32 2008 1.77 2.21 2.72 3.20 2.60 3.80 3.07 3.30 3.72 4.95 3.13 0.36 2009 1.37 1.52 2.54 2.97 4.50 2.96 3.72 4.00 3.91 5.41 3.29 0.25 Source: Vuthiphan Vongmongkol. Analysis of data from householdsû socio-economic survey, 1996›2009. National Statistical Office. Note:A household facing catastrophic health spending means a household that has a health spending of 10% or more of the health household spending.

323 324 CHAPTER 6 Health Service Systems in Thailand

The health service systems in Thailand have continuously developed in terms of capacity building for health services, particularly the increases in health resources, including human resources for health, expan- sion of health facilities, medical technology and equipment, and health financing. There are three major components of health service systems, namely: (1) inputs of health service systems, (2) health services delivery, and (3) capacity of health service systems, which are the outputs of health service systems. The inputs include management mechanisms, health resources, and health financing, which affect health service delivery and capacity of health service systems (Figure 6.1)

Figure 6.1 Relationships of inputs, health service delivery and capacity of health service systems

Capacity of health service Inputs Service delivery systems Management - Health policy - Organization structure - Support system and mechanism - Participation Capacity of health service Health resources systems Health services delivery - Health workforce - Access to services - Levels of health services - Coverage of services - Health facilities - Efficiency of service - Medical supplies and - Types of services systems equipment - Quality of services - Body of knowledge - Equity in services

Health financing - Public sector - Private sector - Household sector

239 Chapter 6 deals with the information about health resources, health financing and capacity of health service systems in seven parts, i.e. (1) health workforce, (2) health facilities, (3) health technology, (4) health expenditure, (5) accessibility to health services, (6) efficiency and quality of health services delivery, and (7) equity in health services, as detailed below: 1. Health Workforce Health workforce is an input that is extremely important for health service systems. The production of health personnel has been undertaken continuously, resulting in an increase in the number of health personnel and their distribution to various health facilities within and outside MoPH. However, there are some problems in this regard, particularly the inadequacy of health personnel, compared with the suitable standard, the problem of distribution to cover all geographical areas, and the quality of personnel, which might be associated with personnelûs workloads. In analyzing the health workforce situation, the following aspects are taken into consideration: quantity of existing personnel, production situation, loss situation and distribution situation, as shown in Figure 6.2.

Figure 6.2 Aspects in the analysis of health workforce situation

Quantity of existing health Production and workforce development of - by type of personnel Loss of health personnel health workforce - by expertise - by service facility

Distribution of health workforce - Distribution by geographical region - Distribution by level of service

1.1 Situation and Trends in Quantity of Health Workforce 1.1.1 Trends in Ratio of Population to Health-care Provider by Type of Personnel The overall situation of health workforce during the past period, using the ratio of population to health-care provider, has shown that the trends in quantities have been improving steadily (Figure 6.3).

240 Chapter 7 Governance of Thailandûs Health Systems

The enactment of the National Health Act, B.E. 2550 (2007), was a major turning point in the Thai health system in the movement towards its goal by expanding from the medical and public health sector to all sectors in society in an çAll for Health and Health for Allé approach as it has been generally recognized that çHealth system Governanceé is a major component in directing and monitoring the health system in a more desirable direction. 1. The National Health System According to the 2007 National Health Act (Government Gazette, Vol. 124, Part 16 A, 19 March 2007), çhealth means the state of human being which is perfect in physical, mental, intellectual and social aspects, all of which are holistic in balance,é and çhealth system means overall relations in connection with healthé. çPublic health systemé means the management of activities related to disease prevention, curative care, health promotion and medical rehabilitation (Public Health Encyclopedia, 1988) and çpublic health serviceé means any service relating to health promotion, prevention and control of diseases and health threats, diagnosis and treatment of illness and rehabilitation of person, family and community. In summary, the çnational health systemé means various systems that cover the operations of health activities in all dimensions, while the public health system and the public service system are parts of the national health system, as diagrammatically shown in the figure below. Figure 7.1 Scope and meaning of health system

1. Public health for individual Health 2. Public health service for non-individual 3. Activities in other sectors aimed at health 4. All activities affecting health

Source: National Health Act, B.E. 2550 (2007).

325 As prescribed in the National Health Act, çHealth Systemsé cover the definitions in the 1st through 4th levels, while çPublic Health Systemé, which is a subsystem, covers the 1st, 2nd and 3rd levels, and çHealth Care/Service Systemsé cover the 1st and 2nd levels. 2. Components of the National Health System In drafting the National Health Bill, efforts were made to set up components of the health system in a comprehensive and coordinated fashion so as to obtain a desirable national health system. The components of the overall health system are divided into 10 sub-systems as shown in Figure 7.2:

Figure 7.2 Components of health system

10 2 Health financing Health promotion 9 system system 3 Prevention and control Health manpower of diseases and health system 1 threats system 4 8 Health information Health policy and Public health and communication services and system strategy system quality control system Health know- Local health ledge generation wisdom system and management Health consumer 5 system protection system 7 6

Source: Modified from the National Health Act, B.E. 2550 (2007).

2.1 Health Policy and Strategy System Health policy and strategy include healthy public policy and public health policy. For empow- ering individuals, families, communities and society, and reducing social inequalities and injustice, the formu- lation process requires cooperation of all partners concerned; and all sectors in society are to be encouraged to take responsibility for health, integrating interdisciplinary knowledge and technology.

326 Regarding the mechanism for developing health policies and strategies, the National Health Commis- sion will coordinate with the governmentûs policy and strategy formulation agency as well as other public and private health agencies and ensure that collaborative efforts are made at the health policy-making and strategic planning levels. 2.2 Health Promotion System A health promotion system means a system established according to the broad definition as per the Ottawa Charter which views health promotion as a role of all sectors in society to develop healthy public policy, develop environments conducive to health, strengthen the community, develop personal skills, and reorient health service systems. 2.3 System for Prevention and Control of Diseases and Health Threats This system aims to decrease morbidity, mortality and disability, and to eliminate health threats, in an effective and timely manner, based on current knowledge and facts as well as the systematic approach of integrated technical and managerial operations. It focuses on the prevention and control of health threats that cause illnesses in minimizing health impacts from physical, biological and chemical factors (including infectious agents) in society. 2.4 System of Public Health Services and Quality Control The system of public health services and quality control in Thailand has been developed based on the concept of state-funded universal health care and the concept of risk-sharing health insurance, aimed at preventing catastrophic health spending, as well as the concept of peopleûs self-reliance and participa- tion. It aims to make all the people get access to basic/essential health services in an equitable manner, or universal coverage of health care. This is to provide health services in a thorough and equitable manner with a mechanism for ensuring efficiency and cost-containment. Moreover, the system has to cover self-care at the individual, family and community levels, emergency services, primary care, secondary services and tertiary services, specialized services and emergency medical services. Besides, there must be systems for development and accreditation of service standards and quality, and for assessment of health technologies that will be appropriately used in health services delivery. 2.5 System for Promotion, Support, Utilization and Development of Local Health Wisdom including Thai Traditional, Indigenous and other Alternative Medicine In the past, local health wisdom was not systematically organized whereas present- day medi- cal and health technologies have considerably advanced, resulting in local health wisdom being given less importance or missing. But when the health situation has changed, local health wisdom or non-mainstream medical care has been revised and become a new alternative. The local health wisdom system includes know- ledge, thoughts, beliefs, and expertise in health care accumulated from practices and experiences. The promo- tion and support of the utilization and development of local health wisdom have to be in line with local

327 lifestyle, tradition and culture in response to the self-reliance principle or that there will be several health-care options. 2.6 Consumer Protection System Consumer health protection means any operation undertaken to provide protection for the people as consumers of health services/products in a safe and fair manner. So, there must be comprehensive systems for all relevant operations in this regard which include the systems for: health professional standard development, public health service standard development, health product standard development, information dissemination, complaint acceptance, inspection, mediation, and remedies in case of damage. The designs of such systems must be based on peopleûs rights so that they will live together in harmony, which is a significant characteristic of Thai society. In addition to the aforementioned systems, the promotion and support of peopleûs system of consumer protection is essential through empowerment of non-governmental organizations working on consumer health protection in parallel with public sectorûs efforts. This is to supplement each other and set up a system of checks and balances. 2.7 Health Knowledge Generation and Dissemination Over the past two decades, Thailand has placed importance on the generation and dissemina- tion of knowledge about health. Several agencies have been established such as the Thailand Research Fund (TRF), the National Science and Technology Development Agency (NSTDA), the Health Systems Research institute (HSRI), the Thai Health Promotion Foundation (ThaiHealth), and the National Health Security Office (NHSO). As a result, there has been a paradigm shift in health research in a systematic manner. More initiatives have been undertaken for health promotion. Therefore, in the future there should be a mechanism for setting directions, and policies for research and knowledge management in a systematic manner so that the capacity of health system will be enhanced with decreased costs and more efficient results. 2.8 Health Information Dissemination System A system for dissemination of health information is to be designed and developed in such a way that it is adequate and easily accessible to the people; and the information system has to be developed so that it is up to date, thorough, timely and easily accessible to the public in an easily understandable fashion. 2.9 System for Production and Development of Public Health Personnel This system covers subsystems of policy and production planning, production operations, development, and retention of public health personnel: and the system requires specific knowledge and management so that it is efficient, of good quality, and able to produce personnel according to the needs of the health system. Much of the public health personnel production is under the national educational system, partly under the Ministry of Public Health and the private sector. Thus, a national system and mechanism

328 should be established to coordinate the formulation of policies and plans in this regard. 2.10 Health Financing System Health financing means the financial management for health such as the use of tax measures to promote elderly care in the family, the promotion of private businesses to take care of their employeesû health, the promotion of healthy environments, and the use of tax measures for tobacco and alcohol consump- tion control. It also includes the management of public finance for the provision of universal coverage of health services. Thailand has had programmes on health financing for a long time based on the çbuilding health leads fixing healthé policy, using both financial and tax measures such as raising alcohol and tobacco taxes and legislating a health promotion foundation law which collects 2% of excise taxes on alcohol and tobacco for use in funding health promotion activities. 3. Mechanism for Governance of National Health System In the past, when mentioning of mechanisms for the governance of the national health system, they were normally referred to as those under the Ministry of Public Health, other agencies, health educational institutions, health non-governmental organizations, for instance. But at present, the social context has changed considerably with new mechanisms taking part in health activities (Figure 7.3).

329 Figure 7.3 Linkages of governance mechanisms in the national health system

Parliament

NESAC NESDB Cabinet

Making NHC&NHCO ThaiHealth Manag- recommenda- ing Ministry of Public Health health tions on Generating HSRI and other ministries NHSO health system working on health promo- policies and Managing health security fund tion fund strategies HAI Implementing health EMIT Statute on Provincial adminis- national tration agencies health system Health Networks of assembly health civil - Academic society and and partners Local administration profes- organizations sional networks Networks of the Other mass media networks Notes: NESAC = National Economic and Social Advisory Council EMIT = Emergency Medical Institute of Thailand NESDB = National Economic and Social Development Board NHSO = National Health Security Office NHC = National Health Commission HSRI = Health Systems Research Institute NHCO = National Health Commission Office ThaiHealth = Thai Health Promotion Foundation HAI = Healthcare Accreditation Institute

As shown in the figure above the MoPH is the principal mechanism of the national health system and has public health agencies at all levels located across the country. In all such efforts, other ministries also play a role in health-related activities in various dimensions in a coordinated fashion, including for example the National Economic and Social Development Board, the Ministry of Interior, the Ministry of Education, the Ministry of Social Development and Human Security, and the Ministry of Labour. In addition, there are other independent mechanisms, some under the supervision of the MoPH, some are not, including: the Thai Health

330 Promotion Foundation (ThaiHealth), responsible for the management of the Health Promotion Fund support- ing all sectors in society to widely carry out health promotion activities in all dimensions; the National Health Security Office (NHSO), responsible for the management of the National Health Security Fund for providing essential health services to the people; the Health Systems Research Institute (HSRI), responsible for the management of funds for supporting the creation and management of knowledge for health; the Healthcare Accreditation Institute (HAI), responsible for the promotion and support of health service quality development in hospitals and other kinds of health facilities; and the Office of the National Health Commission, responsible for making recommendations on health policies and strategies to the government and all sectors in society using the participatory approach involving all concerned in the policy and strategy movement process. Besides, at the local level there are local government organizations such as the Bangkok Metropolitan Administration, Pattaya City, provincial administration organizations, municipalities, and Tambon (subdistrict) administration organizations, totalling more than 7,000 nationwide in number, each responsible for a wide variety of health activities according to the intent of the 2007 constitution and other relevant laws. It is obvious that mechanisms involving health are numerous and different in their missions and they are not under the supervision of the MoPH; rather, they have to work collaboratively in a pluralistic society. However, the MoPH has to play a key role in coordinating the efforts of all agencies to create synergy and move forward the actions of all subsystems towards the achievement of the common goal of health for all. In this connection, the MoPH has to decrease its role as an operator only for essential activities and promote as well as support other organizations and mechanisms to function as operators to the maximum extent possible. 4. Agencies Implementing Health Programmes 4.1 Ministry of Public Health The MoPH is the core agency in the Thai public health system that implements health programmes with a budget share of more than 60%, almost all of which for rural health activities throughout the country. It takes the lead in health-care delivery, sets public health policies for the country and oversees health services in the private sector. Its major developments and administrative system are as follows: 4.1.1 Evolution of the MoPH, 1888›present and Future Trends The development of the MoPH began in 1888 when at that time it was the Department of Nursing under the Ministry of Education. It became the Public Health Department under the Ministry of Interior in 1918, until the establishment of the Ministry of Public Health on 10 March 1942, according to the Reorganization of Ministries, Sub-Ministries and Departments Act (No. 3) of B.E. 2485 (1942). Since then there have been several reorganizations, the first in 1972, the second in 1974, the third in 1992, and the fourth in 2002. In 2006, the MoPH prepared a proposal on its mission and structure, and formally in 2009, the Ministerial Regulation on MoPH Reorganization was issued (Figure 7.4) so that it can efficiently improve the health status of Thai people.

331 Figure 7.4 Evolution of the Ministry of Public Health, 1888-present

Department of Nursing Ministry of Education 1888-1904

Hospitals under Ministry of City Affairs; King Rama V Siriraj Hospital and other divisions under Ministry of Education 1905-1907 First Era Department of Local Administration (Phalamphang) and Department of Nursing, Ministry of Interior 1908-1915

Department of Public Protection Ministry of Interior 1916-1917 } Kings Rama VI & VII Department of Public Health Ministry of Interior Second Era 1918-1941

Ministry of Public Health Affairs Kings Rama VIII 1942-1951 Third Era Ministry of Public Health 1952

Reforms of Ministry of Public Health ● 1st reorganization, 1972 Fourth Era ● 2nd reorganization, 1974

Reorienting the role of MoPH Fifth Era ● 3rd reorganization, 1992 Kings Rama IX

● Health system reforms, 2000 ● 4th reorganization, 2002 ● Proposition on reorganization and Sixth Era restructuring of MoPH, 2006 ● Ministerial regulation on MoPH reorganization, 2009

332 The Future Trends. The MoPH, especially agencies at the central administration level, will become smaller and serve as a mechanism in setting health policies and strategies, controlling, monitoring and setting standards, and coordinating with all other relevant sectors in society to jointly work on health in a systematic manner. Its roles as implementers will be decreased to perform only essential functions as almost all of the budget for health services delivery has been transferred to the National Health Security Office, which will make payments directly to health-care facilities (without passing through the MoPH since May 2006). As for provin- cial administration agencies, their structures and roles have to be revised according to the administrative and financial changes in relation to the policies on public sector reform, decentralization and NHSOûs financial management. 4.1.2 Authority and Administrative Structure of Ministry of Public Health 1) Authority and Mandate of MoPH The Reorganization of Ministries, Sub-Ministries and Departments Act of B.E. 2545 (2002) provides that çthe Ministry of Public Health has powers and responsibilities related to the promotion of health, prevention/control and treatment of diseases, and rehabilitation of peopleûs health, as well as other official functions as provided by laws which indicate that such functions are under the responsibility of the Ministry of Public Healthé. Its principal purpose is to make all Thai citizens healthy, physically and mentally, with good quality of life, being able to live a happy life in society and being valuable resources of the country. 2) Administrative Structure The administrative structure of the MoPH is divided into two levels: central administration and provincial administration. (1) The Central Administration (Figure 7.5) is composed of 10 agencies: (1) the Office of the Minister, (2) the Office of the Permanent Secretary for Public Health and (3) three clusters with eight departments as follows: - Cluster of Medical Services Development, comprising three departments: Depart- ment of Medical Services, Department for Development of Thai Traditional and Alternative Medicine, and Department of Mental Health. - Cluster of Public Health Development, comprising two departments: Department of Disease Control and Department of Health. - Cluster of Public Health Service Support, comprising three departments: Depart- ment of Health Service Support, Department of Medical Sciences, and Food and Drug Administration. Besides, there are other agencies as follows: - State-supervised agencies, under the supervision the Public Health Minister who serves as chairperson of the executive board and the Permanent Secretary as a board member ex officio, totalling three agencies: Health Systems Research Institute, National Health Security Office and Emergency

333 Medical Institute of Thailand. - State enterprise (1): Government Pharmaceutical Organization - Public organizations (2): Healthcare Accreditation Institute (Public Organization) and state health facilities (regional/general/community hospitals and health centres) that are ready to become such an organization; at present, there is only one hospital, Banphaeo Hospital in . In 2007, of the National Health Commission Office was established according to the National Health Act of B.E. 2550 (2007) as a juristic person under the supervision of the National Health Commission chaired by the Prime Minister. Its key role is to coordinate with other state agencies responsible for policy and strategy formulation as well as other health-related public and private agencies in carrying out efforts at the policy, strategy and programme level for health. And it also organizes sessions of national health assembly, area-based health assembly and issue-based health assembly, in addition to developing healthy public

334 Deputy Permanent Secretary

Cluster of Public Health Service Support

Department of Health Service Support Bureau of Administration Bureau of Sanatorium and Art of Healing Division of Design and Construction Medical Engineering Division Primary Health Care Division Health Education Division Department of Medical Sciences Office of the Secretary Division of Planning and Technical Coordination Regional Medical Sciences Centres 1-12 Institute of Biological Products National Institute of Health Medicinal Plant Research Institute Bureau of Food Quality and Safety Division of Cosmetics and Hazardous Substances Bureau of Radiation and Medical Devices Bureau of Laboratory Quality Standards Bureau of Drugs and Narcotics Food and Drug Administration Office of the Secretary Medical Device Control Division Narcotics Control Division Technical and Planning Division Public and Consumer Affairs Division Rural and Local Consumer Health Products Protection Promotion Division Bureau of Cosmetic and Hazardous Substance Control Import and Export Inspection Division Bureau of Drug Control Bureau of Food Control

------

●

●

●

National Health Commission Office

Offce of the Minister

Deputy Permanent Secretary

Healthcare Accreditation Institute

Health facilities (Royal decree enacted for Banphaeo Hospital)

Cluster of Public Health Development

Public organizations - -

Department of Disease Control Office of the Secretary Personnel Division Finance Division Planning Division Bamrasnaradura Institute Rajprachasamasai Institute Office of Alcohol Control Committee Offices of Disease Prevention and Control 1-12 Bureau of Occupational and Environment Diseases Bureau of General Communicable Diseases Bureau of Vector-Borne Diseases Bureau of Non-communicable Diseases Bureau of AIDS, TB and STIs Department of Health Office of the Secretary Personnel Division Finance Division Planning Division Health Impact Assessment Division Division of Physical Activities and Health Regional Health Promotion Centres 1-12 Bureau of Dental Health Bureau of Nutrition Bureau of Food and Water Sanitation Bureau of Health Promotion Bureau of Reproductive Health Bureau of Environmental Health

------

●

- Bureau of Epidemiology

●

Ministry of Public Health

- National Cancer Institute

- Government Pharmaceutical Organization

State enterprise:

Deputy Permanent Secretary

Cluster of Medical Service Development

Councils

Ministerial Regulations of the Ministry of Public Health, 2009

Professional

Department of Medical Services Office of the Secretary - Finance Division Mettapracharak Watraikhing Hospital Institute of Medical Research and Technology Assessment Rajavithi Hospital - Lerdsin Hospital Priest Hospital Sirindhorn National Medical Rehabilitation Centre Institute of Dentistry - Institute of Pathology Prasat Neurological Institute

Department for Development of Thai Traditional and Alternative Medicine Office of the Secretary Thanyarak Institute - Chest Disease Institute Institute of Thai Traditional Medicine Institute of Dermatology Institute of Alternative Medicine The Supreme Patriarch Centre on Ageing Department of Mental Health Queen Sirikit National Institute of Child Health Office of the Secretary Bureau of Human Resource Management Personnel Division Bureau of Strategy Finance Division Planning Division Social Mental Health Division Srithunya Psychiatric Hospital Mental Health Regional Centres 1-12 Galyarajanagarindra Institute Somdet Chaopraya Institute of Psychiatry Rajanukul Institute Mental Health Technical Development Bureau

Public organizations and state-supervised agencies are under the supervision of the MOPH, but not under any of the clusters.

● ------

------● ------

●

- Nopparat Rajathanee Hospital

Source: Note:

Organization chart of Ministry of Public Health

Permanent Secretary

Office of the Permanent Secretary The Central Administration Bureau of Central Administration Information and Communication Technology Centre Health Workforce Development Bureau of Nursing Bureau of Inspection and Evaluation Bureau of Policy and Strategy Bureau of Health Administration

State-supervised agencies

● - - - - Praboromarajchanok Institute of - - - -

The Provincial Administration - Provincial Public Health Offices - District Health Offices

- Health Systems Research Institute - National Health Security Office - Emergency Medical Institute of Thailand

Figure 7.5

335 policies and conducting health impact assessments. (3) The Provincial Administration (Figure 7.6) Public health agencies under the provincial administration are Provincial Public Health Offices, hospitals under the MoPH, District Health Offices, and health centres. Since FY 2004, the government has changed the role of each provincial governor as chief executive officer (CEO) administering all activities within his/her jurisdiction on an integrated manner, aimed at achieving the state mission for the maximum benefit of the people. Thus, the Provincial Public Health Office in each province, which reports to the provincial governor, has to take part in resolving health problems at the local level, serving as one of the provincial administrators, with technical support from the MoPH. In implementing the governmentûs policy on universal healthcare, the MoPH has directed all hospitals and health centres to set up primary care units (PCUs) or community health centres to take charge of health service delivery in a holistic and integrated manner. This is to continue providing health services to the people and community with the systems for home visits, counselling and referrals. Under the universal healthcare system, each provincial and district (community) hospital will serve as a çcontracted unit for primary care or CUPé and subdistrict health centres will be provided with resources from the hospital, but they are still under the supervision of the District Health Officer in their district. In 2010, there were 311 PCUs and 9,768 subdistrict health centres across the country, all being very close to the people In the meantime, the government has set a clear policy on upgrading subdistrict health centres as çsubdistrict or tambon health promoting hospitals (THPHs)é. Since 2010, 2,000 health centres have

336 Figure 7.6 Organogram of Provincial Public Health Administration

Ministry of Public Health Ministry of Interior Permanent Secretary Permanent Secretary

Technical Departments Office of the Provinces Director-Generals Permanent Secretary Governors

Regional Centres Provincial Public Health Offices Provincial Chief Medical Officers (75)

Regional & General Hospitals Community Hospitals Districts District Chief Directors (94) Directors (734) Officers

District Health Offices District Health Officers (878)

Primary Care Units Subdistrict Health Centres Community Health Posts

311 PCUs (THPHS) (151) Chiefs (9,768) Community Health Workers

Community Primary Health Care Centres (48,049 centres) Line of command Village Health Volunteers Line of technical support

337 4.1.3 Health-related Laws There are a number of laws relating to health in the form of acts, ministerial regulations, rules, by-laws and procedures as follows: 1) Acts under the responsibility of the MoPH (4 categories and 23 acts) are listed in Table 7.1.

Table 7.1 Acts under the direct responsibility of the Ministry of Public Health

No. Act 1 Acts related to public health service systems (4) 1.1Sanatorium Act, 1998 1.2Protection and Promotion of Thai Traditional Medicine Wisdom Act, 1999 1.3Government Pharmaceutical Organization Act, 1966 1.4Mental Health Act, 2008 2 Acts related to disease prevention and control (3) 2.1 Public Health Act, 1992, and Amendment No.2 (2007) 2.2 Communicable Diseases Act, 1980 2.3 Zoonoses Act, 1982 and Amendment No.2 (2001) 3 Acts related to consumer protection in health (11) 3.1 Food Act, 1979 3.2 Drugs Act, 1967; Amendment No.2 (1975), No.3 (1979), No.4 (1985), and No.5 (1987) 3.3 Cosmetics Act, 1992 3.4 Hazardous Substances Act, 1992 and Amendment No. 2 (2001) and No.3 (2008) 3.5 Psychoactive Substances Act, 1975; Amendment No.2 (1985), No.3 (1992) and No.4 (2000) 3.6 Narcotics Act, 1979; Amendment No.2 (1985), No.3 (1987), No.4 (2000), and No.5 (2002) 3.7 Medical Devices Act, 2008 3.8 Emergency Decree on Prevention of Volatile Substance Abuse, 1990; Amendment No.2 (2000) and No.3 (2007) 3.9 Tobacco Product Control Act, 1992 3.10 Non-smokersû Health Protection Act, 1992 3.11 Alcohol Beverage Control Act, 2008 4 Acts related to health professions (5) 4.1Practice of the Art of Healing Act, 1999, and Amendment No.2 (2004) and No.3 (2007) 4.2 Medical Profession Act, 1982 4.3 Nursing and Midwifery Profession Act, 1985; Amendment No. 2 (1997) 4.4Pharmaceutical Profession Act, 1994 4.5Dental Profession Act, 1994

338 2) Acts that the MoPH is not directly responsible for their implementation, but shares responsibilities with other ministries such as the Office of the Prime Minister and the Ministry of Interior. (1) Cemeteries and Crematoriums Act, 1985 (2) Narcotic Addict Rehabilitation Act, 2002 (3) Rehabilitation of Disabled Persons Act, 1991 (4) Household and City Cleanliness and Orderliness Act, 1992 (5) Trade Secret Act, 2002 (6) Act Establishing Youth and Family Courts and Trial Procedures for Youth and Family Cases, 1991 (7) National Health Act, 2007 (8) National Food Commission Act, 2008 3) Other health-related acts and announcements under other ministriesû responsibilities. (1) Enhancement and Conservation of National Environmental Quality Act, 1992 (2) Industrial Works Act, 1992 (3) Social Security Act (No. 2), 1990 (4) Protection for Motor Vehicle Victims Act, 1992 (5) Workmenûs Compensation Act, 1994 (6) Labour Protection Act, 1998 (7) Act on Older Persons (2003) (8) Promotion of Social Welfare Act, 2003 4) Acts establishing state-supervised agencies or public organizations related to health. (1) Royal Decree on Establishing Banphaeo Hospital (Public Organization), 2000 (2) Health Systems Research Institute Act, 199.. (3) Thai Health Promotion Foundation Act, 2001 (4) Nation Health Security Act, 2002 (5) Emergency Medicine Act, 2008 (6) Royal Decree Establishing Healthcare Accreditation Institute, 2009 4.1.4 Programmes/Projects of the MoPH The MoPH implements programmes/projects under the National Economic and Social Development Plan and the government plan of action (see details in chapter 3) as well as the policies set by high-level administrators, i.e. the minister of public health and the permanent secretary for public health. In implementing such programmes/projects, though they are carried out in an integrated manner by provincial level agencies, resources and technical since are provided by central level agencies using a vertical support approach. So, collaboration among state agencies concerned needs to be strengthened.

339 4.1.5 Human Resources of the MoPH At present, approximately 80% of MoPH personnel are civil servants and approximately 17% are permanent employees (excluding temporary employees). Between 1999 and 2003, the proportion of civil servants steadily declined as there were more and more çstate employeesé. But in 2004, the cabinet passed a resolution on 11 May 2004 to convert 27,385 state employees of the MoPH to civil servants, resulting in the increase in the proportion of civil servants to 80.3% in 2009 as shown in Figures 7.7 and 7.8. In 2009, the MoPH had a workforce of 212,252, of which 170,336 (80.3%) were civil servants, 37,022 (17.4%) were permanent employees, and 3,893 (1.8%) were state employees; and for state-supervised agencies, there were 1,001 officials and employees (0.5% of the total workforce). For major MoPH agencies, the Office of the Permanent Secretary had the greatest proportion of personnel, i.e. 89.4% of all MoPH civil servants, 76.5% of all permanent employees, and 65.4% of all state employees; and the Department for Development of Thai Traditional and Alternative Medicine had the smallest (only 0.1% of all MoPH workforce), while the Department of Disease Control had similar proportions for both civil servants and permanent employees (Table 7.2). And in 2009, the MoPH recruited some state employees on contract so as to create flexibility in accordance with the modern state management procedures; so, at present there are altogether 3,893 state employees, most of whom are administrative and service support officials (Table 7.3).

340 Table 7.2 Numbers of civil servants, permanent employees, and state employees of MoPH and state- supervised agencies under MoPH, 2009

Civil servants State Permanent SSA officials SSA employees Total employees employees Department/Agency No. % No. % No. % No. % No. % No. %

Office of the Permanent 152,423 89.4 2,546 65.4 28,312 76.5 - - - - 183,281 86.35 Secretary (83.2) (1.4) (15.4) Department of Medical 7,071 4.2 242 6.2 2,411 6.5 - - - - 9,724 4.58 Services (72.7) (2.5) (24.8) Department of Health 1,917 1.1 169 4.3 1,434 3.9 - - - - 3,520 1.66 (54.5) (4.8) (40.7) Department of Disease 3,078 1.8 472 12.1 2,627 7.1 - - - - 6,177 2.91 Control (49.8) (7.6) (42.6) Department of Medical 988 0.6 42 1.1 240 0.6 - - - - 1,270 0.60 Sciences (77.8) (3.3) (18.9) Food and Drug 614 0.4 3 0.1 56 0.2 - - - - 673 0.32 Administration (91.2) (0.4) (8.4) Department of Mental 3,158 1.9 378 9.7 1,560 4.2 - - - - 5,096 2.40 Health (62.0) (7.4) (30.6) Department of Health 926 0.5 10 0.3 379 1.0 - - - - 1,315 0.62 Service Support (70.4) (0.8) (28.8) Department for Development 161 0.1 31 0.8 3 0.01 - - - - 195 0.09 of Thai Traditional and (82.6) (15.9) (1.5) Alternative Medicine Health Systems ------30 3.8 7 3.2 37 0.02 Research Institute (81.1) (18.9) National Health ------642 81.8 165 76.4 807 0.38 Security Office (79.6) (20.4) Emergency Medical ------47 6.0 44 20.4 91 0.04 Institute of Thailand (51.6) (48.4) Healthcare Accreditation ------66 8.4 - - 66 0.03 Institute (100.0) Total 170,336 100.0 3,893 100.0 37,022 100.0 785 100.0 216 100.0 212,252 100.0 (80.3) (1.8) (17.4) (0.4) (0.1) Sources:1.Bureau of Policy and Strategy, MoPH, October 2009. 2. State-supervised agencies (SSA) Notes:1.Figures for civil servants and permanent employees of all departments are based on the numbers of actually filled positions in October 2009. 2. Figures in parentheses are percentages of their respective horizontal lines (of their own depart- mental totals). 341 Table 7.3 Number of state employees of MoPH by professional category, 2009

Professional category Number of personnel 1. Finance and accounting analysts/supply analysts/internal auditors 737 2. Diseases control officers/public health officers/pharmacy technicians/ 353 service support officers 3. Statisticians/computer technical officers/computer system analysts 336 4. Professional nurses 302 5. Environmentalists/public health technical officers 172 6. General service/financial/supply/statistical/data recording officials 172 7. Vocational therapists/physical therapists 332 8. Medical technologists 333 9. Plan and policy analysts 191 10. Legal officers/experts 72 11. Social workers/psychologists 149 12. Human resources officers 143 13. Medical scientists/medical science technicians/sports scientists 82 14. Foreign relations officers/public relations officers/ 70 dissemination technical officers/audiovisual technical officers 15. General administration officers/project coordination officers 146 16. Nutritionists 56 17. Engineers/technicians: civil works/mechanical/electrical/ 65 communicative electrical 18. Radiological technologists/radiographer technicians/x-ray technicians 62 19. Researchers/research assistants 16 20. Librarians/library service officers 16 21. Medical photographers/cardiology technologists 18 22. Pharmacists 6 23. Medical officers 1 24. Thai traditional medicine practitioners 9 25. Dental assistants/dental technicians 8 26. Instructors/special educators 11 27. Entomologists 35 Total 3,893

Source: Bureau of Policy and Strategy, MoPH, October 2009

342 Figure 7.7 Numbers of civil servants, permanent employees, and state employees of MoPH and officials/ employees of state-supervised agencies under MoPH, fiscal years 1981›2009

Civil servants Permanent employees State employees Officials and employees of state-supervised agencies

No. of personol 180,000

170,336

169,622

169,561 169,025

161,464

156,862

155,762

154,001

154,199

151,866

160,000 151,473

151,923

147,168

139,966

167,674 140,000 168,738

129,393

129,485

125,226

123,996 120,000

106,708

104,428

100,000 97,459

90,113 Conversion of

82,896 state employees to

80,000 74,115 civil servants

65,721

63,850

61,476

51,240 60,000 51,540

50,997

50,461

49,563

48,263

48,175

47,939

46,345

46,668

45,741

46,697

45,089

44,955

43,193

44,028

43,023

43,000

43,201

43,040

41,930

41,539 41,074

40,529

39,894

39,530

38,356

37,022 40,000 37,505

21,422

21,507

15,472

1,990

15,258

2,354 20,000 3,893 8,766 1,001 1,001

1,195 768 1,001 0 Year

1981 1983

1985

1987

1989

1991

1993 1995

1997

1999

2001

2003

2005

2007 2008 2009

Sources: Data for 1981›1997 are derived from HEALTH DIARY of the National Health Association of Thailand. Data for 1998›2009 are derived from personnel divisions of all departments, MoPH. Notes: 1. For 1998 onwards, the data represent actually filled positions. 2. Since 2004, MoPH has converted all state employees to civil servants. 3. Since 2005, MoPH has had two categories of personnel by employment method, i.e. state employees and civil servants.

343 Figure 7.8 Proportions of civil servants, permanent employees, and state employees of MoPH and officials/ employees in state-supervised agencies under MoPH, fiscal years 1981›2009

Civil servants Permanent employees State employees Officials and employees of state-supervised agencies Percentage 90

80.3

80.2

80.1

79.6

79.6 80 79.3

75.8

75.7

75.1

74.3

74.4

73.5

73.5

73.2

73.4

72.8

70.8

70.8

70.8

70.6

69.5

69.2

69.3

67.7

70 66.4

64.1

62.4

62.1 60 61.5

50

38.5

37.9

37.6

40 35.9

33.6

32.3

30.7

29.2

29.2

26.8

26.6

26.5 30 26.5

25.7

25.6

24.9

24.3

24.2

23.2

22.3

22.1

21.1

20.7

20.4

20.3

19.4

19.0

18.2 20 17.4

9.8

9.9

7.1 10 7.1

1.8

1.1

0.9

4.1

0.5 0.4 0.5 0.5 0.5 0 Year

1981 2006

1984

1987

1990

1993

1996

1999

2002

2005

2007 2008 2009

Sources: Data for 1981›1997 are derived from HEALTH DIARY of the National Health Association of Thailand. Data for 1998›2009 are derived from personnel divisions of all departments, MoPH. Notes:1.For 1998 onwards, the data represent actually filled positions. 2. Since 2004, MoPH has converted all state employees to civil servants. 3. Since 2005, MoPH has had two categories of personnel by employment method, i.e. state employees and civil servants.

The workforce of the MoPH (excluding permanent/temporary employees, state employees, and officials/employees of state-supervised agencies) classified by major group/profession includes 170,336 offi- cials of actually filled positions (2009) in 4 major categories: executive, managerial, knowledge worker and general positions; most of them (73.9%) are in medical, nursing and public health professionals (Table 7.4).

344 Table 7.4 Workforce of the MoPH (excluding state employees permanent/temporary employees and offi- cials/employees of state-supervised agencies) by major group/profession: number and propor- tion of actually filled positions, 2009 Civil servants Group/Professional category No. % 1. Executive and managerial positions - Executives, inspector-generals 42 0.02 2. Managerial positions - General and specialized directors 1,097 0.6 3. Knowledge worker positions 3.1Medical nursing and public health professions 125,940 73.9 3.1.1 Medicine 11,391 6.7 3.1.2 Dentistry 3,357 2.0 3.1.3 Pharmacy 6,039 3.5 3.1.4 Professional nursing 79,084 46.4 3.1.5 Veterinary medicine 14 0.01 3.1.6 Medical radiology 587 0.3 3.1.7 Medical technology 1,336 0.8 3.1.8 Medical science 800 0.5 3.1.9 Physical therapy/ physical/ occupational/ vocational therapy/ audiology 559 0.3 3.1.10 Psychology/ chemical psychology 213 0.1 3.1.11 Nutrition 228 0.1 3.1.12 Public health 22,218 13.0 3.1.13 Food and drug 91 0.1 3.1.14 Nursing 23 0.01 3.2Other professions 4,134 2.4 3.2.1 Radiation physics 39 0.02 3.2.2 Prosthetics and orthotics/ medical photography 31 0.02 3.2.3 Academic art/ public relations/ dissemination/ audio- visual operation 76 0.04 3.2.4 Librarian 73 0.04 3.2.5 Instructor/ special education 238 0.1 3.2.6 Social welfare 356 0.2

345 µ“√“ß∑’Ë 7.4 (µàÕ)

Group/Professional category Civil servants No. % 3.2.7 Environment/ agriculture/ general management/ 2,470 1.5 human resources/ supply/ foreign relations/ finance and accounting/ internal audit/ statistics/ computer science 3.2.8 Legal affairs 157 0.1 3.2.9 Plan and Policy analysis 694 0.4 4. General positions 39,123 23.0 4.1 General service/ supply/ medical statistics/finance and accounting/ 7,794 4.6 fiscal operation/ computer operation/ agriculture 4.2 Dissemination/ public relations/ audio-visual technique/ 476 0.3 library service/ foreign relations/ graphic design/ photography 4.3 Dental health/ dental technician operation 4,380 2.6 4.4 Pharmacy 3,527 2.1 4.5 Nutrition 221 0.1 4.6 Medical radiology / medical science 4,064 2.4 4.7 Rehabilitation medicine/ vocational therapy/prosthetic-orthotic operation 567 0.3 4.8 Public health 12,474 7.3 4.9 Technical nursing 5,121 3.0 4.10 Survey / mechanical / electric / civil works technicians 499 0.3 Total 170,336 100.0

Source: Bureau of Policy and Strategy, MoPH, October 2009 Notes:1.According to the 2008 Civil Service Act, Section 45 prescribes that there are four categories of civil servant positions, namely executive positions, managerial positions, knowledge work positions and general positions; and in 2008, 245 class series in 8 professional groups were revised. 2. The number of hospital directors (828) under the MoPH has been included in the group of general and specialized directors.

346 Besides, since 1998, the government has implemented measures to downsize the public sector workforce such as not establishing new positions, except for an essential case, notifying of the positions that will be abolished due to retirement, abolishing vacant positions of permanent employees, and early retirement for civil servants. Such measures have resulted in the shortage of workforce in the MoPH. However, as the MoPH has to implement the universal healthcare scheme, temporary employees have to be hired with the government budget on a service contract basis and non-government budget has to be used. Between 2005 and 2009, it was found that the number of temporary employees increased by 35.7% from 84,341 to 114,494; the largest number was in the Office of the Permanent Secretary because there were increased health service workloads at health facilities under the universal healthcare policy, while the smallest number was noted for the Department for Development of Thai Traditional and Alternative Medicine (Table 7.5). When considering the proportion of all kinds of personnel of the MoPH including temporary employees for the period 2005›2009, the proportions for civil servants and permanent employees declined from 56.5% and 14.5% in 2005 to 52.1% and 11.3% in 2009, respectively, while the proportion of temporary employees rose from 28.4% to 35.0% for the same period (Figure 7.9).

Table 7.5 Number of temporary employees in MoPH agencies, 2005›2009 No. of employees Year OPS DMS DoH DDC DMSc FDA DMH DHSS DTAM Total 2005 NA NA NA NA NA NA NA NA NA 84,341 2006 NA NA NA NA NA NA NA NA NA 84,106 2007 75,539 6,135 505 842 937 469 1,922 9 - 86,358 2008 93,897 7,887 508 814 1,010 405 1,907 9 - 106,437 2009 102,833 6,594 549 908 1,013 546 1,963 47 41 114,494

Source: Data for 2005›2006, from Report on public sector workforce, Office of the Civil Service Commission. Data for 2007›2010, from Report on health resources, Bureau of Policy and Strategy, MoPH. Notes:1.Temporary employee means an employee hired with the government budget on a service- contract basis and with non-government budget. 2. No data were available before 2005.

347 Figure 7.9 Proportions of all kinds of personnel of MoPH (including temporary employees), fiscal years 2005›2009

Civil servants Temporary employees Permanent employees Officials and employees of state-supervised State employees agencies Percentage 60 53.3 52.1 57.1 50 56.5 56.7

40 33.6 35.0 28.3 30 28.4 28.8 20 14.5 13.8 13.5 12.1 11.3 10 0.3 0.4 0.7 0.7 1.2 0 0.3 0.3 0.3 0.3 0.3 Fiscal year 2005 2006 2007 2008 2009

Sources:- Personnel divisions of all departments, MoPH. - Report on health resources, Bureau of Policy and Strategy, MoPH.

4.1.6 The Budget of the Ministry of Public Health 1) Proportion of the Budget The proportion of annual budget allocated to the MoPH was 2.7›9.5% of the national budget during 1969-2011 (Figure 7.10) or approximately 0.4-1.6% of the gross domestic product (GDP). It can be noted that the MoPH's budget has increased significantly during the past decade, as the government has allocated more budget to the social service sector from 6.5% in 1993 to 10.1% in 2011, due to a decrease in foreign debt repayments and a lower proportion of security expenditure (Figure 7.12) and the implementation of the universal healthcare policy (Figure 7.11). In FY 2011, the budget of 87,567.5 million baht is allocated for the MoPH plus a health insurance revolving fund of 101,057.9 million baht, totalling 188,625.4 million baht, or 9.1% of the national budget (Figure 7.10). In real terms, the value of the budget for the post-economic crisis period (1998- 2001) was less than that for 1996. It is noteworthy that there were large amounts of foreign loans during 1997- 2001. But since the launch of the universal healthcare scheme in 2002, the value of the budget for 2002›2011 is 1.1›2.2 times higher than that for 1996 (Table 7.6).

348 Figure 7.10 Amounts and proportions of MoPHûs budget compared with the national budget (present value), FYs 1969›2011

National budget MoPHûs budget MoPHûs budget as a Percentage of national budget Million baht Percentage

2,200,000 9.5 10 2,070,000

1,951,700

2,000,000 8.6 9 8.3 9.1 1,800,000 7.9 7.8 8 7.2 6.9 6.9 1,600,000 6.7 7

1,400,000 1,700,000 5.8 1,660,000 6 1,200,000 4.8 1,566,200 4.5 1,023,000 5 1,000,000 4.2 4.0 4.2 1,360,000

832,200

825,000 1,250,000 4 800,000 3.4 3.2

560,000 3 600,000 2.7

400,000 335,000 2

227,500

192,000

161,530.4

153,133.8

48,677

140,000

142,113.6

129,683.3

107,100.8 1

85,914.4

81,000

200,000 70,923.2

59,227.30

55,861.20 29,000 1,533.40

32,898.10 188,625.4 23,960 8,617.60 16,225.10 0 0 Year 643.50 986.60 3,405.805,571.80 9,525.10 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005

2008 2009 2010 2011

Sources:- Bureau of Policy and Strategy, Ministry of Public Health. - Bureau of the Budget.

349 Figure 7.11 MoPHûs budget compared with the national budget (baht)

Prior to having the policy on universal coverage of health care

MoPH budget MoPH budget 986.6 million (3.4%) 5,571.8 million(4.0%) National budget National budget 29,000 million 140,000 million (96.6%) (96.0%) 1972 1981

MoPH budget MoPH budget 16,225.1 million 63,705.1 million National budget (4.8%) National budget 335,000 million 830,000 million (7.7%) (95.2%) (92.3%)

1990 1998

After the policy on universal coverage of health care was launched

MoPH budget MoPH budget 77,720.7 million 129,683.3 million (7.6%) (8.3%) National budget National budget 1,028,000 million 1,566,200 million (92.4%) (91.7%) 2004 2007

MoPH budget MoPH budget 161,530.4 million 188,625.4 million National budget (9.5%) National budget (9.1%) 1,700,000 million 2,070,000 million (90.5%) (90.9%) 2010 2011

Source: Figure 7.9 350 Figure 7.12 Proportions of security, debt repayment, education and public health budget compared with the national budget, FYs 1969›2011

Security Percentage Debt repayment 30 Education 26.2

25.8 25.1 25.2 Public health 25.3

25.0 24.7 24.6

25 23.7

22.8

22.4

21.9

21.7 21.6 21.5 23.7 20.8 24.5 22.6 20.1 20.4 20.4 20.4 20 20.8 21.8 21.0 20.6 20.2 20.0 18.1 19.6 17.6

19.1 17.0

16.2

16.1 17.9 16.1

15.6 16.9 17.4 15.3

14.6

14.2 15 13.3 14.1

13.1 12.6 12.5 12.9 12.6

12.0 11.8 11.2 11.5 10.9 11.3 11.3 10.2 10.5 10 9.1 11.610.7 10.4 7.6 8.0 9.2

10.5

10.1

9.5 8.2 6.5 9.3 7.8 8.7

7.6

5.4 7.6

7.5

7.3

7.1

4.7 7.1 5 4.4 5.7 5.0 5.3 0 year

1969

1973

1977

1981

1985

1989

1993

1998

2001 2002

2005

2008 2009 2010 2011

Source: Bureau of the Budget. Note: There were no health budget data available for 1969-1981 as the health budget was included in the community social welfare service budget.

351 Table 7.6 MoPHûs budget in present value and real terms (million baht) MoPH Health Total MoPH Consumer Budget at Increase/ As percentage Year budget Insurance budget price index 2011 value decrease from of national revolving (present value) (1994 = 100) previous year budget fund (2011 value) 1992 24,640 - 24,640 92.1 45,454 - - 1993 32,898 - 32,898 95.2 58,712 +29.2 5.9 1994 39,319 - 39,319 100.0 66,803 +13.8 6.3 1995 45,103 730 45,833 105.8 73,601 +10.2 6.4 1996 55,236 625 55,861 111.8 84,891 +15.3 6.7 1997 66,544 1,030 67,574 118.2 97,130 +14.4 7.3 (68,934) (99,085) (+16.7) (7.5) 1998 62,625 1,080 63,705 127.7 84,757 -12.7 7.7 (65,065) (86,566) (-12.6) (7.8) 1999 57,171 2,056 59,227 128.0 78,615 -7.2 7.2 (62,787) (83,340) (-3.7) (7.6) 2000 58,426 2,215 60,641 130.1 79,192 +0.7 7.1 (63,001) (82,274) (-1.3) (7.3) 2001 58,697 2,400 61,097 132.2 78,520 -0.8 6.7 (61,563) (79,119) (-3.8) (6.8) 2002 43,311 27,612 70,923 133.0 90,600 +15.4 6.9 2003 41,996 32,138 74,134 135.5 92,955 +2.6 7.4 2004 45,147 32,573 77,720 139.3 94,793 +2.0 7.6 2005 45,024 40,890 85,914 145.5 100,322 +5.8 6.9 2006 52,672 54,429 107,101 152.3 119,478 +19.1 7.9 2007 62,319 67,364 129,683 155.8 141,419 +18.4 8.3 2008 65,515 76,599 142,114 164.2 147,047 +4.0 8.6 2009 72,536 80,598 153,134 162.8 159,812 +8.7 7.8 2010 72,146 89,385 161,530 169.3 162,102 +1.4 9.5 2011 87,568 101,057 188,625 169.9(1) 188,625 +16.4 9.1 Source: Bureau of Policy and Strategy, Ministry of Public Health. Notes:1.MoPHûs budget figures have included the budget of other agencies under MoPHûs supervision, i.e. Health Systems Research Institute and National Health Security Office. 2. The numbers in ( ) include foreign loans for health programmes in 1997›2001: from Sweden, Denmark, OECF, The World Bank, Asian Development Bank and Japan (Miyazawa Plan) in 1997 for 1,360 million baht; in 1998 for 1,360 million baht; in 1999 for 3,560 million baht; in 2000 for 2,360 million baht; and in 2001 for 466 million baht. 3. For FYs 1995-2001, the MoPH received a supplementary budget for health insurance cards called çhealth insurance card revolving fundsé, which were previously included the MoPHûs budget. 4. Since FY 2002, the MoPH has received a budget as çhealth insurance revolving fundé in stead of çhealth insurance card revolving fund and the revolving fund has been managed and allocated by the National Health Security Office since 2005. 5. (1)Consumer price index as of January 2011. 6. The health insurance revolving fund does not include personnel and operating costs.

352 2) Budget Allocation by Department In considering the proportions of budget allocated for each department, it was found that in 2011 the National Health Security Office (including the health security revolving fund) received the largest proportion (54.1%), followed by the Office of the Permanent Secretary for Public Health (37.2%, including salaries for civil servants and employees, which are part of the universal healthcare budget), and the Healthcare Accreditation Institute (Public Organization) received the least (0.03%) (Table 7.7 and Figure 7.13).

353 2

1.8

(%)

Proportion

5

2010

2011

from

Decrease

Increase/

50.4 - 0.03

Amount

-

from

-12.9 2,070,000.0 21.8 -

2009(%)

Decrease

Increase/

2010

Amount

--

from

2008(%)

Decrease

Increase/

2009

112.2 - 54.7 -51.2 164.8 +201.3 0.09

390.3 - 390.3 0.0 525.0 +34.5 0.3

Amount

ly established agencies, according to the bureaucratic reform policy, have

n budget since FY 2009.

t since FY 2002.

get since from FY 2011 an awards.

versal healthcare budget.

- --

-

from

2007(%)

Decrease

Increase/

2008

Amount

-- --

--

from

2006(%)

Decrease

Increase/

2007

Budget received (million baht)

Amount

-- --

--

from

2005(%)

Decrease

Increase/

2006

Amount

-- --

--

from

2004(%)

Decrease

Increase/

2005

Amount

-- --

--

from

2003(%)

Decrease

Increase/

2004

Amount

-- --

--

73.7 120.1 +63.0 113.0 -5.9 113.1 +0.08 134.1 +18.6 151.6 +13.0 368.9 +143.3 173.3 -53.0 255.6 +47.5 0.1

109.9 96.9 -11.8 88.7 -8.5 79.0 -10.9 99.4 +25.8 120.5 +21.2 119.9 -0.5 186.8 +55.8 90.6 -51.5 0.05

2,490.4 2,664.7 +7.0 2,721.6 +2.1 2,937.9 +7.9 3,421.8 +16.5 3,481.2 +1.7 3,758.3 +8.0 3,494.2 -7.0 5,389.4 +54.2 2.9

1,125.6 587.4 -47.8 597.8 +1.8 593.4 -0.7 651.3 +9.8 731.9 +12.4 755.9 +3.4 703.5 -6.9 844.6 +20.0 0.4

28,978.7 32,177.5 +11.0 32,096.6 -0.3 41,016.8 +27.8 49,115.0 +19.7 51,626.9 +5.1 57,058.0 +10.5 58,170.7 +2.0 70,110.4 +20.5 37.2

32,138.5 32,572.8 +1.4 40,889.9 +25.5 54,428.6 +33.4 67,364.1 +23.8 76,598.8 +13.7 80,597.7 +5.2 89,384.8 +10.9 101,057.9 +13.0 53.6

2003

Amount

The budget of the Ministry of Public Health, 2003-2011

Bureau of Policy and Strategy, Ministry of Public Health. For 1997 - 2001, the budget for the Office of the Permanent Secretary included the health insurance card subsidies.

received their own budget since FY 2003.

Medical Sciences 747.3 927.2 +24.1 973.1 +4.9 891.2 -8.4 838.2 -5.9 908.4 +8.4 916.3 +0.9 781.9 -14.7 904.3 +15.6 0.5

. .

2. National Health Security Office. 2. For 2002 - 2011, the budget for the Office of the Permanent Secretary included salaries and wages, which were part of the uni 3. The Department of Health Service Support and the Department for Development of Thai Traditional and Alternative Medicine, new 4. The National Health Security Office, a newly established agency under the supervision of the MoPH, has received its own budge 5. The Emergency Medical Instiute of Thailand, a newly established agency under the supervision of the MoPH, has received its ow 6. The Healthcare Accreditation Instiute, a newly established agency under the supervision of the MoPH, has received its own bud

Department

:1

:1

Whole country 999,900.0 1,028,000.0 +2.8 1,250,000.0 +21.6 1,360,000.0 +8.8 1,566,200.0 +16.2 1,660,000.0 +6.0 1,951,700.0 +17.6 1,700,000.0 MoPH 74,133.9 77,720.7 +4.8 85,914.4 +10.5 107,100.8 +24.8 129,683.3 +21.1 142,113.6 +9.6 153,133.8 +7.8 161,530.4 +5.5 188,625.4 16.8 - Office of the Permanent Secretary Department of Medical Services Department of Disease Control 3,635.6 4,081.5 +12.3 4,048.7 -0.8 2,736.3 -32.4 3,133.2 +14.5 3,379.1 +7.8 3,487.2 +3.2 3,192.2 -8.5 3,367.3 +5. Department of Health 1,185.6 1,340.8 +13.1 1,361.2 +1.5 1,366.7 +0.4 1559.5 +14.1 1,652.7 +6.0 1,776.9 +7.5 1,524.5 -14.2 1,735.2 +13.8 0.9 Department of Mental Health 1,553.2 1,623.4 +4.5 1,721.7 +6.1 1,659.7 -3.6 1,888.6 +13.8 1,917.4 +1.5 2,018.8 +5.3 1,917.3 -5.0 2,330.2 +21.5 1. Department of Health Services Support Department of Department for Development of Thai Tradititional and Altemative Medicine Food and Drug Adminstration 495.5 507.1 +2.3 667.1 +31.6 613.1 -8.1 627.0 +2.3 657.4 +4.8 686.7 +4.5 567.7 -17.3 700.4 +23.4 0.4 Health Systems Research Instiute National Health Security Office 1,600.0 1,021.3 -36.2 625.0 -38.8 644.9 +3.2 810.9 +25.7 807.7 -0.4 936.7 +16.0 858.5 -8.3 961.3 +12.0 0.5 Emergency Medical Institute of Thailland Healthcare Accreditiation Institute Health Insurance Revolving Fund Thai Traditional Medicine - - - 10.0 0.0 20.00 +100.0 40.0 +100.0 80.0 +100.0 150.0 +87.5 130.0 -13.3 138.0 +6.1 0.07 Wisdom Fund National Emergency Medicine Fund

------

------

Table 7.7

Sources Notes

354 Figure 7.13 Proportion of MoPHûs budget by agency, 2011

Dpt. of Medical Service 2.9% Dpt. of Health Service Support 0.4% Dpt. of Medical Sciences 0.5% Dpt. of Health 0.9% Dpt. for Development of Thai Traditional & Healthcare Accreditation Institute 0.03% Alternative Medicine 0.2% Office of the Permanent Secretary 37.2%

Emergency Medical Institute of Thailand 0.4% Health Systems Research Institute 0.05% Dpt. of Mental Health 1.2% National Health Security Office 54.1% Food and Drug Administration 0.4% Dpt. of Disease Control 1.8%

Source: Table 7.7. Note:1.The budget of the National Health Security Office includes the budget for the Health Security Revolving Fund. 2. For the Department for Development of Thai Traditional and Alternative Medicine, the budget has included that for the Thai Traditional Medicine Wisdom Fund. 3. For the Emergency Medical Institute of Thailand, the budget includes that for the National Emergency Medicine Fund.

3) Budget Allocation by Programme MoPHûs budget for 2002›2011 has been allocated for the implementation of nine major programmes (Table 7.8). It should be noted that the universal healthcare scheme is implemented in accordance with the policy of the present government. Thus, its budget has been increased at a much higher rate while those for other programmes tend to receive a smaller or constant budget (Figure 7.14). Nevertheless, as the budgetting system has been changed from the Planning. Programming and Budgetting System to the Results-Based Budgetting System, there have been limitations in collecting all data on budget allocation by programme operation.

355 (%)

Proportion

+22.0 1.1

from

2011

2010(%)

Decrease

Increase/

9

393.3 -1.4 2.8

3,277.0 +8.1 1.7

Amount

from

2009(%)

Decrease

Increase/

2010

40,750.3 +9.3 167,526.3 +19.0 88.8

Amount

NA 3,026.9 NA 3,146.3 NA 1.7

from

2008(%)

Decrease

Increase/

6

Secretary since the budget is part of the surveillance of

as increased considerably.

d revised its role and thus the budget for such purpose

2009

ferred its programmes on environmental surveillance and

ed to the health system development programme; so their

olicy.

Amount

from

2007(%)

Decrease

Increase/

2008

Amount

from

2006(%)

Decrease

Increase/

2007

Amount

from

+133.6 4,073.4 +31.9 4,638.1 +3.0 3,228.5

2005(%)

Decrease

Increase/

5

2006

Amount

NA 2,944.0 -0.7 3,584.7 +21.8 4,197.5 +17.1 4,301.5 +2.5 3,752.7 -12.8 5,035.9 +34.2 2.7

from

2004(%)

Decrease

Increase/

4

2005

Amount

NA 2,968.4

from

2003(%)

Decrease

Increase/

3

2004

Amount

NA 4,951.2

from

2002(%)

Decrease

Increase/

2

2003

Amount

65.7 79.5 +21.0 82.1 +3.3 87.1 +6.1 93.8 +7.7 120.4 +28.4 112.3 -6.7 129.0 +14.9 104.7 -18.8 134.7 +28.7 0.1

2002

Amount

Health budget allocation by major programme, 2002 - 2011 (in million baht)

Bureau of Policy and Strategy, Ministry of Public Health. Approx 11% of the budget for the universal healthcare scheme is earmarked for health promotion and disease prevention. For FY 2003, the budget for disease prevention/control and health promotion was decreased as the Department of Health had trans analysis and water supply provision to the Ministry of Natural Resources and Enviroment, according to the bureaucratic reform p Since FY 2004, the budget for disease prevention/control and health promotion has been decreased as the Department of Health ha has been shifted to the health system development programme, Since FY 2005, the budget for disease prevention/control of the Department of Mental Health and Medical Services has been shift budget for such purpose has decreased. Since 2006, more budget has been allocated for the purchase of antiretroviral druge; so the budget for the HIV/AIDS programme h Since 2009, the budget for AIDS prevention and Control has not been able to be determined for the MoPH Office of the Permanent diseases and health threats at the local level; so the budget for such purpose has decreased.

1 2

3

4

5

6

:

:

Type of programme

and health promotion

and development of personnel

control for patients and the disabled and quality of health resolution services and product alternative medicine

1. Universal health security 53,022.9 57,697.2 +8.8 60,431.2 +4.7 68,207.6 +12.9 78,535.7 +15.3 86,594.5 +10.3 100,949.7 +16.6 128,767.7 +27.6 1 2. Disease prevention/control 7,619.9 6,296.0 3. Health system development 1,519.6 1,674.0 +10.2 2,474.5 NA 3,292.2 +33.0 3,235.6 -1.7 4,026.5 +24.4 5,373.3 +33.4 5,976.7 +11.2 5,470.8 -8.5 5, 4. Support for the production 1,501.5 1,464.6 -2.4 1,495.9 +2.1 1,647.9 +10.2 1,919.3 +16.5 2,426.9 +26.4 3,333.8 +37.4 3,060.7 -8.2 3,031.0 -1.0

5. Development of standards 812.9 819.6 +0.8 1,085.0 +32.4 1,446.9 +33.3 1,513.1 +4.6 1,632.1 +7.9 1,582.6 -3.0 1,891.7 +19.5 1,654.3 -12.5 2,017.

7. Drug abuse prevention and 524.7 538.2 +2.6 1,100.1 +104.4 842.1 -23.5 483.1 -42.6 526.5 +9.0 521.9 -0.9 639.6 +22.6 553.0 -13.5 691.5 +25.0 0.4 8. Thai traditional and 39.1 73.7 +88.5 120.1 +63.0 122.9 +2.3 126.9 +3.2 195.5 +54.1 275.3 +40.8 444.0 +61.3 330.5 -25.6 393.6 +19.1 0.2 6. AIDS prevention and 698.7 885.1 +26.7 1,355.1 +53.1 1,321.5 -2.5 3,087.4 9. Medical rehabilitation services

Source Notes

Table 7.8

356 Figure 7.14 Proportion of MoPH budget by major programme, 2011

Universal health security 88.8%

Drug abuse prevention and resolution 0.4% Others 0.5% Medical rehabilitation for patients and the Disease prevention/control and health disabled 0.1% promotion 2.7% Support for the production and Health system development 2.8% development of personnel 1.7% AIDS prevention and control 1.7% Thai traditional and alternative medicine 0.2% Development standard and quality of health services and products 1.1%

Source: Bureau of Policy and Strategy, Ministry of Public Health. Note: Approximately 11% of the budget for the universal healthcare scheme is allocated for health promotion and disease prevention.

4) Budget Allocation by Type of Expenditure A large proportion of the budget of the Ministry of Public Health (35›47%) is used for staff salaries/wages and operating costs, which have been rising to 58.8% in 2011. As the government has had the universal healthcare policy (for all Thai people), a larger proportion of the health budget is allocated for this purpose, while the investment budget has got its proportion declining considerably according to the economic condition to only 5.2% in 2010, but rising to 11.1% in 2011 in line with the Thailand: Investing from Strength to Strength (Thai Khem Khaeng) policy of the government (Table 7.9).

357 During the first economic crisis (1983›1986), the investment budget decreased from 22.1% in 1982 to 11.3% in 1987 (Figure 7.16). However, during the economic expansion in 1988›1996, the investment budget rose to 38.7% in 1997 but dropped again during the 1997 economic crisis to only 8.8% in 2001. During another economic crisis in 2008, the proportion of investment budget dropped to 5.2% in 2010, but rose to 11.1% in 2011 as there are many construction projects for developing the health service system under the Thai Khem Khaeng Scheme. Notably, although the MoPH was allocated a much less budget during the economic crisis (Table 7.6), it still gives high priority to the budget allocation for helping the poor and underprivileged. The budget for such purposes has actually increased to the level higher than before (Table 7.15). Since 2002, the government has been supporting such programmes called the budget for universal healthcare for all Thai people through the health insurance revolving fund (capitation payment) covering a population of 46 million who have never had any health insurance coverage before. The annual capitation rates are 1,202.4 baht for 2002 and 2003, 1,308.5 baht for 2004, 1,396.30 baht for 2005, 1,659.2 baht for 2006, 1,899.69 baht for 2007, 2,100 baht for 2008, 2,202 baht for 2009, 2,401.33 baht for 2010 and 2,546.48 baht for 2011.

358 .7

2011

Amount %

2010

02.6 34.1 55,979.4 29.7

24.7 51.3 94,855.9 50.3

7,436.0 60.3 110,819.2 58.8

61,530.3 100.0 188,625.4 100.0

55,649.4 34.5 56,726.0 30.1

Amount %

4

2009

Amount %

,428.8 million baht for 2002; 1,929.6 million baht for 2003;

2008

h Securitry Office, which is 24,183.2 million baht for 2002;

0,717.8 million baht for 2007; 69,886.1 millionbaht for 2008;

12.7 million baht for 2008; 6,991.0 million baht for 2009; 7,083.7

Amount %

ht for 1998; 2,056 million baht for 1999; 2,215 baht for 2,000; and

2007

Amount %

2006

Amount %

2005

Amount %

2004

Amount %

2003

Amount %

2002

Amount %

2001

5,379.0 8.8 5,604.3 7.9 3,318.3 4.4 5,191.2 6.7 4,871.9 5.6 7,816.1 7.3 8,833.7 6.8 10,119.1 7.1 12,017.1 7.8 8,444.9 5.2 21,080.2 11.1

Amount %

Budget received by the Ministry of Public Health, FYs 2001-2011(present value: amount in million baht)

2,400 million baht for 2001.

28,608.8 million baht for 2003; 28,652.4 million baht for 2004; 37,286.3 million baht for 2005; 48,269.4 milliobaht for 2006; 6 73,606.7 million baht for 2009; 82,301.0 million baht for 2010; 93,921.3 million baht for 2011. Bureau of Policy and Strategy, Ministry of Public Health 3,920.4 million baht for 2004; 3,603.7 million baht for 2005; 6,132.2 million baht for 2006; 6,646.3 million baht for 2007; 6,7 million baht for 2010; 7,136.6 million baht for 2011.

2. For FYs 2002-2011, other expenses include health insurance revolving funds less the investment budget for the Nattional healt

3. For FYs 2002-2011, MoPHûs investment budget include the investment budget of the National Health Securitry Office, which is 3

: 1. For FYs 1997-2001, subsidies include health insurance card counterpart funds: 1,030 million baht for 1997; 1,080 million ba

ÿ

:

permanet wages

supplies and miscellaneous

construction Total 61,097.2 100.0 70,923.2 100.0 74,133.9 100.0 77,720.7 100.0 85,914.4 100.0107,100.8 100.0 129,683.3 100.0 142,113.6 100.0153,133.8 100.0 1

1.1 Salaries and 28,757.0 47.1 29,489.2 41.6 32,991.3 44.5 34,620.4 44.5 34,770.9 40.5 42,769.8 40.0 47,314.6 36.5 49,871.3 35.1 53,689.3 35.1 55,1 1.2 Temporary wages 50.6 0.1 43.1 0.1 43.7 0.1 44.3 0.1 47.2 0.1 138.9 0.1 204.1 0.1 268.7 0.2 456.0 0.3 546.8 0.4 746.6 0.4 2.1 Compensation, 9,728.1 15.9 4,403.5 6.2 5,667.1 7.6 6,607.7 8.5 6,448.9 7.5 5,523.1 5.2 7,848.2 6.1 8,142.5 5.7 8,587.8 5.6 10,714.9 6.6 10,722.8 5

2.2 Public utilities 848.0 1.4 325.0 0.4 317.0 0.4 309.0 0.4 411.7 0.5 368.7 0.3 384.2 0.3 392.6 0.3 386.8 0.3 389.5 0.2 535.9 0.3 2.3 Subsidies 14,171.5 23.2 3,964.7 5.6 3,166.4 4.4 2,275.4 2.9 2,014.3 2.3 2,107.0 1.9 2,740.8 2.1 3,245.6 2.3 3,655.2 2.4 3,406.9 2.1 4,704.6 2.5 2.4 Other expenses 2,163.0 3.5 27,093.3 38.2 28,630.1 38.6 28,672.7 36.9 37,349.5 43.4 48,377.2 45.2 62,357.5 48.1 70,073.9 49.3 74,341.6 48.5 82,9 3.1 Equipment, land and

Category of budget

1. Salaries and wages 28,807.6 47.2 29,532.3 41.7 33,035.0 44.6 34,664.7 44.6 34,818.1 40.5 42,908.7 40.1 47,518.7 36.6 50,140.0 35.3 54,145.3 35.

2. Operating budget 26,910.6 44.0 35,786.5 50.4 37,780.6 51.0 37,864.8 48.7 46,224.4 53.8 56,376.0 52.6 73,330.7 56.6 81,854.5 57.6 86,971.4 56.8 9

3. Investment budget

Source À¡“¬‡Àµ

Table 7.9

359 Figure 7.15 Budget for free medical services for the poor and underprivileged as percentage of MoPHûs budget, 1979›2001

Million baht Percentage 10,000.0 18 Budget for free medical services for the poor 9,392.1 9,419.6 9,000.0 percentage of MoPHûs budget 8,887.6 16 14.9 15.3 8,000.0 14 14.2

7,029.0 7,000.0 6,370.5 12 10.5 10.8 11.0 6,000.0 10.1 9.8 9.2 9.7 10

4,816.9 9.4 5,000.0 8.0 7.8 7.6 7.7 4,263.5 7.5 7.2 7.3 7.4 7.0 8.6 8 4,000.0

6.3 3,456.0

6.8 4,470.1 6 3,000.0

2,480.0

2,000.0 2,000.0 4

1,500.0

800.0

725.0

705.8

678.5

721.8 659.7 2 1,000.0 603.0

476.7

350.0 300.0 350.0 0 0Year

1979 1985

1982 1988

1991

1994

1997

2000 2001

Source: Bureau of Policy and Strategy, Ministry of Public Health. Note: Since 2002, the budget for medical services for the poor has been converted to the budget for the universal healthcare scheme for all Thai people.

360 Figure7.16 Percentage of MoPH budget by budget category, 1959›2011

Percentage 70 Salaries and wages Operating budget

60.3

Investment budget 58.8

57.6

60 56.8

56.6

53.8

52.6

52.6

52.2

51.0

50.5

50.6

50.4

50.4

48.9

49.0

48.7

48.4

47.9

50 47.2

47.0

47.1

46.8

46.2

46.2

46.1

45.8

45.3

45.0

44.8

44.4

44.6

44.3

44.0

44.1

44.2

43.5

43.7

43.2

43.1

42.7

44.2

42.2

41.9

41.3

40.8

40.5

40.1

40.1

46.3

39.6

39.3

38.6

38.5

38.7

38.3

38.0

37.8

44.6

44.0

37.9

37.4 40 37.1

36.6

36.5

36.1

36.2

36.6

35.6

35.3

41.7

35.3

35.4

41.7

34.5

34.7

34.4

34.5

34.0

40.6

33.8

40.2

33.3

32.9

39.8

32.1

32.5

32.5

32.4

39.0

32.2 33.3

32.2

32.0

38.1

31.5

31.3

37.8

30.1

29.9 29.5 Universal

28.2

34.2 30 33.5

32.7

32.3 healthcare

31.4

24.6

23.6

23.6

29.3

29.3

22.6

22.6

22.4

22.2 22.4

22.1 27.3 30 baht for cancelled

21.5

27.8

27.5

21.1

20.5

27.4

26.1

26.1

19.1

18.9

19.2

25.5

18.7

18.1

18.2

20 17.5

17.0

16.3 Economic crisis

15.8

15.2

21.8

14.2

13.3

13.3

11.7

16.8

11.3

11.5 Economic recession 11.1

Low income Economic crisis 8.8

7.8

7.9

10 7.3

6.7

7.1

6.8

5.6

5.2

All community 4.4

8.3 hospitals Economic expansion 0 Year

2008 1959 2010

1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 1961 2009 2011

Source: Bureau of Policy and Strategy, Ministry of Public Health.

4.1.7 Health Information System (MoPH only) Prior to the 4th National Development Plan period (1977›1981), the MoPH collected a lot of health information reports and statistics, but they were scattered in various agencies. As a result, it was rather hard to compile them for proper use; and the analyses were incorrect resulting in the low levels of data quality and accuracy. Therefore, since the 4th Plan period, the MoPH has implemented the Health Information System Development Project aimed at improving the quality of health information so that it is accurate and comprehensive. The modern technology has been introduced to the development of health information system and the capacity building, using computerized systems at the central and provincial levels. The Management Information System has also been established so that the administrators are able to use the information for decision-making at all management levels.

361 During the 7th›8th Plan periods, the MoPH abolished a number of unnecessary reporting systems, by supporting provincial health surveys and national health examination surveys. In 1997, the MoPH also started collecting information related to all health systems in Thailand as a report on a biennial basis called çThailand Health Profileé. During the 9th and 10th Plan periods (2002-2011), there is a reform of the MoPH health information system, using the modern management information system reform approach based on the elec- tronic individual cards. Under the new system, the structure is of the same standard linking all agencies concerned together as well as the smart-card system in the future. This is in response to the performance achievement indicators such as KPI, E-inspection and the Ministry Operations Centre (MOC) (Figure 7.17). In addition, in 2010 the National Health Commission endorsed the National Health Information System Development Programme and set up a committee to supervise and monitor the implemen- tation of the programme.

Figure 7.17 Linkages and network of the management information system, MoPH

Ministry of Public Health

Committee on Information Subcommittee on Health and Communication Management Information Technology, MoPH System Development, MoPH

National Health Informa- International agencies, tion Centre, Office of the Department/Divisions and system research and Permanent Secretary, information agencies MoPH Units in MoPH

Government agencies outside MoPH

Private agencies and NGOs Provincial Data Banks Other provincial agencies

Individual information Reports not available in the databases of health facilities individual information database

362 4.1.8 Monitoring and Evaluation System As the government has adopted the new public management principle, emphasizing the responsibility for results and outcomes that will affect the people, all government agencies have to lay down their goals and strategies to serve peopleûs needs and use the results-based budget allocation mechanism, beginning in fiscal year 2003. The MoPH has also developed its monitoring and evaluation system as a key management mechanism to illustrate the achievements of programme operations and impacts on the people by using key performance indicators (KPI) for the purpose of achieving the goal of Thai peopleûs health develop- ment at the policy and strategy level. However, that system is used only for programme under the responsibility of the MoPH (Figure 7.18).

363 Figure 7.18 MoPHûs monitoring and evaluation system

The 2007 National evaluation agencies Constitution of NESDB Thailand National development Cabinetûs secretariat The Cabinet goals and strategies Budget Bureau Fundamental state policies and government policies

National Economic Ministerial policies / Results of operations & Social Develop- strategies and plans of ment Plan Revising policies / strategies action Accelerating operation and National Health solving problems Setting budget ceiling Development Plan

State Administration Plan Implementation of strategies National Health to achieve goals Act, 2007 Monitoring and evaluation Ministerial monitoring and 6 months Scope of evaluation evaluation systems, MoPH 9 months 1 year

Impact Health status State- supervised Bureau of agencies Monitoring & under Policy & MoPH evaluation Minister & Perma- Strategy Ministerial goals, Ministerial level nent Secretary Results (MoPHûs Office of policies and M & E agency) strategies Permanent Secretary

Cluster and Cluster chiefs & Departmentsû Major projects departmental level Director-Generals Planning & - Achievement of technical divisions Outputs ministerial goals as per strategies and policies Bureausû Bureau level Bureau directors planning - Innovations groups - Follow-on projects - High budget Provincial planning & spending Provincial level PCMOs strategy groups

364 4.2 Agencies Supporting Health Programme Implementation 4.2.1 Public Sector Agencies Supporting and/or Implementing Health Activities 1) Public sector agencies providing health services and producing health personnel are the Bangkok Metropolitan Administration (BMA), the Ministry of Education (Office of the Higher Education Commission), the Ministry of Interior, and the Ministry of Defence. 2) Public sector agencies implementing health-related activities in connection with the environment, workers, children and women are the Ministry of Industry, the Ministry of Science and Technol- ogy, the Ministry of Agriculture and Cooperatives, the Ministry of Labour, the Ministry of Social Development and Human Security, the Ministry of Education, and the Ministry of Natural Resources and Environment. 3) Public sector agencies supporting the implementation of health programmes in an efficient and effective manner include the National Economic and Social Development Board (planning sup- port), the Bureau of the Budget (budgetary support), the Civil Service Commission (health manpower support), Thailand International Development Cooperation Agency (international assistance), the National Statistical Office (information support), the Thailand Research Fund (TRF) and the Health Systems Research Institute (HSRI) (medical and health research support), the Thai Health Promotion Foundation (health promotion support) and the National Health Security Office (standardized and equitable universal health insurance support), and in 2007, the National Health Commission Office was established (coordination support in health policy and strategy). 4) Public sector agencies responsible for health services for specific groups are the Social Security Office of the Ministry of Labour and the Office of the Insurance Commission of the Ministry of Commerce. 4.2.2 Private For-Profit Health Organizations In the past, most private health facilities were not-for-profit organizations. In addition to providing health services, after the period of rapid economic expansion period (1987›1997), the private sector has expanded considerably in the forms of private hospitals and clinics. Moreover, some private health facilities play a small role in producing health personnel. In privately-run for-profit medical facilities, 13 groups of investors have been formed and listed in the Stock Exchange of Thailand (2010). Such corporates and networks include Aekchon Hospital, Bangkok Dusit Vejakarn Hospital, Krung Thon Hospital, Mahachai Hospital, Chiang Mai Medical Business Co. Ltd., Wattana Hospital Group, Nonthavej Hospital, Ramkhamhaeng Hospital, Smitivej Hospital, Vibhavadi Hospital, Bamrungrad Hospital, Sikharin Hospital, and Bangkok Chain Hospital Public Limited Company. 4.2.3 Health Not-for-profit Organizations There are some 300 to 500 not-for-profit or nonprofit organizations (NPOs) working on health in Thailand; most of them are foundations or associations registered with the Ministry of Culture (Office of the National Cultural Commission and/or the Ministry of Interior). So, a lot of them are juristic persons, but several other small NPOs are non-juristic-person agencies, such as the Rural Doctors Club and the Drug Studies Group.

365 Generally, these organizations receive financial support from international agencies and in-country donations, including government subsidies. The MoPH continues to support NPOs to work on health activities, but the financial support has dropped four-fold from 49.2 million baht in 1992 to only 12 million baht in 2010. In 2010, a total budget of 12.0 million baht has been provided to 43 NPOs (48 projects) for their relevant health programmes for the elderly, disabled persons, the underprivileged, maternal and child health, youths and others (Table 7.10). Besides, another 50 million baht is provided to 763 NPOs working on HIV/AIDS in 2010 (Table 7.11) as they all help the government in implementing health-related development programmes. Besides, since 1997 specialized agencies of the United Nations such as the World Health Organization (WHO) have provided financial aids to several NPOs; previously WHO provided such grants for public sector agencies only. Moreover, since 2002, Thailand has been financially supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria every year (Table 7.12).

366 Table 7.10 Number of not-for-profit organizations with funding support from MoPH, 1992›2010

No. of NPOs No. of projects Budget, baht Year Requesting Supported % Requested Supported % Requested Allocated % 1992 45 42 93.3 91 72 79.1 85,600,000 49,200,000 57.5 1993 142 119 83.8 264 185 70.1 160,844,928 49,200,000 30.6 1994 416 305 73.3 909 654 71.9 334,481,098 49,200,000 14.7 1995 362 103 28.5 615 287 46.7 205,348,213 49,200,000 23.9 1996 150 106 70.7 491 219 44.6 192,234,358 49,200,000 25.6 1997 142 78 54.9 420 180 42.8 230,287,800 49,200,000 21.4 1998 152 101 66.4 258 174 67.4 129,016,142 35,000,000 27.1 1999 177 114 64.4 541 223 41.2 241,270,797 35,760,000 14.8 2000 163 92 56.4 493 191 38.7 257,227,874 46,582,300 18.1 2001 152 66 43.4 411 166 40.4 160,768,084 33,557,800 20.9 2002 161 70 43.5 327 124 37.9 161,955,967 34,965,922 21.6 2003 235 128 54.5 411 251 61.1 160,813,010 34,831,160 21.7 2004 106 70 66.0 295 182 61.7 103,900,200 26,369,545 25.4 2005 104 76 73.1 210 156 74.3 91,655,450 26,454,000 28.9 2006 77 52 67.5 118 69 58.5 71,072,240 20,000,000 28.1 2007 91 72 79.1 127 82 64.6 89,877,311 12,000,000 13.3 2008 75 52 69.3 110 66 60.0 56,216,643 12,000,000 21.3 2009 89 47 52.8 144 58 40.3 77,807,970 12,000,000 15.4 2010 80 43 53.8 109 48 44.0 63,668,165 12,000,000 18.8

Sources:- For 1992›2001, data were derived from the Medical Registration Division, Department of Health Service Support. - For 2002›2010, data were derived from the Primary Health Care Division, Department of Health Service Support. - Public and Consumer Affairs Division, Food and Drug Administration. Note: The Food and Drug Administration provided financial support to NPOs working on consumer protection during 1999›2003 only.

367 Table 7.11 Number of NPOs involved in HIV/AIDS programmes with funding from MoPH, 1992›2010

No. of NPOs No. of projects Budget, baht Year Requesting Supported % Requested Supported % Requested Allocated % 1992 37 23 62.2 42 35 83.3 66,125,734 11,900,000 18.0 1993 38 36 94.7 61 56 91.8 33,123,818 15,000,000 45.3 1994 101 76 75.2 120 91 75.8 72,903,868 10,300,000 14.1 1995 115 94 81.7 209 153 73.2 350,765,292 75,000,000 21.4 1996 186 122 65.6 308 188 61.0 267,232,488 80,000,000 29.9 1997 268 184 68.7 385 247 64.1 309,015,357 90,000,000 29.1 1998 434 244 56.2 725 343 47.3 494,739,684 90,000,000 18.2 1999 596 371 62.2 931 458 49.2 450,972,885 87,262,350 19.3 2000 625 293 46.9 882 372 42.2 368,671,357 60,000,000 16.3 2001 497 371 74.6 730 457 62.6 403,438,189 70,000,000 17.4 2002 660 444 67.3 922 522 56.6 370,340,183 70,000,000 18.9 2003 712 519 72.9 987 605 61.3 337,938,984 70,000,000 20.7 2004 678 508 74.9 868 577 66.5 289,624,851 70,000,000 24.2 2005 795 637 80.1 935 657 70.3 277,646,531 70,000,000 25.2 2006 860 672 78.1 909 692 76.1 210,968,670 36,000,000 17.1 2007 795 637 80.1 935 657 70.3 115,406,097 40,000,000 34.7 2008 705 669 94.9 718 705 98.2 95,164,241 44,000,000 46.2 2009 727 720 99.0 764 750 98.2 109,491,442 50,000,000 45.7 2010 790 763 96.6 812 777 95.7 69,609,067 50,000,000 71.8

Source: Bureau of AIDS, Tuberculosis and Sexually Transmitted Infections, Department of Disease Control, MoPH.

368 Table 7.12 Projects with financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Thailand, 2003›2014

Projects and funding amounts (US dollars) Round Years AIDS Tuberculosis Malaria Total 1 2003 - 2008 146,766,828 11,455,207 - 158,222,035 2 2003 - 2009 30,156,771 - 5,282,000 35,438,771 3 2004 - 2007 1,236,108 - - 1,236,108 6 2007 - 2012 - 16,933,406 - 16,933,406 7 2007 - 2012 - - 17,515,927 17,515,927 8 2009 - 2014 32,258,521 10,240,102 - 42,498,623 Total 210,418,228 38,628,715 22,797,927 271,844,870

Source: The Secretariat of the Country Coordinating Mechanism.

369 370 Chapter 8 Health Promotion System in Thailand

The history of Thai health system in the future will have to have a record saying that, during the decade of 1997›2007, the concept of çhealth promotioné is recognized as a significant development philosophy and strategy resulting in unprecedented changes in health model, system and status of Thai society, with such a philosophy and strategy, çhealth promotioné has been known and defined as ça modern public health approach that emphasizes the participation of people and all sectors in society in developing determinants of health in a holistic manner, especially social and environmental factorsé. Even through the stream of thinking on health promotion has had a long history in Thailand and overseas, the most obvious and powerful upstream events were the Primary Health Care Concept and the Ottawa Charter for Health Promotion, which defines çhealth promotioné as the process of enabling people to increase control over, and to improve, their health. To achieve health promotion is not just the responsibility of the health sector as the effort goes beyond healthy lifestyles to well-being. Health promotion does not only involve the change in personal health behaviour, but is also directed towards changing social and environmental conditions that are fundamental for health, such as peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. Thailand is one of the countries that have moved and applied the health promotion strategy inten- sively in parallel with globalization. Over the past two decades, a number of successful and valuable lessons have been learned. Thus, this chapter covers such experiences in three aspects as follows: 1. Development of international health promotion in relation to the situation in Thailand: From Ottawa to Bangkok towards Nairobi in Kenya 2. Development of health promotion in Thailand 3. Reorientation of health promotion in the future 1. Development of international health promotion in relation to the situation in Thailand: From Ottawa to Bangkok towards Nairobi in Kenya The global concept of health promotion is an extension of the concept of primary health care and health for all, promoted by the World Health Organization (WHO) in the late-1970s. Nearly 10 years after that, the first health promotion conference was held in Ottawa, Canada, on 17›21 November 1986, resulting in the çOttawa Charter for Health Promotioné, which has been recognized worldwide as the bible of health promo-

371 tion. Since then, seven global conferences have been held to exchange experiences and synthesize lessons learned on health promotion strategies periodically among developed and developing countries: the 2nd conference in Adelaide, Australia (1988); the 3rd conference in Sundsvall, Sweden (1991); the 4th conference in Jakarta, Indonesia (1997); the 5th conference in Mexico City, Mexico (2000); the 6th conference in Bangkok, Thailand (2005 with the declaration of the Bangkok Charter for Health Promotion in a Globalized World); and most recently the 7th conference in Nairobi, Kenya (2009). Each of the aforementioned global conferences on health promotion had a different technical focus; however, all aimed to create clarity in the five major strategies for health promotion until they have become todayûs clear and powerful strategies at all levels. 1.1 Ottawa, Canada, the Beginning of Modern Public Health The first stage of the history of çhealth promotioné began when WHO organized the Interna- tional Conference on Health Promotion in 1986 in Ottawa, Canada. The reason for Canada being the host country of the conference was the fact that it was the first country that had implemented health promotion programme since 1974 and had created health promotion strategies continually until they become the modern strategies focusing on social and environmental dimensions; so, Canada was then recognized as the leader of modern health promotion programme. The theme of the first global conference was çHealth promotion: the move towards a new In implementing the health promotion strategies, health public healthé. The essence of the health promo- personnel have to play a role to advocate, mediate, and enable the people to control the determinants of health tion concept and strategy was to support the achieve- and enhance their capacity to take care of their own ment of the çHealth for All by the Year 2000é goal health to the full extent. and the conference adopted the çOttawa Charter on Health Promotioné, which defines çhealth promotioné as the process of enabling people to increase control over, and to improve, their health, which requires stable basic health determinants, namely peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. Thus, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being. The Ottawa Charter lays down five health promotion strategies as follows: 1) Build healthy public policy: All sectors (health and non-health) have to be aware of the health consequences; so, policy›makers have to take responsibilities for health resulting from their policy decisions and identify obstacles to the implementation healthy public policies and then try to find ways to minimize and prevent such obstacles. 2) Create supportive environments: All communities at all levels (local, national, regional and global) have to jointly protect and conserve the environments and nature; the conservation of natural resources throughout the world should be regarded as a global responsibility. 3) Strengthen community actions: As health promotion has to be carried out through concrete and

372 effective community action, more importance has to be given to the empowerment of communities, creating their ownership and the mobilization of local resources to enhance self-help and social support. 4) Develop personal skills: Support has to be provided for personal and social development through providing information, education for health, and enhancing life skills to increase the options available to people to have more control over their own health and environments, and to make choices conducive to health. 5) Reorient health services: The health sector has to support the needs of individuals and commu- nities for a healthier life in line with local health problems and cultural context. Reorienting health services also requires stronger attention to health research as well as changes in health professional education and training, based on the holistic healthcare approach. The Ottawa Charter was the beginning of a çnew public healthé that does not only pay attention to bio-medicine, but also to the roles of all sectors in society in health promotion, taking into account a more active role of the community to take control over the determinants of health. Moreover, it also emphasizes the importance of environmental, economic and social factors affecting health. So, there is a need to link to political campaigns that will recognize the importance of desirable changes. 1.2 çHealthy Public Policyé from Adelaideûs Recommendation Only one year after the Ottawa Charter was adopted, the World Health Organization orga- nized the 2nd International Conference on Health Promo- tion on 5›9 April 1998 in Adelaide, Australia. The conference çThe Health for Allé will be achieved only focused on the exchange of experiences in the implementa- if all public policies recognize the impor- tion of healthy public policy, resulting in clearer strategies on tance of creation and maintenance of live- how to create a healthy public policy, which is one of the five lihood and working conditions conducive health promotion strategies according to the Ottawa Charter. to health. The essence of the conference includes the following: ■ All public policies will have to be stated clearly to indicate the intention for health promotion and equality as well as the responsibility for health consequences that may occur. ■ The creation of supportive social and physical environments for health is the major aim of healthy public policy covering four key areas for further action including supporting the health of women, especially the policy on baby delivery and child rearing by women, food and nutrition focusing on the elimination hunger and malnutrition, control of tobacco and alcohol abuse, and environments for health. ■ The important factor that moves forward healthy public policy is the governmentûs respon- sibility for health. State agencies including agricultural, industrial, commercial, educational and transport sectors have to be involved; and their involvement in health should not be less than that in the economic sector as all need to pay attention to health impacts whenever they set and implement any policy. ■ In implementing health promotion strategy through healthy public policy, there should be

373 coordination and integration of economic, social and health policies as well as integrated operations. Moreover, other sectors in society including private businesses, non-profit organizations, community organizations, labour unions, professional associations and religious leaders are to be promoted to play a role in health promotion through the formation of new health alliances. ■ Challenges in achieving success in the future include equitable resource distribution, creation and maintenance of healthy living and working conditions, promotion of cooperation for peace, human rights, justice, ecology and sustainable development. Besides, there are other challenges related to cooperation in new activities and the equitable access to medical technology. 1.3 Sundsvall Statement on çSupportive Environments for Healthé The second strategy for health promotion stated in the Ottawa Charter, i.e. to create support- ive environments for health, was raised as the theme for the 3rd International Conference on Health Promo- tion, held on 9›15 June 1991, in Sundsvall, Sweden. The conference focused on the importance of environmen- tal factors on health and mentioned about various environmental dimensions conducive to health, creation of a clear understanding about the fundamental scope and strategies for creating supportive environments for health. The essence of each issue discussed and endorsed by the conference is as follows: ■ The environments mean all physical and social factors surrounding us that affect health. It is necessary for the government to be aware of such facts when formulating policies on national development. However, initiatives for creating supportive environments for health must be derived with the participation of all sectors in society, including the educational, transport, housing, urban development industrial and agricul- tural sectors. Health promotion has to be undertaken by the people in the community, local agencies, the government, nongovernmental organizations and international organizations. ■ The dimensions of supportive environments for health include social dimension (social lifestyles, norms, values, tradition, culture and social processes affecting health), political dimension (participa- tion in decision-making through democratic process, decentralization of power and resources, human rights protection, peacekeeping and reduction of weapon competition), economic dimension (reallocation of resources for achieving health for all, sustainable development, and safety and reliability of technology), and dimension related to the acceptance of womenûs skills and knowledge by all sectors. ■ The implementation of the health promotion strategy aimed at achieving health for all must reflect two basic principles, i.e. equity and interdependence of all living things which are important for creating supportive environments for health. The scope of this matter comprises six elements, namely educa- tion, food and nutrition, housing and surrounding community, working and occupation, transport and social support. The strategies for implementation under such a scope are the following: ● Strengthening advocacy through community action. ● Enabling communities and individuals to take control over their health and environ- ment through education and empowerment. ● Building alliances for health and supportive environments.

374 ● Mediating between conflicting interests in society to ensure equitable access to supportive environments for health. 1.4 Health Promotion in the 21st Century The 4th International Conferences on Health Promotion was held in Jakarta, Indonesia, from 21 to 25 July 1997, under the theme çNew Players for a New Era › Leading Health Promotion into the 21st Centuryé. That was the first international conference that had ever been held in a developing country and the first time for officials from private sector agencies to attend such a conference among the participants from 78 countries from all over the world, representing the health, economic, social and development sectors at all levels. The conference reflected the proactive direction for mainstream health promotion, which did not only include the sharing of experiences in the implementation of health promotion similar to those in the previous conferences, but also proposed recommendations to effectively implement such programmes, review and re-examine the determinants of health and to identify the directors and strategies that must be adopted to address the challenges of promoting health in the 21st century. It is regarded as another major milestone in pushing forwards the health promotion strategies at the international level. The essence of the conference is the following: ■ Health promotion has been increasingly recognized that it can develop and change lifestyles and socio-economic conditions as well as supportive environments for health, create more social justice, while promoting human rights and creating social capital. So, it is a cost-effective investment. ■ The implementation of health promotion should include all the five strategies in an integrated manner beginning at a community of a certain setting such as a market, a school or a municipal area. In addition, it has to support health literacy and people-centred participation for sustainable development. ■ Social determinants of health vary with the surrounding conditions. Thus, it is important that health promotion should be developed according to changes that occur rapidly at present and in the future. The basic factors affecting health include food, shelter, income, education, peace, security, social relations, justice, respect of human rights, ecosystem and use of resources, etc. Besides, there are other important factors such as the rising proportion of ageing population, undesirable health behaviours, drug abuse, violence, emerging and reemerging infectious diseases, antimicrobial resistance and transnational factors such as global economy, technology and the environment. ■ Health promotion in the 21st century requires new approaches for creating collaboration among relevant sectors as well as multisectoral collaboration responsibility for health. Moreover, more the attention has be paid to social responsibility for health, investments for health development of the country as a whole, strengthening and expansion of partnerships for health, enhancement of community capacity and empowerment of individuals for health promotion, and establishment of infrastructure for health promotion, which includes mechanisms for funding, resource utilization, training, and development of political, legal, educational, social, and economic environments for health promotion.

375 1.5 Statement on Health Promotion for Bridging Equity Gap The 5th Global Conference on Health Promotion focusing on the theme çHealth promotion: Bridging the equity gapé was held in Mexico City from 5 to 9 June 2000 and attended by participants from both public and private sectors from about 100 countries. The conference reviewed the importance of health promotion and determinants of health, problems of inequities in health, and made recommendations for health promotion in the following aspects: ■ Health promotion is not services provided for the people; rather, it is something under- taken by and for the people either as individuals or as groups, aiming to create skills and capability for the people to take control over the determinants of health in a holistic manner. This is to create an understanding of the linkage various factors affecting health, which will lead to self-health development. It is noteworthy that health promotion is important for resolving health problems and developing humans and health. Besides, the importance of such strategies is a means for bridging social disparities, which have to be carried out using the principle of science in line with the political context and sensitivity. In this effort, it is also extremely necessary to promote the role and participation of women. ■ On the road to sustainable success in health promotion, the important things to be implemented are as follows: ● Promotion of science and art for health promotion through policy formulation and operation based on empirical evidence, which requires investments in research and evaluation, development of the indicators of well-being and other indicators, development of interactions and collaboration among researchers, policy-makers and other relevant individuals or communities, identification of strategies for retrieving, compiling, synthesizing and communicating the findings from research and evaluation. The communication of empirical evidence has to be consistent with the social and political context. The information from the case studies presented at the conference indicated that the factors supportive of health promotion in the community include the brotherhood among The four key commitments are to make the practitioners and partnerships among personnel and promotion of health in the globalized world: agencies, mobilization of resources from all sectors, capacity 1) central to the global development agenda; 2) a core responsibility for all of government; building for communities and human resource development 3) a key focus of communities and civil and networking among practitioners. society; and ● The creation of skills and political 4) a requirement for good corporate activities for health promotion requires the democratic practice. process, socio-political movements, health service reorienta- tion, interaction development and programme/project development to enhance the potential for implement- ing health promotion strategies and creating driving forces at the local, national and international levels. 1.6 Bangkok Charter for Health Promotion in a Globalized World The Bangkok Charter was adopted during the 6th Global Conference on Health Promotion,

376 held from 7›11 August 2005 in Bangkok, Thailand. The conference examined the determinants of health based on the context of globalization, determined guidelines for strategic actions for health promotion according to changes in the present situation, and made a declaration of health promotion aimed at achieving çhealth for allé as follows: ■ Health promotion in the present era has to take into account new determinants of health resulting from globalization, increasing inequalities, new patterns of consumption and communication, commercialization, global environmental change, urbanization, and others such as rapid and adverse social, economic and demographic changes that affect working conditions, learning environments, family patterns, and the culture and social fabric of communities. These factors result in the rising weaknesses of the vulnerable groups. However, there are positive sides of globalization that open up opportunities for cooperation to improve health and reduce transnational health risks. Such opportunities include enhanced information and communication technology and improved mechanisms for global governance and the sharing of experiences. ■ All sectors and all localities have to cooperate in the operations for further improving the strategies for health promotion. Progress towards a healthier world requires strong political action, broad participation and sustained advocacy. 1.7 Call for Action for Health Promotion From 26 to 30 October 2009, the World Health Organization organized another Global Conference on Health Promotion in Nairobi, Kenya. More than 500 participants from 102 countries worldwide attended the conference. That was the 7th conference held at the beginning of the third decade of health promotion at the international level. The conference reaffirmed the importance and worthiness of health promotion in improving health and quality of life of the people and reducing inequities and poverty. It also supports the call to all stakeholders to cooperate and create participatory actions in health promotion. Moreover, there is a call for action that will lead to the reduction of inequities in health, recognition of the role of health promotion, primary health care and determinants of health, which are important and can complement each other to achieve well-being of the people. The results of the conference provide the directions and strategies for the creation of health promotion that are suitable for present-day situations. In summary, since the concept of health promotion was first endorsed by the important mechanism, i.e. international conference on health promotion, the World Health Organization has played a key role in adopting and implementing such strategies through international/global conferences continually held for sharing experiences in health promotion. To date, seven of such conferences have been held, signifying the importance of health promotion and reflecting the movements of the principles of health promotion that become clearer and clearer. Over the past two decades, the awareness of the benefit of health promotion has caused the movements at all levels of society and areas to improve peopleûs health with the ultimate goal of çhealth for allé.

377 2. Development of Health promotion in Thailand Thailand has had a long experience in health promotion in parallel with health system development, especially çthe management of social and environmental determinants of health in a holistic manner through community participationé, which is the essential meaning of health promotion adopted in Thailandûs public health development. Such development is divided into two major periods, before and after the period of 1997, during which the Thai Health Promotion Foundation (ThaiHealth) was established. 2.1 Health Promotion before the Primary Health Care Era Before the period of the 1st National Economic and Social Development Plan (before 1951), Thailand implemented a number of activities, implicitly according to the meaning of health promotion, namely the management of environments for health in parallel with the provision of health services by the government. Obviously, such activities or projects involved the prevention of major disease outbreaks and environmental sanitation, the eradication of dangerous infections diseases (yaws, smallpox and plague), the development of maternal and child health, nutrition and dental health, and the development/dissemination of modern public health technology to the communities. Moreover, there were the Rural Health Development Project that focused on the improvement of sanitation and water supply for preventing and controlling gastro›intestinal diseases including intestinal parasitic diseases. During the periods of the 1st through 3rd National Economic and Social Development Plans (1951›1976), there were several projects on health promotion and environmen- tal sanitation implemented in a more concrete manner such as the production of nurses and midwives and those involving the development of maternal and child health, nutrition (National Nutrition Development Plan), family planning, community health, and occupational health. Tobacco Control is a concrete example of the health promo- 2.2 Health Promotion in the Movements on tion process leading to changes in society çPrimary Health Careé and çHealth for Allé beginning with the establishment of the Between 1977 and 1987, the first decade of National Tobacco Control Committee in primary health care in Thailand, not only were basic health 1989 and the Group of Health and Media services provided (nutrition, maternal and child health, family Organizations Against Importation of Cigarettes in 1989 thru 1991. Such efforts planning, environmental sanitation essential drug, etc.) as the the brought about the promulgation of the elements of primary health care, the training of village health Tobacco Product Control Act and the volunteers (VHVs) and village health communicators (VHCs) Protection of Non-Smokerûs Health Set in was carried out for all villages throughout the country. That 1992 as well as the increase in tobacco tax was the occurrence of community participation in health de- for the first time in Thailand in 1993. The velopment that is extremely important and has had a long- important event has reflected constant lasting effect until today. During such a period, many com- movements for tobacco control during the first phase before the Thai Health Promo- munity health innovations were created such as village drug tion Foundation was established. funds and community funds for health development in other

378 forms, resulting in the transfer of technology to communities and the development of management skills as well as community participation in self-healthcare and community health development. 2.3 Application of the Ottawa Charter Between 1987 and 1997, even though there had been the implementation of the policy on primary health care and health for all by the year 2000 (Health for All 2000) which resulted in the changes in community participation for rural health development through VHVs/VHCs and several innovations, the situation of urban health development including industries, private agencies and urban residents/communities did not show a significant role in health promotion. However, when the Ottawa Charter on Health Promotion was adopted during the last part of that Decade, the trends in implementing the charterûs strategies also had an effect on urban health promotion efforts, as a result, many projects involving, for example, healthy cities, health-promoting schools, health-promoting hospitals, and health-promoting workplaces. It can be said that decades before 1997 were the decades of health promotion nurturing in Thailand. No Smoking Campaign Thai society has been aware of the danger Several rural health development policies and projects were of tobacco and trying to campaign on non- an expansion of community participation in self-healthcare smoking among Thais for a long time. The and creating supportive environments for health. Over the campaign was seriously started in 1986 two decades of the implementation of the primary health through the No Smoking Campaign Project care policy, opportunities were open for local communities to of the Folk Doctor Foundation. The project take care of their own health through such activities as train- later became the Action on Smoking and ing of VHVs/VHCs and setting up village health funds. In Health of Thailand in 1996, which has been operational until today. Besides, the addition, during that period there were three major initiatives 1987 No-Smoking Campaign running events and changes resulting in a clearer concept and rapid conducted by the young rural doctors was development of health promotion concepts during the recorded as one of the landmarks for following decades; such changes include the control of Thailand in raising public awareness about tobacco consumption, the running campaign against no smoking in public places and the rights smoking, and the promulgation of the Tambon (Subdistrict) of non-smokers in Thai society; the actions Council and Tambon Administrative Organization Act, B.E. against smoking were quite strong during that period and became the key turning 2537 (1994). point in creating the policy and legal The first two projects were regard as those measures against smoking. involving social movements towards the formulation of public policy on the protection of non-smokerûs health, while many tambon administrative organizations (TAOs) established nationwide by the aforementioned Act had their expanded roles covering such health activities as health promotion, disease prevention, and environmental sanitation development.

379 2.4 1997›2006: The Main Road Towards Health Promotion Since 1997, the concept of health promotion has been most clearly and intensively adopted in Thailand; and many continual conditions and activities have occurred and become facilitating conditions for such development. The promulgation of the 1997 Constitution of Thailand was a significant contribution to the development of health promotion strategies as it opened up a new era of participatory democracy and representative democracy which supported and facilitated the participation of all sectors in all development actions including health promotion. The Constitution had many provisions related to health and as a result, health-related activities have to seek public involvement. So health promotion require peopleûs participation so that they will work collaboratively with health personnel as well as other sectors in society to achieve the çHealth for Allé goal in a more concrete manner according to the intent of the Constitution. An annual technical conference, held on 6›8 May 2008 by the Health Systems Research Institute on çHealth Promotion: A New Role of Everyoneé, was the first and clearest concrete action ever taken in Thailand since the concept of health promotion stated in the Ottawa Charter was adopted. The conference was attended The Songkhla Provincial Health Assembly by representatives from several sectors in reviewing the The Songkhla provincial health concept and lessons learned from the charter aimed at mak- assembly began with the understanding the ing çhealth promotioné the role of all sectors in society. fact that health problems cannot be resolved solely by the mechanism of the Ministry of The conclusion made at the conference, çThai Public Health. In 2006, all sectors in society has to have a new imagination about health and change Songkhla province had a consensus that it the strategy from defensive to proactive by giving more was time for them all to collaborate in importance to health promotion and disease prevention as moving the province towards well-being well as civil society to the maximum through the mobilization using the çSongkhla Provincial Health Plané as the theme for provincial health of all sectors in society at the individual, organization and assembly, which was the social forum for all policy levelsé, has become the concepts and movements for public and private sector agencies to jointly health system reforms on the new roads of health promotion learn and push the health plan to be adopted in a concrete manner in the following phase. as the key health policy on moving towards Moreover, the process and products their desirable direction in making Songkhla residents reach to status of well-being resulting from the subsequent national health system reforms are regarded as the environmental factors and an extremely The Songkhla Health Plan clearly specified important origin of present-day health promotion programmes. that during the two-year period (2006-2007) it would be the Provincial Health Strategic 2.5 Health System Reform Plan of Songkhla that would support the The national health system in Thailand programmes of the public sector and other originated from the çNational Health Report: Recommenda- relevant partners through the cooperation of tions for Health System Reform According to the 1997 all public and private agencies including net- work members to learn and work together. Constitution of Thailandé, prepared by a working group

380 under the Public Health Commission of the Senate, Chaired by Professor Dr. Prasop Rattanakorn and the Regulations of the Prime Ministerûs Office, B.E. 2543 (2000), on National Health Reform, the appointment of the National Health Reform Commission (NHRC) and National Health Reform Office (NHRO). Coordinated by NHRO, the goal of health system reform was pushed forward under the philosophy çbuilding health proactively leads fixing health defensively (building health leads fixing health)é. The movement for enacting the National Health Act to be used as a tool for health system reform was another step that significantly affected the development of health promotion. The çtriangle that moves a mountainé strategy, including knowledge creation, social mobilization and linkage with the policy-making or political process, was used in drafting the legislation and pushing forward the health system reform. The process was unprecedented in terms of public participation involving all sectors at all levels and in all areas of society. Finally, it was the movement for changing the method of thinking about health, from focusing on repairing or fixing ill health to building or promoting good health. That was the opening of public forums for the people to participate in making decisions on major issues in the health system reform. The çhealth assemblyé process is a provision in the 2007 National Health Act which prescribes that it is a major mechanism and is efficient in moving reforming and turning the concepts of health promotion into living concrete actions. While drafting the National Health Act, the çhealth assemblyé defined as çthe process in which the public and related state agencies exchange their knowledge and cordially learn from each other through a systematically organized forum with public participation, leading to suggestion of healthy public policy and public healthinessé played a significant role in mobilizing cooperation and generating learning for various sectors as well as a million citizens in jointly revising, developing and promoting health and extensively setting public policies. çThe health assembly process helps all concerned to learn effective ways of health promotion that have an impact in the learning process within the areas of network members as civil society of well-being and supports the healthy public policy process on the horizontal scaleé. The success of çhealth assemblyé has been evident in a concrete manner is several provinces as it becomes a public forum for pushing forward health development which has health promotion as the core element.

381 Health assembly, Nakhon Pathom province: Community learning curriculum for Nakhon Pathom residents The health assembly in Nakhon Pathom province was originally formed in response to the water pollution problem in the , which is like a blood vessel for residents of the province. The assembly was attended by representatives from çhouseholds, Wat (Buddhist monasteries), schools and communitiesé and emphasized public policies affecting health. The working group of the assembly presented the knowledge and situation synthesized from the real events for use in drafting the National Health Act; and several other activities were held, i.e. an exhibition on environmental conservation, talks on waterways and health, conservation tourism, and water resource management; çrecommendations on health policies and strategiesé were made and pushed forward for adoption for developing a teaching/learning curriculum related to health. ● Pushing for adoption and translation of policy into action. The mechanism and action of local group leaders had led to the adoption and use of the curriculum in a concrete manner, especially in the case of çTha Chin Riveré, making the process even stronger and more powerful in the movement. Besides, after the provincial health assembly, the process was adopted for other issues in almost all forums that were seeking ways to resolve local problems and draw up policies/strategies on such matters. Finally, the çcommunity learning curriculumé was successfully drawn up by and for the communities.

The health system reform process, especially the drafting of the National Health Act, cannot only be regarded as having resulted in the health system development, but also in health promotion relating to the rethinking of the health concept using the çbuilding health leads fixing healthé approach and the viewing of health in a broader perspective. 2.6 The Inception of Thai Health Promotion Foundation The inception of the Thai Health Promotion Foundation (ThaiHealth) in 2001 is regarded as the most important landmark signifying the strength of health promotion in Thailand, as a result of the campaigns against smoking conducted during the previous decade. After all academic, social and public sectors had worked together for some time, they proposed that a legislation be passed to collect taxes on alcohol and tobacco and that a health promotion fund be set up as a public organization. In July 2000, the Royal Decree on Establishing Health Promotion Fund was enacted and later the Thai Health Promotion Foundation Act was enacted (on 8 May 2001); the Act prescribes that 2% excise taxes be collected on tobacco and alcohol for setting up the Health Promotion Fund. That was the formal establishment of the Thai Health Promotion Foundation. At present, ThaiHealth is a state agency under the supervision of the Prime Minister that is not under the bureaucratic or state-enterprise system. The responsibilities of ThaiHealth are to advocate, stimulate, support and provide funding to various organizations in society for health promotion activities with no framework limitations. Rather, ThaiHealth is open to new or creative ideas or approaches that will lead to the expansion of values and creation of health behaviours for the people in an efficient and extensive manner.

382 It is a new model of health agency according to the resolution of the World Health Assembly on support for health promotion. ThaiHealth operates with the vision of çSustainable Health for Thai Citizensé and the mission çpromote, support and develop health promotion process leading to sustainable well-being of Thai people and societyé, with the aim of çbeing a small agency that carries out a big task, whose impact is the higher level of quality of life of Thai peopleé. It normally works with and among members of networks or partners with several mechanisms composed as çThai health systemé that has the meaning broader than hospitals and the Ministry of Public Health, but also covers other agencies of various ministries, including local government organizations, community organizations, non-governmental organizations, and other private sector agencies. ThaiHealth operates without using state power but with a limited number of personnel and a limited budget and the three-power or çtriangle moving a mountainé strategy. First, intellectual power including wisdom space for extensively expanding the scope of health. To make this effort efficiently, the knowledge from all sectors needs to be gathered; and it has been further developed in response to changing situations and according to the context and the needs of target groups. The body of knowledge coupled with the learning process of all sectors will expand the wisdom space and create the great intellectual power for health promotion. Second, social power which is the expansion of social space to extensively cover social partnerships for mobilizing power, which is necessary for working, campaigning and monitoring of health promotion activities in a continuous manner. However, such an effort needs to be made in an integrated fashion with joint actions for skill development together with all network members with the same ideology and goals; all of them have to be properly linked to expand social space and create a driving force for health promotion. Third, policy power which is the expansion of space of participatory policy process; policies generate systems and structures as components for health promotion that will affect the people in a broad scale with a lasting effect longer than short-term campaigns. In particular, policies that are developed with wisdom and multisectoral cooperation will be acceptable, resulting in practical cooperation and sustainability (http:// www.thaihealth.or.th/about/get-to-know). ThaiHealth deploys four channels in promoting health, i.e. health promotion through çissuesé (such as alcohol, tobacco, food, etc), çorganizationsé such as educational institutions, workplaces, etc, çcommunities or areasé, and çtarget groupsé. At present, ThaiHealth has 13 programmes, namely Tobacco Consumption Control; Alcohol Consumption Control; Traffic Injury and Disaster Prevention; Health Risk Factors Control; Health Promotion for Specific Population Groups; Health Promotion in Communities; Health Promotion for Children, Youths and Families; Health Promotion in Organizations; Physical Activity and Sports for Health; Social Marketing; Open Grants and Innovative Projects; Health Promotion through Health Service Systems; and Supportive Systems and Mechanisms Development for Health Promotion. Over the past decade, ThaiHealth has significantly created impacts and movements in health promotion in Thai society extensively in many dimensions/areas and all levels, for example: ■ Cooperation with the Alcohol Beverage Control Committee, the Centre for Alcohol

383 Studies, civil society and the Stop Drink Network in pushing for the enactment of the 2008 Alcohol Beverage Control Act. ■ Working, in collaboration with local and international partners and networks (the Ministry of Public Health, the National Tobacco Consumption Control Committee; the Thai Health Promotion Institute, and the Action on Smoking and Health, Thailand) on effective and powerful movements for adoption of policies, legislation, law enforcement related to tobacco consumption control. Such efforts include the establishment it the Tobacco Control Research and Knowledge Management Center (TRC) and the Thai Health Professional Alliance Against Tobacco, the drafting of the Framework Convention for Tobacco Control (FCTC) and becoming one of the Parties of the Convention, and the movement for increasing the tobacco tax to 80% in 2007. ■ Support for the reduction of road traffic accidents by urging the government to adopt road accident problems as a national agenda by establishing the Road Safety Operations Centre and the Committee on Road Safety Operations to oversee activities related to road safety especially law enforcement, traffic engineering, public education, public relations, etc, as well as other proactive operations. ■ Encouragement and cooperation with various sectors in establishing networks for the empowerment of families and communities for all age groups throughout the country; one of such activities was the development of systems for classifying TV programmes (TV programme rating). 2.7 Community Health Fund Health promotion systems in Thailand during this decade are carried out through the National Health Security Act, B.E. 2545 (2002), which guarantees universal access to health care and has incorporated the çbuilding rather than fixing healthé concept into the basic benefit package for health-care recipients. Such an effort has been made by allocating budget for health facilities to carry out health promotion activities in parallel with curative care. Moreover, the Act also supports the establishment of a çCommunity Health Fundé at the subdistrict (tambon) level to chiefly finance health promotion activities. The çFundé is defined as a local or community health security fund responsible for health supporting health promotion, disease prevention, rehabilitation and primary medical care essential for livelihood, according to an announcement of the National Health Security Office pursuant to the 2002 Act. 2.8 Statute on National Health System: The Future Dream The movements on National Health Act resulted in the promulgation of the 2007 National Health Act, which prescribes that a statute on national health system be drawn up. According to the original intent, during the National Health Act drafting process undertaken by members of all relevant partners in the health system movement during the last decade, the legislation was expected to serve as a master law on health or Health Constitution. But before the Act was actually enacted, there were revisions in certain parts of the draft law, taking out the part that dealt with desirable image and details of health subsystems, but prescribing in section 25(1) that the National Health Commission (NHC) has

384 duty to prepare a çStatute on National Health Systemé for use as a framework and guide for setting policies, strategies and procedures of various sectors of the country. This is to ensure proper directions of national health system reform with clarity and power showing the commitment of society; and the statute covering at least 12 subsystems must be reviewed/revised at least every five years so that the framework for setting the future image of the health system will have dynamism and can be used for resolving problems and providing direction for the national health system according to changing situations. The Act also prescribes that the Statute on National Health System, approved by the cabinet, shall obligate all state and other relevant agencies to take action within their own duties, according to Sections 46, 47 and 48 of the 2007 National Health Act. The National Health Commission prepared the 2009 Statute on National Health System, which prescribes the principles for the participation and hearings of all sectors based on technical information and the knowledge management approach so that the Statute will reflect the joint intent and commitment of society to use it as a reference in setting their directions and goals until the year 2020. The 2009 Statute on National Health System was endorsed by the Cabinet on 30 June 2009 and then submitted to members of the National Assembly (both the House of Representatives and the Senate) and published in the Government Gazette Vol. 126, Part Special 157 D (Ngor) on 2 December 2009. In the Statute on National Health System, health promotion is one of the 12 essential matters required by law and elaborated in Chapter 4 of the Statute with principles, objectives and measures. The principles specified in the Statute are as follows: Health Promotion must be undertaken to create holistic well-being for all in society, to primarily decrease morbidity, disability, and untimely death, and to lessen health costs in accordance with the concept çhealth promotion comes before health repairé. Health promotion is to be comprehensively implemented at every level, from conception to the final moment of life, with at least the following five strategies: 1) Building healthy public policy 2) Creating supportive environments for health 3) Strengthen the community according to the principle of sufficiency economy, with empha- sis on participatory development 4) Developing health-related skills of the individual, family and community 5) Reorienting public health services system to strengthen the publicûs health. Under the aforementioned principles, the four goals or objectives specified for accomplish- ment by 2020 are as follows: (1)To put in place the development of a concrete and participatory healthy public policy for good health. (2)To put in place the environment and surroundings in a variety of tangible ways to facilitate the publicûs health. (3)To put in place health promotion for the individual, family, community and society in a balanced and interconnected manner in accordance with the principle of health promotion.

385 (4)To put in place strong health efforts covering 80% of all the subdistricts in the country.

The future scenario and direction of health promotion in Thailand prescribed in the 2009 Statute on National Health System shall be legally binding, according to the social intent, upon relevant state agencies, partners and civil society organizations in the performance of health promotion activities of their powers and duties in a unified and forceful manner.

Statute on National Health System, B.E. 2552 (2009) Chapter 4: Health Promotion Measures: The State shall encourage state agencies at all levels and all social sectors to develop participa- tory healthy public policy based on an adequate knowledge and involvement of all sectors throughout the process so as to bring about good public policy. State agencies shall arrange to develop policies and plans to accommodate the development of healthy public policy and implement them in a concrete manner on a regular basis. The State shall support state agencies at all levels and all social sectors to develop the environment and environmental conditions in a healthy manner covering the physical, biological, economic, and social dimensions, e.g. management of public parks, health parks, sports grounds, community grounds, healthy workplaces, healthy urban communities, healthy town planning, safe transportation systems, good water management systems, and healthy agro- industrial systems, etc. The State and various sectors shall promote and support education and exchange of learning of the individuals, families, and communities in order to generate knowledge and skills in the way of life and promotion of health. This will eventually lead to individuals, families, and communities having a greater capacity to look after themselves and becoming increasingly self-reliant on a continual basis. This will include the opening up of more public spaces and the development of tools and innovation taking into account the social context, geo-ecological culture and local wisdom in response to changes in an informed manner. The State and various sectors shall promote and support the strengthening of individuals, families, communities, and networks, including promotion of the distribution of essential medicines, medical supplies, knowl- edge and technologies in a sufficient and all encompassing manner, aiming to encourage self-care and self-reliance in the health of individuals, families, and communities. The State shall promote and support public participation and capacity building towards the preservation and protection of natural resources, as well as the environment and environmental conditions, in a healthy manner. The State and various sectors shall develop financial and fiscal measures to support the promotion of health and quality of life of children, youths, women, people with disabilities, the elderly, and the socially disadvantaged. This will be done with an emphasis on management at the community level for sustainable development, including promoting the development of a community welfare system, community funds, and various community activities aiming at the promotion of holistic health. The State and all social sectors shall promote knowledge generation and management, research, technol- ogy, capital and marketing in order to develop healthy and environmentally friendly agriculture, industry, business, and services, with an emphasis on social responsibility, such as promotion of organic farming using chemical-free pesticides, promotion of community-friendly and environmentally-friendly industry, and the promotion of businesses and services that do not have negative impacts on health. The State shall arrange to develop strategic plans on sexual health and reproductive health on a partici- patory basis and support their implementation in a concrete manner. The State shall support the development of laws pertinent to the development of sexual health and reproductive health.

386 3. Reorienting Health Promotion in the Future According to the past and present-day experiences, the health promotion system in Thailand has progressed a great deal with a tendency to expand or branch out into several dimensions and directions. This is due to the fact that structural and systemic conditions have been designed to facilitate such an expansion, including, the 2009 Statue on National Health System, the 2007 National Health Act, health assembly mecha- nisms (national and local), the Health Promotion Fund, community health funds, expanded roles of local government organizations, etc. All of these conditions/mechanisms are favourable to the strength and growth of health promotion. Health assemblies (area-based, issue-based, and national) will be social space for the participation of all sectors in creating, monitoring or evaluating public policies and resultant effects. Meanwhile, a large number of local government organizations have taken development actions and learned to see and use health issues as their operational policies and objectives. Nevertheless, trends in social and global changes together with intensive globalization may cause both crises and opportunities for health promotion. In the future, the social, economic and political problems and conditions of the country and the world may change in the following aspects which may require attention in dealing with health promotion in the future: 3.1 Globalization and Changes in Peopleûs Health Problems The world including Thailand, in the not-too-far future, will be facing the change in the population structure, i.e. ageing society with fewer births, longer life expectancy and a larger proportion of elderly people. As a result, there will transboundary labour migration as well as economic, cultural and technological globalization, which will result in changes in lifestyles and food consumption, global climate changes, natural disasters, etc. Such conditions will be the determinants of changes in their peopleûs health problems in the next decades. Chronic diseases such as diabetes, hypertension, cardiovascular diseases, paraly- sis, etc, resulting from unsuitable eating patterns and lifestyles, have become a more important health problem compared with infectious diseases. However, a number of emerging diseases (SARS, avian flu) and re-emerging diseases (tuberculosis, malaria, filariasis, dengue haemorrhagic fever, etc.) are still health problems linked to climate change and population migration, especially in the working-age group, due to international economic and political disparities and globalization, Besides, problems related to global disasters are expected to be clearly on the rise. Such problems will be conditions and challenges to the national health problems and a proof of the worthiness of health promotion and disease prevention efforts, not merely facing new problems, which are hard to solve and complicated, but there will be factors affecting the situations in many different groups in society.

387 3.2 Changes in Social, Economic, and Political Context Affecting Peopleûs Lifestyles and Well-being The intensified globalization at present and in the future will affect Thaisû lives and social conditions in many aspects. Thai society is facing both crises and opportunities. The social crisis we faced in the past still prevails as called çcompounding crisisé, including being in a confusion trap (a directionless society; no one knowing when the confusion will end; unconfidence in the countryûs situation resulting in the slow-down of investment, consumption and employment, and inducing a vicious cycle of economic recession that might have an impact on society); a conflict trap (Thai society having never experienced this kind of conflict before; being divided into different groups with conflicts that may lead to violence); an uncompetitive trap (the countryûs competitiveness index having been steadily declining in terms of macroeconomic, public sector efficiency, private sector capacity and infrastructure dimensions); and a disparity trap (gaps between the rich and the poor, and gaps beginning to appear for power, wealth and opportunities between the informed and the uninformed). Such traps seem to have been affecting the lifestyles and rhythms of pace in the future of Thai society; and it is hard to say by how much and for how long. The external economic and political fluctuation remains a threat to the countryûs economic and political stability. Even though the financial crisis and economic recession in the West have declined and the overall economy has had a sign of recovery, other forms of crisis, such as natural disasters and environmental degradation, are risk factors for political and economic stability at all times (such as the dry-up of the Me Kong River, believed to be part of large development projects in the countries upstream, affecting all the countries downstream having to face droughts resulting in a declined paddy yield and a fight for water for rice planting in all regions of the countries). Poverty and socio-economic disparities will continue to be the determinants of health, while the political conflicts have resulted in a decline in political ethics, but the popular sectorûs role in polities has become more evident in a non-formal manner. In the social sector, emerging lifestyles resulting from previous development programmes are çhaving an impact on the change in population structure from the family level to the large society level which is more complexé. Such lifestyles have caused changes in urban families; working-age people tend to focus on earning income to build up financial status rather than having a family. So, they get married at an older age and have fewer children, resulting in a lower proportion of child population and a 1:2:4 crisis in the future (a social crisis when one grandchild has to take care of two parents and four grandparents). Such a condition causes the children of new generation to become isolated without any personal relationship with other people, living in his/her own world; they do not know themselves and tend to be fragile users/consumers, not producers. Emerging lifestyle results in over consumption, particularly consumption of sign rather than utilities. Changes in social, economic and political conditions will be contextual conditions leading to new questions that are challenging to health development and health promotion, which are profoundly associated with social determinants of health with an expanded scope of health too large to define.

388 Chapter 9 Lessons Learned from the Control of Pandemic (H1N1) 2009 in Thailand

1. Introduction Pandemic (H1N1) 2009, or pandemic influenza H1N1, 2009, [initially called influenza A(H1N1)] is caused by the H1N1(2009) virus (or H1N1 2009 virus), in the group of A(H1N1) viruses, first reported in April 2009. The genetic composition of the virus is a combination of those found in avian, swine and human viruses. It is unknown as to how and where the virus originated and how/when the virus was transmitted to humans. As the virus can rapidly spread from human to human, the influenza is regarded as an important emerging disease. The disease control involves the following measures and strategies: 1.1 Early detection. Emphasis is placed on disease surveillance, research and laboratory testing so as to detect the virus as quickly as possible. As an emerging disease, 60% of the cases occur in animals and then spread to humans, it is necessary to conduct surveillance programmes in both animals and humans in the same linked system. This is to ensure that as soon as an outbreak occurs in animals, which may be transmitted to humans, disease control efforts can be made immediately so that the disease will not widely spread from human to human. The H1N1 2009 virus was first detected in humans before being detected in animals, which was too late as the virus had already spread widely in the U.S.A. and Mexico at about the same time. 1.2 Containment. In theory, for an outbreak of a new kind of influenza with human-to-human transmission, in the beginning stage of the outbreak, say within 3 weeks, there would not be so many patients, there is an opportunity to prevent the spread of the outbreak using all strict measures such as screening and isolation of symptomatic cases, quarantine of contacts or travellers from an infected region until it is certain that such persons do not have the disease and can be allowed to live a normal life, or giving antiviral prophylaxis to all contacts or targeting antiviral prophylaxis for the entire community, or geographical antiviral prophylaxis for the entire district or province. The containment measure to stop the outbreak will affect the freedom of people as well as domestic and international travel and trade. So, it should be used only during the beginning stage of disease control. As it was rather late when pandemic (H1N1) 2009 was detected, the transboundary transmission had already occurred, the disease containment could not be undertaken and it was

389 not worth while compared with the disease severity. That was why the U.S. did not use this measure despite being a country with technical strength and preparedness in almost all aspects. 1.3 Mitigation. After the disease has spread widely, the disease control will focus only on essential measures including treatment of symptomatic cases, prevention of new infections through non- pharmaceutical interventions, behavioural changes (hand-washing, use of face masks when ill, avoidance of social activities by staying at home, not going to school, school closing, stop working or stopping all social activities for a certain period of time. For instance, in Mexico, the Mexican president announced an emergency situation and closed all schools across the country and cancelled all social gatherings between 25 April and 6 May 2009. Meanwhile, research has to be carried out to seek pharmaceutical interventions such as medicines or vaccines to minimize morbidity and mortality to the extent acceptable. 1.4 Elimination and Eradication. If the infectious agent has it life cycle relying on and multiplying only in humans and most patients have clear clinical symptoms, chances are high to eliminate and eradicate the disease with various measures. But for the H1N1 virus, its life cycle is in birds, domestic poultry and many kinds of mammals such as pigs and humans. About one-third of the patients may be infected with mild symptoms. So, it is impossible to eliminate or eradicate influenza. There will be already a new strain of H1N1 influenza caused by a new virus which is close the old virus against which humans have some immunity, or totally different from the old strain. In the latter case, the outbreak will occur and rapidly become a pandemic. 2. Chronology in Thailand and Abroad The major events related to pandemic (H1N1) 2009 in a chronological order are briefly as follows:

2.1 Mar 2009 (1) 18 March: Mexican authorities began picking up cases of çinfluenza-like illnessé but understood as seasonal influenza. 2.2 Apr 2009 (1) 12›21 April: Cases of atypical pneumonia with 2 death were reported in Oaxaca, Mexico. (2) 23 April: The U.S. Centers for Disease Control and Prevention (CDC) announced the identification of a new influenza virus strain, untypable influenza A, in California. (3) 24 April: The Mexican Ministry of Health issued an epidemic alert for severe influenza. WHO warned of the pandemic potential through the International Health Regulations focal points in Member States. (4) 25 April: The Ministry of Public Health (MoPH) through the Department of Disease Control, Thailand, set up an operations centre to cope with the epidemic in Mexico. The media began covering news of çswine flué from CNN.

390 (5) 27 April: WHO raised its alert level from 3 to 4 (on a scale of 6), indicat- ing human-to-human transmission in a locality. (6) 27 April: MoPH of Thailand proposed that the disease be called çMexico influenzaé rather than çswine flué to avoid confusion among members of the public and an impact from non-consumption of pork; the suggestion was informally sent to WHO. (7) 29 April: The National Influenza Control Committee held a meeting to review the measures for disease control in the country. (8) 29 April: WHO raised the alert level from 4 to 5, indicating transmission from one area to another but no more than 2 regions. 2.3 May 2009 (1) 7›8 May: ASEAN+3 Health Ministerûs special meeting on influenza A (H1N1) was held in Bangkok to review measures for the region. (2) 12 May: Thailand reported the 2 cases of influenza A(H1N1), both were Thai nationals who just returned from Mexico. The media had an obser- vation that MoPH was not transparent as no information was disclosed regarding the patientsû age, address and hospital providing treatment; MoPH responded that the non-disclosure was done at the request of the patients and their relatives who feared social discrimination. (3) 30 May: The date of illness onset of the first case who got infected within the country was reported from the family whose parents had just returned from the U.S.A. and spread the virus to their son who did not travel overseas with them. 2.4 June 2009 (1) 9 June: MoPH confirmed human-to-human transmission in the country among workers at an entertainment place in Pattaya City, initially with the notification from the Taiwanese disease control agency of a Taiwanese getting infection while travelling in Thailand. (2) 10 June: Confirmation of an outbreak in a private school in Bangkok. (3) 11 June: WHO raised the pandemic alert level from 5 to 6, the highest level, indicating that there had been outbreaks throughout the world with infected persons in 74 countries and the transmission could no longer be controlled and contained, resulting in unavoidable widespread. (4) 13 June: Confirmation of an outbreak in a state-run school in Pathum Thani province. Newspapers reported widespread transmission of the illness. (5) 21 June: MoPH officials and professors of medical schools informed the public on TV not to panic.

391 (6) 20 June: The first death occurred but was reported to MoPH on 26 June as the private hospital treating the patient did not notify MoPH. A press briefing was held on 27 June and there was a suspicion that MoPH concealed the information. (7) 23 June: As notified, an outbreak investigation was conducted at a naval base in Sattahip district, Chon Buri province; later, one private died on 29 June. (8) At the end of June, there were cases reported from 39 provinces and 3 deaths (cumulative number). 2.5 July 2009 (1) 4›8 July: A long weekend during the Buddhist lent, many people went upcountry, resulting in a widespread of the disease throughout the country. (2) 7 July: The Cabinet passed a resolution to close down all tutorial schools for 2 weeks as they were the places where students from many provinces gathered. The schoolsû operators met with the minister and administra- tors of MoPH to express their disagreement. (3) Patients were crowding all public and private hospitals in Bangkok; private rooms had to be booked in advance. (4) MoPH was strongly criticized for the errors in situation assessment, resulting in the people being careless in self-protection and a large number of illnesses and deaths. (5)‹ 14 July: The Cabinet passed 3 major resolutions: allowing H1N1 patients to stop work without counting non-workdays as leave-days; providing an additional 10 million tablets of antiviral drug (worth 250 million baht); and placing an order for 2 million doses of vaccine (worth 600 million baht). (6) 14 July: The administrator of the Bangkok Metropolitan Administration announced the closure of all 436 BMA schools for 1 week. (7) Many secondary school students from other provinces went to a concert played by a band of teenage Korean singers in Bangkok; many of them returned and spread the virus in such provinces as Ubon Ratchathani, Nakhon Ratchasima and Khon Kaen; and some died in Maha Sarakham. (8) A meditation at Wat Dhammakaya in Pathum Thani provinces was attended by more than 100,000 students; some of them returned home with the infection and transmitted the virus to others, causing further outbreaks in their localities.

392 (9) 17 July: Clinical Practice Guidelines, third edition, was launched for patient care across the country. (10)17 July: The prime minister, as chairperson of the Thai Health Promotion Fund Committee appointed a Subcommittee on Support for the Prevention and Control of Pandemic (H1N1) 2009 to take part in campaigns for the participation of the public and all sectors against the pandemic influenza. (11)As of the end of July, there were reports of H1N1 patients in 76 provinces with the cumulative death toll of 65. 2.6 Aug 2009 ■ For H1N1 patients to receive antiviral drug çoseltamiviré sooner, MoPH requested that private clinics join the pandemic influenza treatment programme, but a small number of them (about 10%) agreed to participate. ■ MoPH in collaboration with WHO undertake a review of the pandemic influenza control programme in Thailand. ■ As of the end of August, there were reports of H1N1 patients in all provinces, from 85% of the districts throughout the country, with the cumulative death toll of 130. 2.7 Sept 2009 ■ The outbreak situation became less severe. As of the end of September, there were reports of 165 deaths cumulatively. 2.8 Oct › Nov 2009 ■ The first wave of outbreak became less severe and the incidence was lowest in November. 2.9 Dec 2009 ■ MoPH began warning of a second wave of outbreak. 2.10 Jan 2010 ■ The second wave of outbreak began. ■ 11 Jan: vaccination campaign was launched with 2 million doses of inactivated vaccine. 2.11 Feb 2010 ■ Newspapers reported on the foetal death in a pregnant women vaccinated with H1N1 vaccine; as a result, many in the target populations did not come to get vaccination ■ An expert committee was set up to investigate and confirm whether the foetal death and motherûs illness were associated with the vaccine. 2.12 Apr 2010 As of 2 April 2010, MoPH could get 28,674 pregnant women vaccinated with 31 cases of adverse drug reactions, among them, 15 were non-severe and 16 were severe (9 foetal deaths, 4 abortions, 1 head accident, 1 severe allergy and 1 pulmonary hypertension). Of all ADR cases, only one was considered by the committee as related to the vaccination, i.e. the case with pulmonary hypertension; the rest were unrelated. 393 2.13 June › July 2010 The committee recommended that vaccination for pregnant women be continued as the rate of irregularities during pregnancy among pregnant women was not higher than that among pregnant before the vaccination campaign. 2.14 Dec 2010 MoPH warned of the outbreaks of new and old strains of H1N1 influenza, i.e. seasonal influenza and mostly H1N1 influenza 2009. As of 11 December, there were 110,815 reported cases of all stains of influenza with 168 deaths, of whom 143 were due to H1N1 2009 influenza and 25 due to unknown strains.

3. Strategy for Morbidity Reduction As pandemic (H1N1) 2009 is transmitted from human to human, detecting many cases of the illness at about the same time and the same place is a preliminary indicator of an epidemic at the particular place. In practice, the Department of Disease Control has proposed that if more than 5 cases are detected during a one- week period, it is regarded that an outbreak has occurred in that place. Major measures for outbreak control are as follows: 1) Self-isolation. Any patient with respiratory or influenza›like symptoms is to get medical treatment at home for 7 days (in case of severe symptoms or at high risk of serious illness, he/she should see a doctor immediately). 2) School or public place closure. Activities are suspended at places with public gathering such as school classes or the entire school or entire factory, etc. If the morbidity rate is greater than 15%, a joint decision should be made in this regard by school administrators and others concerned such as the parents association and public health officials, taking into account the impacts in all aspects. 3) Hand hygiene. Campaign on hand-washing for every body. 4) Clean touching-surface. Cleaning all materials, supplies and equipment normally or commonly touched by many people such as telephone, keyboards, door knobs, etc. 5) Face mask. One with symptoms of cold/influenza is advised to wear a surgical mask. 6) Screening. Screening of people so that those with influenza-like symptoms will not participate in any group activity. After the outbreak in Thailand was confirmed in June 2009, outbreaks occurred in many places; some interesting events are briefly described below: 3.1 Schools In Thailand, there are schools under the Ministry of Education in all subdistricts, districts and provinces throughout the country with a total of approximately 12 million pupils (in primary and secondary

394 schools) and 2 million college/university students. As of 19 October 2009, there were reports on outbreaks and closures of 476 schools. According to disease investigation reports, the important features of the outbreaks are the following: 1) Overall morbidity rate: approximately 9.2%-65.1%, depending as the characteristics of schools and activities. 2) Epidemic-inducing activities: new student reception (hazing) parties, camping with shared room and board, inter-institutional sports events, army reserve force training, marching band practice camping, concert attendance, and meditation retreats. 3) Physical conditions inducing epidemic: a large air-conditioned school classroom with too many students numbering more than the specified standard, resulting in students having to sit too close to one another. 4) Obstacles to control measures: the students who were sick did not stop going school for fear of being unable to catch up with class or there was no caregiver. Some schools were closed when the epidemic was not so widespread, but after the school was reopened, the re-outbreak occurred. The screening measures could not be undertaken in practice such as temperature taking, students had no regular classroom (having to move to different classrooms), and there was no isolation room for a sick student while waiting for the parent until the time to go home. 3.2 Entertainment places There are a lot of entertainment places in Thailand, but those with reported outbreaks were such places as night clubs (with singing and dancing) in the provinces with tourist destinations. Besides, viral transmission was found at concerts, music festivals and movie theatres with the following interesting characteristics: 1) The overall morbidity rate among workers: 33% 2) Epidemic-inducing activities: crowded places with singing and dancing, having no separate water-drinking utensils for workers. 3) Physical conditions inducing epidemic: a tightly closed place, air-conditioned with no ventilation and too many revellers exceeding the specified standard. 4) Obstacles to control measure: closing of a business would result in a loss of income and workersû unemployment; not being able to thoroughly educate all the revellers, and screening all revellers could not be done in practice. 3.3 Military barracks Outbreaks in barracks were reported only during the training of new conscripts in June 2009 such as at the Sattahip Naval Training Camp, the Phetchabun Army training Camp and theNakhon Ratchasima Army Training Camp (personal communication, Major Kritin Silanan). 1) Morbidity rate: 16.8%›29.5%

395 2) Epidemic-inducing activities: having to live closely together for weeks or months during the training; being conscripts from various provinces; and arduous training. 3) Physical characters inducing epidemic: using some utensils together such as glasses. 4) Obstacles to control measure: screening of first cases of illness and preventing them from taking the training. 5) Good example: as it had a good command and support system, symptomatic cases could be isolated to live together in a cohort ward for 7 days. 3.4 Prisons MoPH received outbreak reports from at least two prisons (Saraburi and Ayutthaya). 1) Morbidity rate: approx. 18.9%›20.51% 2) Epidemic-inducing activities: good-behaviour prisoners who did community services might have contacted with an H1N1 patient; then he/she might carry the virus and then transmit it to other prisoners or to relatives on a çmeeting-relatives dayé. 3) Physical activities inducing epidemic: overcrowding; sleeping in a room closely together with many other prisoners; and using the same drinking utensils. 4) Obstacles to control measure: inability to reduce overcrowding in prison cells; lack of water for hand washing; lack of face masks. 5 Good example: modifying a prison cell as a cohort ward. 3.5 Hospitals There are community, general and regional hospitals in all districts and provinces as well as private hospitals with a total workforce of approximately 450,000. Outbreaks were reported among personnel of many hospitals such as those at radiology departments of two hospitals, operating room staff of a general hospital in the South, and a medical school in the central region. And there could be some patients who came for treatment of other illnesses but might get infected with the H1N1 virus in the hospital. 1) Morbidity rate: as there was disease investigation that could confirm H1N1 infection, the immunological study could be used to determine how many health-care providers were actually infected. However, the infection could possibly be within or from the community. 2) Epidemic-inducing activities: relatives with H1N1 infection visiting patients with H1N1 influenza and other diseases staying in the same ward. 3) Physical activities inducing epidemic: common examination room; central air-conditioning of the common room. 4) Obstacles to control measure: screening of relatives visiting the patients; it was difficult to do as the hospital had several entrances and exits. 5) Good examples: setting up a special clinic (flu clinic) for H1N1 patients; requiring the patients and relatives to wear surgical masks when coming into the hospital; having cleansing gel at various places in the hospital.

396 4. Strategies for Morbidity Reduction As of 20 January 2009, MoPH had received reports of 198 deaths (97 males and 101 females) since the beginning of the outbreak. Of all deaths, 11 were children under 5 years old, 10 were school-age and teenage children (5›14 years), 27 were teenagers and young adults (15›24 years), 127 were working-age adults (25›59 years), and 23 were elderly persons (60 years and over); and among them, 129 (65%) had a history of co-morbidity including overweight or obesity (22 cases) and pregnancy (12 cases), etc. To reduce mortality, MoPH undertook two major measures as follows: 4.1 Rapid Diagnosis and Retroviral Therapy Even though there are guidelines for the antiviral therapy for H1N1 patients with serious illness and probably with any chronic disease, and the H1N1 influenza outbreak just occurred from June to July, there was confusion about how to care for the patients by the people and the attending physicians. Among the people who had been keeping themselves abreast of the situation, when getting sick with the disease, they would see a doctor immediately even though the condition was not serious. On the contrary, a number of patients who were seriously ill or at risk of being seriously ill did not quickly seek medical treatment. Besides, the physician still provided medical care as if the patients had seasonal influenza without giving any antiviral drug oseltamivir. So, it was found that among the fatal cases, there were those who had seen the doctor more than 48 hours after onset or those also given antiviral drugs. Thus, in mid-July 2009, MoPH together with experts from various universities developed the Clinical Practice Guidelines for Care of Patients Infected or Possibly Infected with Pandemic H1N1 2009, which covers the guide for diagnosis, treatment and self-care when ill. The guidelines helped ensure that the services were rendered according to the established standards and lessen the confusion in this regard; however, a number of physicians were unaware of such guidance, indicating the problem of communication in the medical system. 4.2 Vaccination for Vulnerable Groups. The Cabinet approved the purchase of 2 million doses of vaccine against pandemic H1N1 2009, worth 600 million baht, for vulnerable groups at risk of severe illness or death. The vaccine purchase order was placed in August 2009 and the vaccines were actually received in late December 2009. The vaccination of vulnerable groups was started on 11 January 2010, especially for approximately 500,000 pregnant women, 180,000 obese persons (weighing >100 kg), 70,000 persons with mental disabilities or self-care inabilities, 840,000 patients aged 6 months to 65 years with chronic illnesses (lung, heart, liver, kidney, blood, immunity, diabetes, etc.), and 370,000 health personnel directly involved with patient care. 5. Major Lessons Learned from Emergency and Crisis Management Overall, Thailand was able to control the disease in the same manner as other developed countries. In the beginning stage of the outbreak, it was estimated that there might be as many as 1,200 deaths due to H1N1 influenza. A situation review revealed that the estimate might be too high and could be adjusted downwards to 900. However, based onthe data as of January 2010 with the death toll of 198, the total number

397 of deaths might be only 300 to 400. Thus, MoPHûs operations might be able to save almost 500 lives. And obviously, the morbidity could be delayed, i.e. rather than having only one wave of outbreak, there were actually several waves. However, many important lessons were learned during the first three months of the outbreak as follows: 5.1 Coordination and Command In the beginning of the outbreak, there were only patients infected from aboard (April › May 2009). The coordination and command were undertaken by the Emergency Response Operations Centre at the Department of Disease Control. Meetings were held every day (even on Saturdays and Sundays), twice a day during the initial stage in the morning and afternoon, for central-level officials and those at 12 regional offices for disease control, using the teleconference technology. When the outbreak was initially reported in the country, WHO announced that the disease had become a pandemic. As a result, the coordination and com- mand was raised to the ministerial level. However, some problems in this regard were noted as follows: a) Lack of unity and powers in making assignments and directives. Compared with the SARS outbreak control, which had a smaller scale and less complexity, a war room was established and full authority was delegated to one of the deputy permanent secretaries with full support in all aspects. But during the outbreak of pandemic H1N1 2009, which had a larger scale and more complexity, the unity of command was lacking; reports submitted to high-level administrators were not systematically distributed to all concerned. As a result, the operating units could receive the outbreak information (such as the numbers of infected persons and deaths) chiefly from the press briefings. b) Communications from the central level to the provincial and district levels, especially on technical guidelines and ministryûs announcements, were done via the Internet when such information was posted on the ministryûs websites, which were designed for easy follow-up as to which items were new or old and what the changes were. No other channels were used to inform all operating officials at the provincial level to see the details on the websites. However, short messages were sent via mobile phone to all physicians later. 5.2 Risk and Crisis Communication In the beginning, MoPH could effectively communicate with the public with the message that the outbreak was caused by human-to-human transmission; so, it should not be called çswine flué as some people would not want to eat pork. Thus, the name of the disease was changed initially to çMexican influenzaé and later to çpandemic H1N1 2009é, which was generally accepted by the media and the public. But later on, there was a failure in risk communication, beginning with the mediaûs observation that MoPH had concealed certain details. At the first press briefing, no information was given about the patientsû age, the country they had travelled to, and where they were being hospitalized. The ministry did not disclose such information at the request of the patientsû parents for fear that the patients would be discriminated by their friends. Later on, a major turning point occurred on around 10 June 2009 when there were outbreaks at an entertainment place in Chon Buri province and a private school in Bangkok as well as many other schools in neighbouring

398 provinces. Knowing of such outbreaks, many parents took their children, both with symptomatic and a symp- tomatic illness, to get tested to see whether they were infected H1N1 virus; the number of clients was so large that the health facilities could not cope with the peopleûs needs. MoPH were trying to inform the public that pandemic H1N1 2009 was not as virulent as initially reported (saying the case-fatality rate in Mexico was as high as 5%). So the people should not panic and not every case had to seek medical care at hospital. But it turned out that there were some reported deaths and MoPH did not receive any notification of such a death at a private hospital in Bangkok, when the press had some clues about that and asked for details from MoPH after the incident had occurred for 8 days. After an investigation, it was found that the death had actually occurred and MoPH held a press briefing. With such delayed and incomplete communication, the media began to feel unconfident in MoPHûs transparency; thus, they started probing for more information at various hospitals and reporting on the number of suspected deaths on a daily and hourly basis. Since then, MoPH had to play a defensive role in informing the public about each case reported by the press as to whether or not the case was infected with H1N1 virus. Such public communication was done unsystematically without proper preparation; rather, it was done on a case by care basis by many informants. In many instances, the information was not in the same direction, especially for sensitive matters, for example the death of a pregnant woman, a patient not receiving antiviral drugs, or delayed diagnosis or misdiagnosis, etc. The level of public dissatisfac- tion was so high and critical that the governmentûs stability was affected as it was unable to deal with various problems. However, the situation eased later by using the following approaches: a) Changing the press briefing schedule from daily to weekly beginning in late July, with a better analysis of public sentiments and preparation of the issues. b) Asking the third persons who were respected by the public to participate in the press briefings such as university professors and representatives from the World Health Organization and the U.S. Centers for Disease Control and Prevention. c) Lessening the self-protection attitude and listening to as well as expressing regrets for unexpected dissatisfactions such as delays in getting medication. 5.3 Intelligence and Assessment Technical staff concerned had assessed the outbreak situation and agreed that Thailand was unable to avoid pandemic H1N1 2009. So, what could be done was to delay the outbreak and take the mitigation measure, allowing it to spread slowly in a controllable manner. Then the public health system including hospitals would have sufficient time to get prepared and appropriately cope with the patients. A draft paper on situation review and a strategic plan was prepared describing the numbers of cases and deaths as well as measures for reducing morbidity and mortality, but it was not accepted by the administrators and others concerned at least in the following matters: a) Cancelling the screening measure at airports. Screening for returning Thais had led the general public to understand that it was an important measure and could prevent disease transmission in the

399 country. Thailand had to seriously undertake strict measures, similar to those for SARS, like other countries such as Japan, Hong Kong, Singapore, China, etc. Screening for immigrants had to be done thoroughly with measures for quarantine or repatriation; so, it was the key measure requiring a lot of workforce and efforts. However, it was found that screening was unable to prevent the spread into the country. Other countries (such as Japan, Australia, New Zealand, Singapore, Hong Kong and China) using this measure was unable to stop the spreading either. b) Informing the public to clearly understand what would be happening in the country. During the outbreak, at least 20 million people would be infected and as a result, there would be approximately 15 million patients and 1,200 deaths if the pandemic H1N1 2009 was let to naturally take it course like that for seasonal influenza (Figure 9.1). It was thus proposed that measures for mobility/mortality reduction be under- taken, gradually from less stringent to more stringent depending on the severity of the outbreak. But the estimation that had to be based on various assumptions yielded the figures for the period after many deaths had occurred rather than the overall picture before the outbreak to be communicated with the public. So, that proposition was rejected for fear of causing more panic among members of the public. Until the peak of the outbreak, such figures were mentioned again and the advisory committee on disease control strategy was asked to give a press briefing. Later on, the prime mister also used the figures when addressing the public on radio.

Figure 9.1 Estimated numbers of infected persons, patients and deaths due to pandemic H1N1 2009, Thailand, July 2009

Deaths 1,260 Estimaed health impacts from the first wave of influenza A (H1N1) outbreak in Thailand, Severe cases provided no intervention 157,000 Assumptions: R = 2 Seeking care 0 3,150,000 Symptomatic: 50% of total infections Seeking medical care: Symptomatic 20% of symptomatic 15,750,000 infections Severe cases: 1.0% of symptomatic infections Asymptomatic Deaths: 80/ million 15,750,000 symptomatic infections

infected 31,500,000

Source: Working Group on Technical Matters and Strategy, Department of Disease Control, MoPH, 2009.

400 5.4 Surge Capacity Mobilization Even though the situation had become a serious emergency, due to the lack of unity for outbreak management and surge capacity, the officials responsible disease surveillance, investigation and control, both central and provincial levels, were limited to only a small number of people. So, they could not cope with the situation that required continuous efforts (with no holidays) from May through September (approximately 150 days). Moreover, there were problems related to the use of emergency funds; there were efforts to use the funds within the provincial governorûs authority without declaring a disaster zone. But such an attempt was rejected by the Comptroller-Generalûs Department as the situation was actually part of a strategic plan with regular budget. So, it was not a disaster and the ministry to make a request for budget from the government central funds, which had to be approved by the Cabinet, for allocation to other ministries on a case-by-case basis. In resolving this situation, an emergency situation or disease transmission zone should be declared according to the Infectious Disease Act. Besides, amendments should be made to relevant laws, including the Infectious Disease Act, so that a certain amount of reserve would be made available as the central level and could be expended immediately and replenished later, with a paper audit system. 6. Opportunity for Development Amidst problems and difficulties, pandemic H1N1 2009 gave an opportunity for developing the Thai public health system in the following aspects: 6.1 Development of disease surveillance and investigation system. In the past, under the influenza surveillance system, there were just morbidity and mortality reports, which were actually much fewer than reality. The H1N1 2009 pandemic has led to improvements in the surveillance system as follows: ■ Surveillance of patients with influenza-like infection (ILI). The proportion of ILI patients to all outpatients was monitored on a weekly basis for use as a warning sign for deterring the cause of such occurrence, especially when the proportion was greater then 10. ■ Sentinel influenza surveillance by examining randomly selected outpatients and inpatients to see the rate and trend of infections. This tool clearly helped alert the second wave of outbreak (Figure 9.2). ■ Outbreak reporting in schools, industries, barracks, prisons and other places. It was found that the large number of reports was unprecedented; surveillance and rapid response teams (SRRTs) were dispatched to take necessary actions and the outbreak control could be accomplished more rapidly. ■ Morbidity and mortality monitoring. Every death was investigated to determine the risk factors and weaknesses that needed to be improved. And dead case conferences were held at the hospitals. ■ Monitoring of adverse events following immunization (AEFI). As MoPH had purchased 2 million doses of dead influenza vaccine for immunizing the vulnerable groups, the AEFI

401 monitoring was necessary. Upon receipt of event reports, severe cases would be reviewed thoroughly by the experts committee.

Figure 9.2 Number and proportion (%) of lab confirmed H1N1 pandemic cases to all ILI patients attending outpatient services at 13 sentinel hospitals from the 29th week of 2009 to the 6th week of 2010 (19 July 2009 › 7 February 2010)

Number (cases) Percentage 140 100.0

120 80.0 100

80 60.0

60 40.0 40 20.0 20

0 0.0 19 26 2 9 16 23 30 6 13 20 27 4 11 18 25 1 8 15 22 29 6 13 20 27 3 10 17 24 31 7 Jul Jul AugAug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Nov Dec Dec Dec Dec Jan Jan Jan Jan Jan Feb Week Neg 20 52 49 52 70 75 86 78 90 109 92 76 87 76 76 60 75 75 75 65 51 62 63 56 56 70 64 57 65 60 Flu A 0 0 1 1 1 1 1 0 2 0 1 3 1 3 3 0 2 0 0 1 0 0 0 0 1 0 0 0 0 0 Flu A:H3 0 0 0 0 0 0 0 1 0 3 0 3 2 3 6 3 2 2 2 0 0 0 0 0 0 0 0 2 1 2 H1N1PDM 44 45 52 52 42 43 43 39 26 27 23 14 11 6 7 5 6 5 6 4 4 4 6 6 8 10 22 23 19 24 H1N1inILI 68.846.4 51.049.5 37.2 36.1 33.133.1 22.019.4 19.8 14.6 10.9 6.8 7.6 7.4 7.1 6.1 7.2 5.7 7.3 6.1 8.7 9.7 12.3 12.525.6 28.0 22.4 27.9

Source: Bureau of Epidemiology, Department of Disease Control, MoPH.

6.2 Development of laboratory services. Because of the outbreak, the laboratories of various agencies had to enhance their capacity to do the PCR testing. Such agencies include all 14 regional medical sciences centres, Bamrasnaradura Institute, medical schools, and some private hospitals and laboratories. MoPH should establish quality assurance measures for such laboratories, which would lead to further develop- ment in both quantitative and qualitative aspects, by requiring the reporting of all kinds of influenza. This will also save as a means of disease surveillance. Besides, some laboratories such as those under the Chulalongkorn Universityûs Faculty of Medicine and the Department of Medical Sciences also conducted drug-resistance tests. The laboratory at Chulalongkorn conducted the test on 850 strains and only 1 strain was found to be antibiotic

402 resistant (personal communication: Dr. Yong Phoosuwan) and the DMSc laboratories could detect 5 drug- resistant strains out of all 424 strains tested (personal communication: Dr. Rungruang Kitphati). Such results did not indicate any severity of the disease. 6.3 Development of vaccines. During the avian flu outbreak and the preparedness planning to cope with H1N1 pandemic, Thailandûs National Health Security Board approved the expansion of the seasonal influenza vaccination programme to cover all vulnerable groups beginning in 2008 resulting in an increase in the annual demand for the seasonal flu vaccine from 300,000 doses to 4 million doses. That is regarded as the demand creation in response to the construction of the vaccine production plant. Meanwhile, when the outbreak occurred, WHO supported the Government Pharmaceutical Organization (GPO) of Thailand to develop a pilot plant in accordance with the WHOûs GMP requirements and carry out a research and development programme for producing pandemic live-attenuated influenza vaccine using pre-master seed of influenza A(H1N1) pandemic strain provided by WHO. The strain had been derived from Leningrad 17 strain from Russiaûs Institute of Experimental Medicine and used in the country for more than 50 years. After getting the premaster seed, the virus was cultured in fertilized chicken eggs for viral propagation and producing a nasal spray vaccine in May 2001, after the phase II vaccine trial was completed, the results were used for vaccine registration with the Thai Food and Drug Administration; and then GPO will further develop live-attenuated vaccines against H5N1 influenza and seasonal influenza. At about the some time, GPO received an investment budget of 1,400 million baht for building an industrial plant for producing live-attenuated influenza vaccine. The construction is currently underway and will be opened for operation in 2013. If the production capacity is expanded, the quantities will be sufficient for the countryûs need with the potential to cope with a large outbreak in the future. 6.4 Development of networks. Controlling an emerging disease or rapidly spreading, severe epidemic, it is extremely essential to have epidemiological networks for disease surveillance, investigation, diagnostic laboratory services and medical treatment. Besides, there must be campaign networks for public education. During this outbreak the Thai Health Promotion Foundation (ThaiHealth), through it networks, provided knowledge and conducted campaigns on desirable behaviours for disease prevention. It is thus extremely important to continue supporting such networks to carry on their operations with a linkage and support for each other, with the policy support from MoPH. 7. Conclusions The rapid outbreak of pandemic H1N1 2009 throughout the world within two months was a proof of the capacity of the health ministry in each country. For Thailand, the outbreak occurred rapidly in June 2009, initially among school children in primary and secondary schools in Bangkok; and then the disease spread to their family members or parents who in turn spread the virus to their colleagues in the workplaces as well as other people in the communities. As of the end of 2009, there were 10 million infected persons. The

403 factors contributing to the outbreak in various places or communities include physical factors such as over- crowding of students in a classroom. More important than the physical factors were the group activities of people or students, such as overnight camping, where such people had to carry out activities in close contact with each other or enjoy entertainment activities or concerts. Even though in general Thailand was able to control this outbreak and reduce the number of deaths by half (approximately 500 deaths) and delay the outbreak into several waves, there are several lessons learned. For example, the lack of security in emergency and crisis management, risk communication and inability to make the people understand and cooperate in certain actions and the lack of resource mobilization to systematically respond to such an emergency. Mean- while, there were opportunities for further development in such fields as surveillance system, extension of lab capacity, in-country vaccine development, and the creation of networks of epidemiology, laboratories, medical treatment, and public education on healthy behaviours. Such lessons and opportunities can be used for improving and preparing to cope with the future outbreaks of seasonal or other strain influenza that will be more and more virulent as well as another emerging disease that would be a threat in the future.

404 Chapter 10 Participatory Development of Healthy Public Policy and Statute on National Health System

1. Meaning and Evolution of Public Policy In the past, çpolicyé was understood that it was an issue undertaken only by the government and state agencies. As a matter of fact, çpolicyé is drawn up all the time in each society and every policy created will have an impact on a large number of people. Thus, policy is a matter that every one is to be involved in as the world has progressed a great deal. Transboundary transfer/communication of knowledge and information as well as social complexity has made people begin to express the needs to have and exercise the right to choose the rule including policy that might affect their livelihood or community. The role of the central government begins to decline in importance; policy is not confined only as a political policy of various political parties, governments, ministries, and departments; rather, policy can also be formulated by the popular sector, the private sector, the community and society. Thus, this kind of policy should be called çpublic policyé which means çdirection or guide that the entire society has deemed or believed that actions should be carried out in such a directioné without any written statement from the government or state agency. An analysis of public policy in Thai society in the past has revealed weaknesses in the policy process resulting from: 1.1 Peopleûs inaccessibility to public policy process. The people were excluded from the process or had just an opportunity to perfunctorily learn about it. The 2007 Constitution of Thailand has tried to close this gap with a provision in Section 87(1): çThe state shall promote public participation in the determination of public policies and economic and social development planning both at national and local levelsé. 1.2 Imbalanced importance given to various values and dimensions. Importance tended to be chiefly given to economic dimension favorable to certain groups of people, while the majesty lost an opportunity and were disadvantaged. For example, the policy on industrial estate development for çMap Ta Phuté which benefited non-resident investors, while local residents had to cope with health-deteriorating pollution, changes in livelihood, and society overwhelmed with non-local cultures, resulting in problems related quality of life of children, youths and family members.

405 1.3 Public policy created with the lack of inadequate technical evidence. Such a policy was especially the one set according to the information or data obtained from some groups of people that benefited from, but did not take into account the impact on other aspects such as policies on energy and building a power plant in the locality. 1.4 Lack of impact assessment and consideration of various options. There were no mechanisms and methods for impact assessment in various aspects; nor were there several options. More importantly, there was no public participation in the policy formulation process such as the water management policy that focused on supporting the industrial sector resulting in a fight for water from the community and agricultural areas rather than getting together to appropriately share and utilize limited resources. 1.5 Lack of systems for monitoring and evaluation of public policies. There have been no such systems especially for the created or implemented policies until negative impacts have occurred cumulatively and become serious and chromic without any problem resolution or policy revision as appropri- ate. Prof. Dr. Prawase Wasi has mentioned about three evil deeds (akusala-kamma) in public policy resulting in çpolicy corruptioné, which include: 1) Lack of knowledge › resulting from wishful thinking, conflict of interest, lack of information/ evidence, and lack of rational consideration. 2) Lack of wide-scale participation › policy formulated by only a few people without the broad participation of stakeholders, but affecting the people of the whole country. 3) Lack of morality › lack of ideology for righteousness and all peopleûs benefit, but for the benefit of certain people or groups.

On the contrary, a good public policy process should be based on three good deeds as follows: 1) Intellectual process › using the evidence or facts that have been analyzed to obtain çknowledgeé so-called knowledge-based policy formulation. 2) Social process › as the policy will affect all people that are stakeholders in society, the society should play a role or take part in the process of learning and policy formulation in a transparent manner. 3) Moral process › the public policy process should have the ideology for righteousness and maximum benefit for all members of society without any vested interest for any particular group.

The key element of public policy formulation is the çprocessé, i.e. the participation of all con- cerned in society is needed for sharing/exchanging information and knowledge, drawing up public policy directions, jointly implementing the policy, following up on policy implementation, and reviewing/revising the policy on a continuous basis. It has to be accepted that the movement for the participatory action in public policy formulation in Thailand has resulted really from the awareness and drive of the popular sector or civil

406 society, outside the public sector. The role of civil society in public policy process has been so extensive that there has been an impact on the formulation and monitoring of public policy, which previously was confined only to relevant state agencies. That reflects the fact that certain groups in society have more realized the importance of çpublicé than çpersonalé interest. Recently, the factors that have accelerated and empowered the civil society participation with the public sector in the public policy process is the provision of the 1997 Constitution, which is regarded as one of the most democratic constitutions and resulted from the joint movements of the people and academics in the participatory democracy for political reforms since 1992. The constitution contained a clearly stated provision that urged Thai citizens to give importance to, and recognize, the basic right of human beings and also give rise to the empowerment of various civil society organizations. 2. Participatory Development towards Healthy Public Policy In 1998, the primary health care strategy was adopted in the Alma-Alta Declaration of Health for all by the year 2000 and became the beginning of major health care reforms, shifting from centralized health systems towards the expansion of community hospitals and subdistrict health centres as well as village health volunteers assisting in providing health care for villagers. A major campaign using various formats was con- ducted on tobacco control by public and private sector agencies including non-profit organizations for the mass media, academics and lawyers. The campaign deployed the social marketing strategy against cigarette smoking and the Ministry of Public Health played a lead role in the enactment of significant laws: the Tobacco Product Control Act of B.E. 2535 (1992) and the Non-Smokersû Health Protection Act of B.E. 2535 (1992). In addition, there have been movements on healthy cities, healthy schools and healthy workplaces. The major occurrence resulting from health system reforms during the period 1978›1996 was the opening of space for the people outside the state and health sectors to participate in health programmes; and the definition of çhealthé has been expanded beyond the issue of çdiseaseé. The implementation of various public policies has had an impact on health and well-being, positively and negatively, directly and indirectly. For example, agricultural development policies focusing on yield enhancement with wide-scale utilization of growth-stimulating chemicals and pesticides. Despite increased yield and income, such practices have a direct impact on farmersû health, chemical contamination, and consumersû safety, as well as on environmental pollutions so-called çpoisoned landé. On the contrary, the implementation of public policy gives the importance to health and well-being as called çhealthy public policyé emphasizing the creation of health security. For example, the public policy on transport gives the importance to road safety and the agricultural promotion policy gives the importance to pesticide-free agriculture.

çHealthy public policy means a direction or guide that the society has collectively deemed or believed that the policy should be implemental with an explicit concern for health and the society is prepared to be accountable for the health consequences of such policy; meanwhile, the policy aims to create health-enhancing social and physical environments and make health choices accessible for citizens to lead healthy lives.é

407 Both terms (healthy public policy and public health policy) might be confusing among some persons concerned as they have different but related meanings. Healthy public policy has a broader meaning related to all development efforts in society, while public health policy deals with the policy for the implementation of public health programmes and is thus important for the improvement of peopleûs health. However, that is not sufficient to prevent and control health impacts from public policies and other health threats. For example, under the governmentûs policy on universal healthcare, during the New Year and Songkran (Thai New Year) festivals there are a large number of road traffic accidents and injuries and every injured case has the right to medical service at any state hospital. But that is regarded as short-term problem solving, thus, at present, many state agencies, public benefit organization, academics, private sector agencies and the general public have urged the government to pay attention to formulate public policy on issues that are the root causes of problems, i.e. developing mass transit systems, improving road safety conditions, creating driving disciplines among motorists, enforcing the anti-drunk-driving measure; controlling alcohol advertisements and sales, etc. They are broader than public health policies but important for health and related to a large number of people outside the health sector. Professor Prawase Wasi mentioned about the public policy process that çIt should not be a short- ened process of making recommendations to be proposed to policy-makers, but the emphasis should be on participatory learning by all sectors concerned so as to reach social understanding, social value and social practice, taking the recommendations as a by-product. The creation of a good healthy public policy should be a çParticipatory Public Policy Processé or PPPP with the participation of all sectors according to çthe triangle that moves the mountainé strategy (Figure 10.1) introduced by Prof. Wasi including three principal sectors: 1) Technical and professional sector, including academics from educational institutions/ universities and policy research funding agencies (such as the Thai Research Fund, the Health Systems Research Institute, and the National Research Council of Thailand), health professionals and other relevant persons. 2) Popular and social sectors, including civil society organizations, the mass media, non-governmen- tal organizations, private sector agencies, elderly persons groups, disabled persons groups, children and youth groups, and disadvantaged groups. 3) Political and civil service sector, including state agencies (ministries and departments), represen- tatives of independent organizations (the National Economic and Social Advisory Council and the National Human Rights Commission), political sector (cabinet members, members of parliament), and local government organizations at all levels.

408 Figure 10.1 The çtriangle that moves the mountainé strategy

1. Knowledge creation/management

2. Social movement 3. Linkage with political and civil service sector

Source: Prawase Wasi, 2002.

The initiation of public policy process may be undertaken from any of the angles or sectors, but with a real participatory action involving the receipt of information and participation in thinking, planning, decision-making, implementation, benefit-taking, monitoring/evaluation and examination of the healthy public policy, not just organizing a meeting to inform the people attending such meeting. In this process, each sector can exert their capability in support of the policy development. For example, the technical sector can play a key role in the creation of wisdom or knowledge which is the foundation for synthesizing a good policy, while the popular sector, including the private sector and the mass media, can play a key role in the monitoring effort, informing or warning the society as a whole to be aware of any health-affecting project or a policy that will be implemented in the locality, or suggesting which new policy should be created and then actively participate with the technical and policy-making sectors in developing a public policy using the interactive learning through action approach. Such undertaking is to be done without my egocentric feelings, emotion and obstinacy. Another key element in this effort is respecting and valuing other peopleûs knowledge. The policy- making sector has to sincerely respect the value and equality of the popular sector participating in the process; meanwhile, the technical sector has to be open to different opinions, not always regarding their own knowledge as correct. The popular sector has to listen to different views for careful consideration. If the public policy process moves along amidst the atmosphere of valuing and knowledge sharing, there will be a process of knowledge management leading to intellectual innovation of a high-quality healthy public policy that is timely agreed upon by all sectors concerned.

409 3. Development of Mechanisms for Participatory Healthy Public Policy: From çPrimary Health Careé towards çHealth System Reformé and çNation Health Acté The beginning of health system reforms in Thailand was the formation of a health community that grow up along with citizen politics after the 14 October 1973 incident such as the Coordinating Committee on Non-Governmental Organizations for Primary Health Care, the Rural Doctors Foundation, the Folk Doctor Foundation, and the Consumer Protection Foundation. One of the factors that helped strengthen the health community was the primary health care in 1977 that enhanced the experience in health system management in the popular sector to become networks, which, even though not being large ones, later became diverse and expanded to the protection of rights. In 1986, the declaration of the Ottawa Charter at the first international conference on health promotion was the new era of health promotion that clearly gave importance to the strengthening of community action and the creation of healthy public policy. When the 1997 Constitution of the Kingdom of Thailand was promulgated, the participatory development of healthy public policy began to be seriously undertaken under the flag of health system reform. Since 1990, the trends of health sector reforms have began all over the world due to several causes such as rising medical care costs, lack of health security for the people, and poor quality of health care. The reforms focused on medical service system chiefly using financing measures. For Thailand, health care reforms had a major difference in that they emphasized social movement and empowerment in joining technical, social and political forces. The new and desirable health system of Thailand focused on disease prevention and health promotion, adjusting the thinking system and operating structure to be holistic in nature, distrib- uting the roles and strengthening the capacity of the people, communities and society to jointly take responsibility for health care even from the personal behaviour level to health policy-making and health management at the community, local and national levels. In 2000, the Senate Standing Committee on Public Health prepared çA Report on National Health Systemé with recommendations for health system reform according to the 1977 Constitution of Thailand, including the overall picture of the desirable health system and clearly proposing the drafting of a National Health Act for use as a major health legislation for peopleûs health development in the long run. That was the first time for the term çHealth Systemsé was officially used in a broader meaning than the term çPublic Health Systemsé that was previously used. As a result, the process of Thai health system reform was formally estab- lished as per the Regulation of the Prime Ministerûs Office on National Health System Reform on 31 July 2000, deploying the coordinating mechanism of three major sectors: the people, technical and political sectors, so-called çthe triangle that moves the mountainé strategy. According to the regulation, the National Health System Reform Commission was chaired by the Prime Minister and composed of representatives from the three major sectors, and the National Health System Reform Office (HSRO) was established under the Health Systems Research Institute (HSRI) to serve as the secretariat in undertaking national health system

410 reform efforts and getting the National Health Act passed as the major health legislation for Thai society. Under the direction of Thai health system reform with the çbuilding health leads fixing healthé policy, the focus was on changing the way of thinking about health among all Thais and urging them to realize the right to health, i.e. health is a matter for everyone, not waiting to be provided by the state, and is broader than çdiseaseé and çorgané. Health deals with çthe entire system interconnected holistically having an impact on the health status of the people throughout the country and all health-related factors, namely personal, environmental, economic, social, physical and biological as well as health-care system factorsé. The health system reform movement utilized the National Health Act drafting process as a tool to mobilize cooperation and opinions from all sectors. Thus, the drafting of the legislation was both the process and the target, which was different from the previous law drafting process. For almost 8 years of the law drafting, more than 1,000 public hearing forums were organized with more than 3,000 networks and more than 100,000 participants from health community networks, state agencies and health professionals taking the lead role. Finally, the National Health Act passed the third reading of the National Legislative Assembly on 4 January 2007 and came into force on the date of its publication in the Government Gazette Volume 124, part 16 A, on 19 March 2007. The National Health Act, B.E. 2550 (2007), was regarded as the first that was prepared with public participation throughout the 8-year period from start to finish. The Act has become a new tool for society to have a mechanism for all sectors to work on health and jointly create healthy public policy through various modes especially The çNational Health Commission (NHC)é chaired by the Prime Minister and comprising 39 members from 3 sectors (13 members each), namely the technical and professional sector, the state/political sector including independent organizations and local government organizations, and the civil society and community sector, with the National Health Commission Office (NHCO) as secretariat. The 2007 National Health Act has created at least 4 kinds of tool for participatory development of healthy public policy as follows: 3.1 Statute on National Health System. According to the Notional Health Act, Section 25(1) prescribes that NHC has the duty to prepare the Statute on National Health System for use as a framework and guide for setting policies and strategies (including principles, targets and measures) and implementing national health programmes, as a tool for projecting future scenarios and directions of that health system as jointly agreed by the society and for all agencies to use in formulating their healthy public policies without any policy conflicts, as detailed in section 4 of this chapter. 3.2 Health assembly. The 2007 National Health Act provides that çhealth assemblyé is a process open to all sectors in society to work together through the use of technical knowledge and unanimity, sharing knowledge for creating a good healthy public policy, and transforming the policy into concrete achievements, through the government, state agencies, partner organizations or communities. Health assembly is a product of the innovative health system reform process. The report on knowledge synthesis related to mechanism and process for formulating health system reform policy and

411 strategy, especially healthy public policy, prepared by Assoc. Prof. Dr. Churnrurtai Kanchanachitra, suggests that çhealth assemblyé be organized as a forum for the popular sector and all other sectors concerned to comment on government policy from the first step of concept formulation, policy recommendation, and policy implementation. The development of health assembly progressed in parallel with the health system reform process. In 2001, a çhealth system reform forumé was held as a demonstrative health assembly; and in 2002, forums of provincial health assembly, area-based health assembly, issue-based health assembly, and national health assembly were formally held, focusing on informing the participants and getting them to take part in drafting a law. Public hearings were held in all 4 regions of the country and then 526 forums on çUniting forces towards National Health Acté were held at the district level before preparing the first draft of the National Health Act. After that, forums for provincial health assembly were held across the country to comment on the draft health legislation. In such efforts, a system was drawn up for determining the proportions of participants, based on the principle of the composition of the participants in the process that translated the triangle that moves a mountain strategy into action. Of all the participants, not more than 15% each were from the civil service and political sector and the technical/professional sector, and 70% were from the popular sector. The health assembly process has continually progressed from a forum of commitment in 2002 when the national administration publicly announced its support for the draft legislation. On the day of receiving the draft National Health Act, the prime minister said ç...when it is the peopleûs desire to have a National Health Act, which will make the national health issue not become the issue of any particular sector or the government, which is correct. As I am on the Cabinet, having the duty to do as the majority of the people desire and for the majority, the government will accept this matter for further action in the administrative and legislative processes.é In 2003, the conceptual framework was set as a slogan çUsing knowledge and love to jointly seek the way forwardé. The health assembly for that year emphasized technical actions and friendly dialogues with rationalization and listening to all sectors. In 2004, the national health assembly was able to draw up a clear policy and strategy recommendation and the National Health System Reform Commission (HSRC) could submit the çRecommendations for Formulating Health Policy and Strategyé, as endorsed by the 2004 National Health Assembly, to the Cabinet for review and approval. In that year, more than 80% of the forums of local health assembly undertook action on the issue of food and agriculture for health as the issue-based health assembly had been working an such an issue since 2003; and theme for National Health Assembly was çFood and Agriculture for Health: Threats from Chemicalsé. In 2005›2006, the themes for national health assembly have gone beyond the issue of public health to well-being and sufficiency economy. Meanwhile, project proposals were accepted from interested groups of people that wanted to organize forums of area-based and issue-based health assembly to confirm the principle that health assembly is a çpublic spaceé that is not confined to any particular group. According to Section 3 of the National Health Act, B.E. 2550 (2007), çhealth assemblyé means çprocess in which the public and related state agencies exchange their knowledge and cordially learn from each other through a systematically organized forum with public participation, leading to suggestion of healthy public

412 policy or public healthiness.é There are three types of health assembly as prescribed in Sections 40›45 as follows: 1) Area-based health assembly › organized for a particular locality or area with a certain boundary such as a provincial health assembly, a regional health assembly, or a river basin health assembly. 2) Issue-based health assembly › organized for a certain public issue such as a health assembly on agricultural chemicals or a health assembly on overweight and obesity. According to Section 40 of the Act, both types of the above-mentioned health assemblies can be organized by the people or networks in the public or private sector with the support of the National Health Commission Office (NHCO) as per the criteria and procedures prescribed by the National Health Commission (NHC). A recommendation from any health assembly for a state agency to implement or use in formulating a healthy public policy, the law requires that such a recommendation be submitted to NHC for further action as appropriate. 3) National health assembly › according to Section 25(3), NHC has the duty to organize a national health assembly at least once a year to develop healthy public policy at the national or locality level that requires special attention and then push for a concrete action. The law requires that NHC set up a National Health Assembly Organizing Committee (NHAOC) to take charge of such matter including setting criteria and procedures so that the assembly will be held in a systematic manner, with adequate technical back- up, creative and broad public participation for creating the acceptance of all sectors. The First National Health Assembly (NHA) was held at the United Nations Conference Centre, Bangkok, on 11›13 December 2008 › the first one organized under the 2007 National Health Act. In organizing the assembly, NHC appointed Dr. Suwit Wibulpolprasert as the chairperson of NHAOC based on the format, process and system for management of the World Health Assembly, which has been organized continuously since 1948, to the extent possible in the Thai context. So, the format and process were different from those for the previously held national health assemblies. Regarding the participants at the assembly, in addition to assigning groups according to the triangle that moves a mountain strategy, constituencies were established: 178 networks in 2008, 180 in 2009 and 182 in 2010; the representatives of such networks only were eligible to attend and voice their opinions in the assembly. The opinions expressed were then regarded as those of their networks, not individual opinions as previously practised. The agenda of the assembly was prepared systematically; the issues to be proposed for specified period, especially for NHAOC to review and draft the resolution, according to the established criteria; and a meeting for comment on such a matter was held to reach a consensus for finally preparing the NHA resolutions in a systematic manner. As for the Second and Third National Health Assemblies, the process was praised and valued by society and gained more attention from various state agencies as noted by their participation on the NHA Organizing Committee as well as in the resolution drafting process and making comments in the assembly. The major focus of the NHA is the creation of mechanism and process for all sectors to reach a çconsensusé in setting public policy without voting on any particular matter.

413 The desirable images of NHA in the future are as follows: 1) Being a process that is significant and powerful with faith, joint ownership and social acceptance. 2) Being a system that is feasible with the participation of all sectors. 3) Linking with health assemblies on specific localities or specific issues as well as the public policy processes. 4) Focusing on healthy public policy issues at the national and international levels or significant local issues. 5) Having resolutions or recommendations that can be effectively implemented.

Figure 10.2 Systems and mechanisms for health assembly

Criteria and methods in Pushing National Health organizing NHA proposals to Assembly Organizing National execution (NHAOC) Section 41, 42, 43, 44 Health (through ● Cabinet Assembly NHC or Section 42 NHCO or ● Parliament/ others) politcal sector linkages NHC. ● State agencies Section 25(3) ● Local Area-Based government Health organizations Criteria and methods for Assembly Pushing ● organizing and supporting Local proposals communities area-based and issue-based to health assemblies Tecchnical ● Academic/ NHCO execution power professional organization Section 40 Multisectoral Society mechanism Issue-Based ● Private/ Mechanism State Health business/or Technical The Secretariat Assembly other Regional organizations

Source: Health Assembly Bureau, NHCO.

414 The National Health Assembly in the new model is a new tool in society that needs to be continuously developed in the future based on at least three challenges as follows: 1) Do the representatives of the groups and networks attending the assembly really represent their groups/networks and are their opinions acceptable to their groups/networks? 2) How does NHA move to ensure the implementation of the resolutions? 3) How to develop the capacity of the groups/networks in the health assembly process, especially in the areas of developing policy recommendations, considering resolutions at the NHA, and advocating their implementation? The fact that the 2007 National Health Act requires that the government supports three types of health assembly regularly every year is because it has been recognized that the health assembly process is the key to health system development in response to the changing situation in a timely manner, especially in the following aspects: 1) Health assembly is a significant tool for the participatory healthy public policy development. 2) Health assembly is a social movement process that values all participating partners to work together on health, not just holding a meeting on an ad hoc basis. 3) Health assembly is a public space for all sectors to work together creatively according to the participatory democracy principle. At present, it has been accepted at the international level that the health assembly process is a social innovation of Thailand, which has progressed considerably and needs to be further developed ceaselessly. 3.3 Health Impact Assessment (HIA) The HIA of public policy is a new tool prescribed in the 2007 National Health Act and the development of HIA tools also took place during the same period as that for health system reform. However, there are some differences as the HIA process had been developed and used in some other countries with WHOûs technical support for Member States. In 2001, for the first time the technical information related to HIA was presented in connec- tion with two public policies: HIA on contract agriculture and farming and the Eastern Seaboard Development Project. One of the recommendations on national health system reform before closing the NHA was that: çIn the national health system, there must be an HIA system for various public policies and there must be a concrete system to manage the health impacts from public policiesé. In 2002, HSRI pushed forward çhealthy public policyé and proposed that çHIAé be used as a tool, which had a linkage with the drafting of the health legislation in how to prevent or resolve the problems that had happened or would be happening. There were participatory learning processes with civil society organizations and non-profit organizations in organizing provincial health assemblies in different localities such as the Map Ta Phut industrial zone in Rayong province, the Songkhla Gas Pipeline Project, and the area with water pollution in Nakhon Nayok province. Raising such

415 issues at the NHA created a heated debate as they were issues with high levels of conflict. That was regarded as the beginning of a good learning process for healthy public policy development, especially the importance and necessity of preparing technical background paper for rational discussion. Until 2007, the social mobilization and learning in Thailand had made many sectors to learn of the term çHIAé and Section 67 (paragraph 2) of the 2007 Constitution also prescribes that: çAny project or activity which may seriously affect the quality of the environment, natural resources and biological diversity and health shall not be permitted, unless its impacts on the quality of the environment and on health of the people in the communities have been studied and evaluated and consulta- tions with the public and interested parties have been organizedÇ.é Moreover, Section 10 of the National Health Act prescribes that: çIn the case where there exists an incident affecting health of the public, a State agency having information relating to such incident shall expeditiously provide and disclose such information and the protection thereof to the public. Section 11 of the Act prescribes that: çAn individual or a group of people has the right to make a request for an assessment and to participate in the assessment of health impact resulting from a public policy. An individual or a group of people shall have the right to acquire information, explanation and underlying reasons from state agency prior to a permission or performance of a programme or activity which may affect his or her health or the health of a community, and shall have the right to express his or her opinion on such matter.é Moreover, Section 25 (5) of the Act prescribes that NHCO has powers and duties çto prescribe rules and procedures on monitoring and evaluation in respect of national health system and the impact on health resulting from public policies, both at the policy-making and operational levelsé. During 2007›2008, the NHC expedited the endorsement of the new tool, beginning with NHCOûs establishment of a working group chaired by Dr. Wiput Phoolcharoen to draft a system, mechanism and criteria for HIA related to public policies which were approved by the First NHA in 2008. Based on the resolution, NHC appointed a committee on development of system and mechanism for HIA chaired by Dr. Wiput Phoolcharoen and also established an HIA Coordinating Unit (HIA Co-Unit) to serve as the secretariat of the committee. The HIA system and mechanism was drafted based on technical review and lessons learned in other countries and consultations as well as public hearings with all concerned in the public, private, academic, and popular sectors, including operators of private businesses and officials of non-profit organiza- tions; and the final version was approved by NHC in October 2009. To date, NHC has issue the Notification of NHC on Rules and Procedures on Assessment of Health impact Public Policies, B.E. 2552(2009), dated 8 November 2009. That means HIA is a tool that has been legally recognized. According to the Notification, HIA means ça participatory learning process of society in the

416 analysis and forecast of positive and negative impacts on peopleûs health that might result from one or more policies, projects or activities, if implemented during the some period of time or in the same locality, through the application of various tools and participatory processes as appropriate to the decision-making beneficial for the peopleûs health in the short and long termsé. And according to the intent of the National Health Actûs chapter on rights and duties related to health, HIA should be carried out based on seven principles: (1) democracy, (2) fairness, (3) appropriate use of information and evidence, (4) practical appropriateness, (5) cooperation, (6) holistic well-being, and (7) sustainability. Based on the above principles, the projects and activities that should undergo HIA are classified into two aspects: 1) Projects and activities with the types and sizes as stated on the list of projects/activities possibly having a serious impact on the community and their HIAs have to be carried out as per Section 67 of the Thai Constitution. 2) Development planning activities that might have a serious impact on community health in the future, namely: city planning and improvements possibly leading to projects/activities that will have a serious health impact in the future; regional planning (such as regional development strategic plan); transport network planning; electricity generating development planning; mineral/mining development planning; farm- ing/cultivation of genetically modified organisms; large-scale agriculture; operations related to dangerous substances; toxic waste and radioactive substances; free trade or international agreements as per Section 190 the Thai Constitution; and planning to implement a project/activity in any areas that should be conserved such as water catchment areas, class 1 river basins, and wetlands of national and international significance.

417 Figure 10.3 Linkages of systems and mechanisms for health impact assessment in Thai society

HIA as per powers and duties of local agencies Principles of HIA in Thailand = Right, good governance and participatory social learning Local process for creating healthy public policies community Support for HPP development through HA and HIA processes Community particpation process Operator submits of EIA consulting firm The Cabinet EIA report as per Section 67 State agencies Independent ministries NHC ONEP organization departments NHCO HIA System & Mechanism EIA process Development Communitte As per Section Expert HIA Reader Public Policy HIA Consortium 67 committee Network Approving agency HIA Coordinating Unit(Secretariat) 1. Promote and support the development of systems, mechanisms, models, rules and procedures for HIA 2. Promote and support the work of HIA networks 3. Promote and support the establishment of KM/CB/public communications and HIA information system 4. Promote and support the use of HIA for HPP through HA and other channels Source: HIA Coordinating Center, NHCO. Notes: ONEP = Office of Natural Resources and Environmental Policy and Planning, Ministry of National Resources and Environment EC = Expert Committee NHCO = National Health Commission Office While developing the HIA rules and procedures, NHCO also supported communities, aca- demic networks and state agencies to use the HIA tool in real-life situations for developing public policies as the tool had been designed according to the social participatory process. That was for all sectors to participate in the review of health impacts that might occur and then in the assessment and management of such possible impacts. The local communities that actually used the tool on an experimental basis are: Bang Saphan district in Prachuab Khirikhan province where a full-scale steel production plant is located; the impact assessment of agricultural use of large amounts of chemicals in Bo Ngoen village in Pathum Thani province; the impacts of handicraft industries in Ban Thawai in Chiang Mai province; and the impacts of global warming in Kula Ronghai Field in the Northeast.

418 But the case that has mode the HIA tool well-known the most in society is the impacts of industrial development in Map Ta Phut, Rayong province. The case study was started on 9 April 2007 when the Eastern Peopleûs Network handed over a letter to the Secretary-General of the NHC, requesting that an issue- based health assembly be held, according to Sections 5, 10 and 11 of the 2007 National Health Act. The purpose was to seek ways to resolve conflicts and build up the communityûs capacity to take part in the local public policy process, leading to health equity for the residents in Map Ta Phut subdistrict and other areas in Rayong province. Later on, NHCO supported the Healthy Public Policy Foundation (HPPF) to implement the project, including data search and conducting issue-based and area-based health assemblies until 14 policy recommendations could be submitted to NHC for Rayong provincial development in August 2008. In addition, NHC agreed to appoint a committee, chaired by Thanphuying Dr. Suthawan Sathirathai, President of the Good Governance for Social Development and the Environment Institute to study, support and monitor the implementation of NHCûs proposals. During that period of time, on 3 March 2009, the Rayong Administrative Court passed a verdict which says on the last page that: çthe defendant has to notify that the entire area under the jurisdiction of the Map Ta Phut Municipality and those of Noen Phra, Map Sa and Thap Ma subdistricts of Mueang Rayong district and Ban Chang subdistrict of Ban Chang district are designated as pollution control zones for the operations related to the control, abatement and elimination of pollution as required by law. The action is to be accomplished within 60 days as from the date of this verdicté. In the details of the verdict, it refers to the provision of Section 5 of the 2007 National Health Act, which prescribes that: çA person shall enjoy the right to live in the healthy environment and environmental conditionsé as well as the NHCûs resolution of 1 August 2008. Later an, the National Environment Board passed a resolution to declare the areas under jurisdiction of the Map Ta Phut Municipal- ity and surrounding subdistricts as the pollution control zone on 30 April 2009. As for the NHCûs resolutions to be submitted to the Cabinet on 19 May 2009 for consider- ation, the Cabinet passed a resolution for relevant agencies to adopt the three policy recommendations related to the impacts of industries in the Map Ta Phut area according to the NHCûs resolution as follows: 1) Relevant state agencies shall disclose the information on health impacts from industries and disseminate the ways to prevent the impacts and ways for health promotion during the pollution period to the public rapidly and continuously. 2) Relevant state agencies shall develop plans and operating procedures for preventing and mitigating industrial hazards and draw up plans for the prevention and mitigation of chemical accidents at the provincial level. 3) NHC shall support the development of central mechanism for operations and strengthen- ing of the popular sector using the area-based health assembly process. Regarding the other two recommendations, i.e. (1) the government shall review/revise the Rayong provincial development guidelines with the participation of local residents throughout the process and (2) the government shall delay the expansion and construction of new industries in the Map Ta Phut and Ban

419 Chang areas, by establishing guidelines and processes for making decisions on approving/permitting such expansion or building in accordance with Section 67 of the Thai Constitution, the Eastern Seaboard Develop- ment Committee, chaired by Deputy Prime Minister (Mr. Korbsak Saphavasu), was assigned to consider. Later on, the committee agreed to all the five recommendations and directed that all relevant agencies/organizations undertake the following: 1) Endorsing the conceptual framework for Rayong provincial development in a balanced and sustainable manner. 2) Reviewing the Rayong provincial guidelines for balanced and sustainable development and revising it in accordance with the conceptual framework on such a matter. 3) Establishing good-quality and thorough systems of basic economic and social service. 4) Drawing up a plan of action for reducing and eliminating pollution in the pollution control zone. 5) Delaying the expansion and building of new industries in the Map Ta Phut area and taking action in accordance with Section 67 of the 2007 Constitution; and expeditious actions were to be undertaken by the Office of the Council of State, the Ministry of Public Health, the Ministry of Industry, and the National Health Commission Office. In June 2009, 43 members of the Anti-Global warming Association and the public jointly filed a lawsuit against the state agencies that allowed 76 new industries to resume their construction even though such industries might have a serious negative impact on the community as per Section 67 of the Constitution. In December 2009, the Administrative Court suspended the construction of 65 projects and allowed 11 projects to proceed. And after further consideration, the court allowed another 19 projects to proceed; so, the remaining 57 industries were still awaiting the courtûs decision. The most recent dispute occurred when the four-party committee, appointed by the prime minister and chaired by Mr. Anand Panyarachun to expeditiously resolve the issues according to Section 67 of the Constitution, prepared recommendations on 18 projects that might have serious impacts on the environ- ment, natural resources and health, but the National Environment Board announced that only 11 projects were under such a category. However, when taking the announcement as the criteria for reviewing the applications, it was found that most of them were not the projects that might cause serious impacts to the community. At the NHC meeting, the proposal on criteria for project review was considered as proposed by the relevant technical review committee and working group and finally made recommendations for the Cabinetûs endorse- ment. The Cabinet resolved that the National Environment Board and the Subcommittee on Decision of Complaints Related to Projects that Might Cause Serious Impacts on the Community were to adopt the results of the study and aforementioned recommendations for revising the announcement. According to the developments and actual cases in society, it is noteworthy that HIA, as a participatory and multidisciplinary process in society, has a boarder dimension than medical and health dimension, as it covers holistic well-being and uses a positive approach, not just undertaking for granting or not

420 granting any approval. It is an intellectual process, rather than legal or authoritative measures, for joint academic and social learning purposes and assessing the health impacts on the people and community result- ing from public policies of the government, private sector entities, local agencies and the communities. The process would lead to the determination of alternatives, making decision on such alternatives, seeking ways to minimize such health impacts for the well-being of the people and community. 3.4 Tools for Other Forms of Healthy Public Policy Development Tools other than that proscribed in health laws include the establishment of specific mecha- nisms of NHC and support for the operations of networks and other organizations. Between 2007 and 2010, four committees were established by NHC to develop healthy public policies as follows: 1) Commission on Human Resources for Health. The commission is tasked with the implementation of the Strategic National Plan on Human Resources for Health, 2007›2016, which was approved by the Cabinet as proposed by MoPH. The first Chairperson of the Commission was Prof. Dr. Kasem Wattanachai and the current chairperson is Dr. Mongkol Na Songkhla. The secretariat includes the director of HSRI, the director of the Bureau of Policy and Strategy, the director of the Human Resources for Health Development Office (HRDO), and representatives of NHCO. The policy-related achievements of the commission include the comments given on the guide- lines for developing a health workforce requirement plan and a public sector health development project, the solution of health workforce problems in Southern border provinces, and the national health system statute, and the preparation of proposition on the Medical Error Compensation Bill, proposed by MoPH, and the appointment of the patient-doctor relationship enhancement subcommittee, chaired by Dr. Suphan Srithamma. 2) National Commission on Traditional Wisdom Development. The Commissions duty is to oversee the implementation of the National Strategic Plan for Thai Wisdom and Thai Healthy Lifestyle Development, 2007›2011, as approved by the Cabinet and proposed by MoPH, under the chairmanship of Dr. Vichai Chokevivat with the secretariat including a deputy director-general of the Department for Development of Thai Traditional and Alternative Medicine, HSRI director, director of the Thai Health Institute and a representative of NHCO. Major policy-related achievements of the Commission include the appointment of a subcom- mittee on development of Thai traditional medicine hospitals (the first prototype hospital was established in Sakon Nakhon province with the collaborative efforts of the clerical and non-clerical sectors including Rajamangala University of Technology Isan Sakon Nakhon Campus and local government organizations in the province, and the participation in 2009 as a co-host in making policy recommendations that were strategic goals and the 2009 Statute on National Health System through an issue-based health assembly held during the National Herb Expo; the proposal was adopted as a resolution of the 2nd National Health Assembly in the agenda on çDevelopment of Thai traditional medicine, indigenous medicine and alternative medicine as a major health- care system in parallel with the modern medical system.

421 3) Commission on Studies of Health Impact from International Trade. The commission was appointed by NHC as per the resolution of the 1st National Health Assembly under the agenda on çpublic participation in formulating policies on free trade negotiationsé chaired by Mrs. Sirina Pawarolanwittaya, a NHC member from the private sector. The commission has the duty to promote and support all sectorsû participation in studies and monitoring of international trade negotiations and examination of positive and negative impacts resulting from the stipulated agreements. The purpose is to improve the agreements in the future and provide compensation for any damage that would occur. This mechanism is independent of the governmentûs existing trade negotiation mechanism but linked to each other. The secretariat of the commis- sion includes the secretary-general of the National Economic and Social Development Board and Dr. Churnrurtai Kanchanachitra, vice president of Mahidol University. 4) National Health Information Commission. The commission is now in the process of getting established to oversee the implementation of the Strategic Plan for Health Information Development, 2010›2019, as approved by the Cabinet and chaired by Dr. Somsak Chunharas; its secretariat includes officials to be assigned by HSRI, MoPHûs Policy and Strategy Bureau and the National Statistical Office. This national mechanism is different from other national committees in that it will consist of officials or representatives from three sectors (state, academic/professional and popular/private) which will jointly work, without using any legal mechanism and authoritative power, based on their technical expertise, together with the secretariats of other commissions, on a multisectoral basis, NHC will not play a key role in the operation of this commission; rather, it will provide support with facilitative functions. In addition to the aforementioned commissions, there are other tools or modes for public policy development as follows: 1) Public policy development through networks such as the network for policy on agriculture and food for health which has been developed from the network on drafting the national health legislation. The network consists of representatives from state agencies, academics, non-governmental organizations, and the health community. In the past, the network could develop proposals for consideration as resolutions of the First National Health Assembly, particularly on the agenda for çagriculture and food during crisisé. After that, the network continued working on creating knowledge and coordinating with various agencies to advocate the importance of food security, community organic agriculture, and the role of local government organizations in supporting the sustainable agriculture system. 2) Public policy development through cooperation with two academic institutions: (2.1) Technical cooperation with Khon Kaen University (KKU). Under the 2008 KKU- NHCO cooperation agreement, KKUûs Research and Development Institute is the lead agency in collecting the information or knowledge about the impacts on the Northeast (Isan) resulting from public policies, especially on five issues, namely: (1) KKU: a community of well-being; (2) Khon Kaen: the city of well-being; (3) the Northeast and food security; (4) the Northeast and human/social security; and (5) water management for the Northeast. In 2009, public policies were presented to the KKU community on çgood areas and at-risk areasé on

422 campus; and the community also participated with the Khon Kaen network in formulating public policy on city of well-being. (2.2) Technical cooperation with Mahidol University in developing a healthy public policy towards being the wisdom of the land. In 2009, four public forums, called çSalaya Dialogueé were organized to exchange ideas on healthy public policies: (1) pandemic influenza H1N1 2009, which later on became recom- mendations on the emerging disease together with MoPHûs Department of Disease control, Ministry of Agricultureûs Department of Livestock Development, and the Ministry of Natural Resources and Environment, which were included on the agenda of, and approved by, the 2009 National Health Assembly for further action; (2) medicines in Thailand are very expensive and many Thais have no access to essential drugs; (3) looking at impacts before thinking about compulsory licensing (or CL of certain drugs); (4) the future of Thailand after the global crisis: regional cooperation towards society of good livelihood; and in 2010, another three forums of Salaya Dialogue were organized on: (5) health knowledge gap to policy; (6) teenage pregnancy (mae wai sai)Ça big problem to be jointly tackled; and (7) universities and Thailand reform. Moreover, a talk was held on obesity as a silent threat for Thai children. The results of the forums were reported to the University Council that was much interested in the matters. In 2010, linkages have been initiated among the Thai Health Promotion Foundation, the Health Systems Research Institute, the International Health Policy Program, the Social Research Institute at Chulalongkorn University, and the National Health Commission Office. At the beginning, the Social Inequity Reduction Network (SIRNET) was established to create knowledge and awareness of social determinants of health, leading to a policy for reducing health status gaps in society through participatory movements with all sectors. 4. Intent and Acquisition of Statute on National Health System çStatuteé, or thammanun, according to the Thai Dictionary of the Royal Institute, B.E. 2552(2009), mean a law dealing with the organization of an agency such as the Act on the Organization of Military Court and the Statute or Law on the Organization of the Courts of Justice. By the same token, despite the fact that the original intent of the drafting of the National Health Act, the entire law was meant to also serve as the statute of the health system. However, when the draft law was being reviewed by the Office of Council of State, especially Chapter 6 on policy and strategy guidance for health with details on desirable health systems such as those on health promotion, prevention and control of health threats, public health services and quality control, and others, totalling eight issues, it was deemed that having such details in an Act would have more disadvan- tages than advantages because such systems should be dynamic like other systems that might change according to social context and situations at the community, national and international levels. So, the entire chapter 6 was deleted but prescribed that NHC has the duty to prepare the çStatute on National Health Systemé for use as a framework for setting health policy and strategy as well as a guide for health programme operations of the country. The National Health Act, Section 47, prescribes that the statute has to cover at least 12 issues as shown in Figure 10.4.

423 Figure 10.4 Essence of the National Health Act, B.E. 2550 (2007)

Well-being for all

Healthy public policy

National Health Commission (NHC) Health Assembly National Health Commission Office (NHCO)

Statute on National Health System ● Philosophy and principal concept of health system ● Local health wisdom ● Desirable characteristics and goals of health system ● Consumer protection in health ● Health security and protection ● Creation and dissemination of knowledge about health ● Health promotion ● Dissemination of health information ● Prevention and control of health threatening factors ● Production and development of public health personnel ● Public health services and quality control ● Health financing

Peopleûs participation at all levels of health system

Source: Bureau of Health Statute and Public Policy, NHCO.

In this connection, Thailand is the first country in the world that has developed a statute on health system that is legitimate and endorsed by law. 4.1 Status of the Statute on National Health System. According to Section 48 of the National Health Act, the Statute that has been approved by the Cabinet shall be binding upon state agencies and other relevant agencies in the performance of activities under their powers and duties. But more impor- tantly, in the social context, the Statute is regarded as the social commitment and references for setting directions and targets proportion of health systems of the country in the future. So, the process, essence, and translation of statute into action are the social mechanisms and processes that are linked with the movement for participatory development of health systems in response to the needs and benefits of all sectors. 4.2 In the process of drafting the Statute, the law requires that NHC took into consider- ation the ideas and recommendations of health assemblies and then submit the draft Statute to the Cabinet for approval, submit it to the House of Representatives and the Senate for acknowledgement and then get it published in the Government Gazette. The law also requires that, for the Statute to be suitable for the changing

424 health situations, it has to be reviewed/revised let least every five years. After the law came into force, the process for drafting the Statute was undertaken from 2007 to 2009 as briefly stated below: 1) In 2007, NHC appointed the çWorking Group on Development of Systems and Mecha- nisms for Drafting a Statute on National Health Systemé whose duties were to draft the systems and mecha- nisms, with the participation of various sectors to the extent possible, aiming to make the statute 2) important and valuable, thus, the systems and mechanisms had to be accepted by various participating organizations since the beginning of the process, through participatory and systematically orga- nized public forums, opening to all ideas/comments from the drafting of the 2007 National Health Act. The draft systems and mechanisms were presented to a forum on çMovement and participatory learning of the statute drafting processé, organized at the UN Conference Centre, Bangkok; and the draft was endorsed by the forum which was attended by more than 1,000 participants. 3) In 2008, the year of Statute drafting, in January NHC appointed the Statute Drafting Committee, chaired by Dr. Bunloo Siripanich having the secretariat comprising the NHC secretary-general, HSRI director, and director of MoPHûs Policy and Strategy Bureau. Later on, six working groups were established comprising representatives of various state, academic, professional, private, popular sectors; and the secretariat also had officials from various partners/agencies such as the Health Insurance System Research Institute, the National Health Foundation, the Thai Health Institute, the Health Consumer Protection Programme at Chulalongkorn University, and the Department of Health. The Statute drafting was undertaken for the entire year beginning with a workshop for members of the committee and working groups on defining the scope, process, essential matters and timeframe of the Statute; and finally, the timeframe of the first Statute was set for the long-term health system to end in the year 2020. After that, the working groups undertook a situation and knowledge review of each issue, followed by public hearings and drafting the essential matters for each issue in May and June, which were publicized in the mass media for the people to learn of the Statute. The second workshop was then held to formulate the philosophy and principal concept as well as desirable characteristics and goals of the health system to be used for writing the details of each chapter. Between July and August, each of the subcommittees began drafting each chapter of the draft Statute; 8 public forums were held to reach a consensus agreement on the future of the health system, which was an innovation of public dialogue with more than 400 participants. The first draft of the Statute was widely presented and discussed at 75 provincial public hearings in August through October including specific group discussions with approximately 3,000 participants; totalling, more than 10,000 participants attended the public hearings throughout the drafting process. After that another workshop was held to review the essential matters and revise the entire draft so that everything was consistent as the second draft which was submitted and approved by the First National Health Assembly on 11›13 December 2008. However, some observations from the NHA were given to the Statute Drafting Committee for further revision. 4) In 2009, the year of success in preparing the Statute, after the Statute Drafting Committee

425 had finalized the Statute, as per NHAûs observations, in January, the draft Statute was submitted to NHC for review and endorsement for submission to the Cabinet. And on 30 June 2009, the Cabinet approved the Statute on National Health System, B.E. 2552 (2009), with no alternation and after that the Statute was acknowledged by the Senate and the House of Representatives on 7 and 10 September, respectively, and then came into force upon its publication in the Government Gazette (Volume 126, Special issue 175 D) on 2 December 2009. 5. Statute on National Health System, B.E. 2552 (2009) The first Statute covers the timeframe for the overall health system of the country until 2020 and contains 12 chapters (111 Sections). Chapters 4›12 deal with subsystems ranging from health system through health financing, each was written in the same format including the principles, objectives and measures for use with no rigid binding or implementing methods because the Statute is not a programme or project. Another important principle of this Statute is the fact that local partners or networks can establish their own health statutes as far as they do not contradict the provisions of the Statute on National Health System. 5.1 Essential Matters of the Statute by Chapter are the following: Chapter 1: Philosophy and basic concepts of the health system. Health is a basic right of the people and the health system is part of the social system and part of the national security system. The health system must give high importance to health promotion leading to sustainable well-being and self-reliance of the people; and all sectors must jointly push forward the national development from consumerism towards the path of sufficiency economy. Chapter 2: Desirable characteristics and goals of the health system. The health system must be based on the principles of virtue, ethics, humanitarianism, good governance, knowledge, and wisdom. Chapter 3: Provision of health security and protection. Health security and protection must cover all the people living on Thai soil and all the factors affecting health, not being confined to ensuring access to public health services. Chapter 4: Health promotion. Health promotion must be undertaken to create holistic well- being for the entire society, primarily aimed at decreasing morbidity, disability, and untimely death, and cutting health-care spending, in accordance with the concept çhealth promotion comes before health repairé. The objectives are to develop participatory healthy public policy process and empower the communities regarding health-care capability, covering at least 80% of all subdistricts throughout the country. Chapter 5: Prevention and control of diseases and health-threatening factors. The aims are to create the solidarity of relevant agencies in preventing and controlling diseases and health-threatening factors, to develop the surveillance system, and to use the tax measures, by encouraging peopleûs participation in all the efforts as well as decentralization and capacity building for the community to carry out certain activities such as health impact assessment. Chapter 6: Public health services and quality control. The primary-care system has to be

426 supported so that its quality and dignity are accepted, respected, and trusted by the people, the services are to be provided by family physicians or health-care providers through the humanized health-care system in a concrete manner. And the state should not support or give any tax incentive and investment privileges to any business-oriented health services. Chapter 7: Promotion, support, use and development of local health wisdom, Thai tradi- tional medicine, indigenous medicine, and other alternative medicines. The people are to be supported to have the right to choose and access various medical care systems on an equal basis. The health-care system is to include traditional Thai and herb-derived drugs in the National List of Essential Medicines, i.e. at least 10% of all drugs are traditional or herb-derived drugs, establish at least one model Thai traditional medicine hospital in each region of the country, and have in place a system, mechanism and adequate budget for local wisdom development. Chapter 8: Consumer protection. Urgent action is to be taken to establish an independent consumer protection organization in accordance with the Constitution; and there must be in place mechanisms for the surveillance and inspection of goods and services with public participation so that the products and service offered are of high-standard and quality, safe and fair for all in an equitable basis. And there must be a system of efficient and appropriate compensation for damages that may occur as well as a system for consumer protection against any negative impacts resulting from international agreements and relevant laws as provided in the Constitution. Chapter 9: Generation and dissemination of knowledge about health. Public policies must be drawn up from a comprehensive, adequate and reliable knowledge base whose sources must be publicly disclosed. Thus, state agencies and relevant sectors have to invest and play a role in the generation, manage- ment, communication and dissemination of health knowledge. Chapter 10: Dissemination of Health information. Such an effort must be impartial, fair and comprehensive through appropriate channels so that the people can understand and use in making decisions on health behaviours leading to well-being, while being protected to receive correct and adequate health information. Chapter 11: Formation and development of public health personnel. The state has the duty to formulate policies and plans on the production, development and distribution of public health personnel in an equitable manner so as to meet the needs of the country, while ensuring that they have good quality, ethics, good social-conscience and sufficient numbers to provide public health services to the people in collaboration with other health-related personnel in a multidisciplinary manner. Chapter 12: Healthcare financing. This effort aims to create equity in benefiting from state health services, reduce the proportion of national health spending, decrease the number of families suffering from economic crisis resulting from a high medical-care cost, increase the tax rates for business-oriented health-care businesses or health-deteriorating products, and support the establishment of community health funds.

427 5.2 Benefits for Thais from the Statute. One of such benefits is the reference on the direction and goals of the health system that is the social commitment for the future. Thus, after the Statute has been prepared and enacted, it would be valueless if nothing is done to transform the principles, concepts, objectives and essence in the Statute into action to see concrete achievements. All agencies, organizations, institutions, communities, people of all localities, levels and networks, including popular sectorûs networks, civil society organizations, communities, local government organizations, professional organizations or individuals, aca- demic institutions, educational institutions, state agencies at the ministerial, departmental, or divisional level, private sector agencies, businesses, non-governmental organizations and non-profit organizations can make use of the Statute. If all agencies and networks implement their programmes according to the framework of the state, the health system of the country will have a clear direction, suitable for such a period of time, which can be revised after various contexts are reviewed at least every five year. The guidelines prescribed in the Statute are not fixed or non-revisable, but during a certain period of time, the health system of the country needs a clear direction so that the achievements of development efforts will be tangible in accordance with the principles and suitable goals for such a period. 5.3 Examples of the use of the Statute. The commitments of state and other relevant agencies required by law are the following: 1) Using the Statute as a reference in designing plans related to health at all levels such as the National Economic and Social Development Plan, the 11th National Health Plan (being formulated), and the Strategic Plan of the Health Systems Research Institute, 2011›2015. 2) Transforming the Statuteûs essential matters including directions and goals into the na- tional administration plan and 4-year plans of action or annual plans of action of state agencies, and using some content in the Statute as a reference for developing policies, programmes/projects as well as budget request proposals. 3) Creating policies and goals in a concrete manner for action by policy-making agencies of the government, national committees or agencies responsible for certain issues such as setting directions and goals of the government or political parties, and the National Drug System Development Committee for inclusion of certain traditional Thai drugs and herb-derived drugs in the National List of Essential Medicines. Regarding the use for social and community benefit, the entire Statute what can be used including the concepts, principles, goals and directions, or its certain parts can be used such as some of the goals or measures for developing local health systems as follows: 1) Using the Statute as a guide for developing an area-based health statute. To date six areas have done so, namely: Cha-lae Subdistrict Health Statute in Singhanakhon district, Songkhla province, led by the Cha-lae Tambon (subdistrict) Administrative Organization (TAO) and being the first area-based health statute of the country, and Sung Men District Health Statute in Phrae province, led by the district hospital and being the first district health statute of the country. In 2010, another four area-based health statutes were established for Rim Ping Subdistrict Municipality in Lamphun province, Mueang Mo TAO in Phrae province,

428 çCha-laeé is a small subdistrict in Singhanakhon district, Songkhla province, with a population of about 3,000. The subdistrict enacted the first area-based health statute in the world under the leadership of Mr. Khunthong Boonyaprawit former chief executive of Cha-lae TAO, who had been asked: çHow can we get the TAO committed to allocating budget for implementing the subdistrict health development plan on a continuous basis and cause the subdistrictûs residents to practise what has been written in the plan?é And then, the participatory process for drafting the health statute was initiated using the knowledge about health from academics from educational institution located in the locality. Subcommittees were set up to undertake various functions, namely statute drafting, public communi- cation and participation campaign, public hearings, and follow-up/evaluation. Finally, the Health Statute Bureau was established to coordinate all the processes and activities including the long-term implementation of the statute. The Cha-lae Subdistrict Health Statute was enacted The essence of the Cha-lae Subdistrict Health Statute, B.E. 2552 (2009), includes the following: Section 5. The general standard of practice of Cha-lae residents is to observe item 5 of the Five Precepts (of Buddhist Teachings) and at least another item of the rest of the Precepts. Section 10. Control the odour, solid waste, night-soil, sewage, noise, dust, light, smoke and vehicle speed so that they are at the suitable levels jointly established. Section 23. There shall be a professional nurse and a dental nurse at the proportion of 1:5,000 or as per communityûs needs. Section 45. Support the marketing and consumption of the products of Cha-laeûs residents Section 51. The Cha-lae TAO has to allocate budget for the implementation of the Cha-lae Subdistrict Health Statute in the amount of at last 20% of all of its annual revenue. ** Mr. Khunthong was assassinated on 25 November 2009. All the aforementioned health statutes have the same feature, i.e. using only the principles of the Statute on National Health System, but the essence was based on the concrete goals and actual health status information and needs of the localities in drafting the statutes with the participation of all sectors. And then the long-tern scenario of the community health system in the future could be drawn up for use as the guiding principles in determining the programmes and activities of the subdistrict development plan in accordance with the jointly agreed upon directions. 2) The use of certain specific goals, measures or issues of the statute in developing guidelines for programme operations or movements to achieve concrete results of certain groups or organizations working specific issues such as marginalized peopleûs health, Thai traditional medicine, womenûs health, child health, adolescent health, and health of the disabled and the elderly. The movements mentioned above require collaborative actions of all sectors and a higher level of cooperation then that obtained during the past two years of statute drafting, to date, NHC has set up two committees, one on follow-up support and evaluation of the implementation according to the Statute on National Health System, chaired by Dr. Banloo Siripanich, and the other on health system research develop- ment for supporting the Statute on National Health System, chaired by Prof. Dr. Vicharn Panich, to serve as a mechanism for creating strategies for translating the Statute into action through knowledge management, creating essential knowledge and social mobilization as well as evaluation and making recommendations for drawing up the next statute.

429 430 Chapter 11 Health Decentralization

1. Background The Determining Plans and Process for Decentralization to Local Government Organizations (LGOs) Act, B.E. 2542 (1999, or the 1999 Decentralization Act) and the Plan of Action on Decentralization to LGOs (No. 1, or the 1st Decentralization Plan), B.E. 2545 (2002), were enacted and created in accordance with the Constitution of the Kingdom of Thailand, B.E. 2540 (1997), aiming to transfer missions or responsibilities to LGOs that are prepared to take such responsibilities within the established 10-year period. At present, the implementation under the 2nd Decentralization Plan is underway to move this effort forward so that local residents will receive better public services with good quality, fairness and transparency, for their better quality of life. The 2007 Constitution has provisions on key principles for decentralization to LGOs in Chapter 5 (Directive Principles of Fundamental State Policies), Sections 70 and 80, and Chapter 14 (Local Administra- tion), Sections 281›290. Under the 1st Decentralization Plan of 2002, two groups of details were elaborated as follows: 1.1 Establishing an Area Health Board (AHB) to take charge of the transfer of health-care facilities, on a network a cluster of services basis, as well as the health security scheme to AHB by 2003. In 2002, the Ministry of Public Health (MoPH) appointed the AHB to serve as an advisory board in each of 52 provinces, focusing on the first 10 provinces. But the operations were suspended as the ministry had to undertake other urgent actions, i.e. the healthcare reform according to the universal coverage of healthcare policy and the public sector reform according to the Reorganization of Ministries, Sub-ministries and Departments Act, B.E. 2545 (2002). Later on, the Committee on Decentralization to Local Government Organizations (CDL) passed a resolution on 25 April 2007 requiring that MoPH transfer subdistrict health centres to LGOs. As the Decentralization Act requires that 35% of the national budget had to be allocated to LGOs, all state agencies were requested to accelerate the transfer of missions including budget to LGOs. In this regard, MoPH transferred 28 health centres to LGOs including Tambon (subdistrict) Administrative Organizations (TAOs) and municipalities in December 2007 and August 2008.

431 1.2 Transferring the responsibilities for health services to LGOs. A total of 34 health programmes from 7 MoPHûs departments were to be transferred, but to date only 7 have been transferred, i.e: 1) Provision of subsidies for health behaviour development 2) Resolution of underweight problem among children 3) Prevision and development of water supply 4) Promotion of maternal and child health 5) Promotion of school-age and adolescent health 6) Promotion of health for the working-age group 7) Promotion of health for children and the elderly 1.3 The CDL issued the 2nd Decentralization Plan of 2008 as endorsed by the Cabinet on 2 January 2008 and reported to the National Legislative Assembly, with which all state agencies are required to follow. As for MoPH, the plan specifies the scopes of health programmes that have to be transferred as follows: 1.3.1 Public health service system: including the systems of health promotion, disease prevention, rehabilitation and medical services. 1.3.2 Missions to be transferred: 1) Missions and budget for public health services including health promotion, disease prevention, rehabilitation, basic medical care, as well as health centres and personnel to LGOs that are ready to undertake such responsibilities. 2) Missions related to medical care at community and general hospitals as an option for any LGO that is ready to take the transfer according to the criteria established by CDL and MoPH, or they may operate such missions together with relevant state agencies. 3) Regional, specialized or higher-level hospitals are to be run by MoPH or jointly run with a LGO or transferred to a LGO with a higher level of readiness. 4) Missions related to the prevention and control of dangerous infectious diseases. LGOs may cooperate in such missions within their respective provinces as per the policy, and under the supervision, of the Provincial Health Board, the Provincial Public Health Office, MoPH, and other relevant ministries or departments. 5) The minister of public health shall appoints administrators of LGOs, competent offi- cials and LGOsû health Officials as public health officials under the Communicable Diseases Act, B.E. 2523 (1980) to be functioning under the supervision of MoPH. 6) The minister of public health shall appoint LGOsû health officials as public health officials under the Public Health Act, B.E. 2535 (1992). 7) The minister of agriculture and cooperatives shall appoint LGOsû administrators and public health officials as competent officials under the Animal Epidemics Act, B.E. 2499 (1956). 1.3.3 In the first phase, the transfer shall be done according to the readiness of each LGO and

432 in the final phase, for any LGO that is not ready, the transfer will be done to the Provincial Administrative Organization (PAO). 2. The Transfer of Health Centres to TAOs According to the 1st Decentralization Plan of 2002, MoPH was prepared to transfer 35 health centres to LGOs that had passed the readiness assessment. But during the process, some TAOs were upgraded as subdistrict/town municipalities. So, the transfer was rather slow and only 28 health centres could be transferred, 22 on 1 December 2007 and another 6 on 28 August 2008. MoPH held a ceremony transferring 22 health centres to LGOs on 30 November 2007 in the Paichit Pawabutr Conference Room, Building 7, 9th Floor, of the Office of the Permanent Secretary chaired by Dr. Mongkol Na Songkhla, the then Minister of Public Health. At the ceremony, Dr. Suwit Wibulpolprasert, acting permanent secretary, was assigned as a signatory in the document transferring the missions and property to the representatives of LGOs, while the Ministry of Interior was represented by Mr. Somporn Chaibangyang, Director-General of the Department of Local Administration, serving as a witness of the transfer. 2.1 Principles of health decentralization. In this regard, MoPH operates according to the principles and purposes of the 1997 Constitution and the 1999 Decentralization Act as well as Decentralization Plan No.1 of 2002 as follows: 2.1.1 Aiming for the maximum benefit of the people, allowing LGOs to have long-term capacity to make decisions and revolve health problems to achieve better results than before the decentraliza- tion and to have a health system that is equitable and efficient and of good quality. 2.1.2 Aiming to have a flexible and dynamic system leading to a continuous and sustainable decentralization process for health development. 2.1.3 Aiming to have a participatory system by creating a strong participatory mechanism and process at the central, regional, local and popular levels. 2.2 Implementation guidelines MoPH deployed the participatory approach in developing the health decentralization guidelines through consultative meetings extensively with all concurred at all levels. The guidelines were endorsed by the MoPHûs ministerial meeting and then by the CDL as briefly illustrated in Figure 11.1. Besides, for the transfer to be undertaken efficiently with the readiness and satisfaction of all parties, three conditions were set for the transfer of health centres to LGOs as follows: 2.2.1 To guarantee that the receiving LGOs had a transparent and efficient operating system, the transfer would be done only to those that received a good management award in 2005 or 2006. 2.2.2 To guarantee that the receiving LGOs were interested in undertaking health programmes, the transfer would be done only to those that participated in the subdistrict health security fund. 2.2.3 For the operations to be carried out by health centre staff with willingness to do so, the transfer would be undertaken only for the health centres with at least 50% of the staff willing to be transferred.

433 Figure 11.1 Guidelines for health decentralization

1. Four characteristics of decentralization 1.1 LGOs are service buyers 1.2 LGOs jointly operate with central/regional agencies 1.3 LGOs partly operate by themselves 1.4 LGOs operate the whole pregramme

3. Principles: aiming for 3.1 Maximum benefits for people 3.2 Flexible/dynamic system 3.3 Participatory system

2. Scopes of transferred mission 4. Models 2.1 Medical care, disease prevention and 4.1 Separate transfer rehabilitation 4.2 Service network transfer 2.2 Missions or services for families, 4.3 Establishing an autonomous public organization individuals or communities 4.4 Establishing a service delivery unit

● Decision-making mechanism/ Key conditions process with participation from all ● Personnel sectors ● Financial system ● Support mechanism/process ● Health-care system

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH.

434 2.3 Steps and process for transferring health centres to LGOs

Subcommittees on decentralization of health mission to LGOs at the provincial level for receiv- ing the transfer of health centres develop mechanism, process, criteria and procedures for assessing readiness of LGOs in taking the transfer: 3 subcommittees were set up

Submission to the ad hoc subcommittee on management of health mission transfer to LGOs for approval

Submission to the Committee on Decentralization to LGOs for approval and issuance of notification on mechanism, criteria and procedures; and notification to the Department of Local Administration

Department of Local Administration notifies LGOs and sends the notification on mechanism, process, criteria and procedures for LGOûs readiness assessment to take the transfer of health centres

LGOs send applications for readiness assessment in the established format together with supporting documents and venues

The 18-member subcommittee on decentralization of health missions to LGOs reviews the applications; the 9-member working group on LGO readiness assessment carries out the pretransfer and post-transfer assessments

Subcommittee on decentralization of health missions to LGOs prepares a report as per the prescribed format to the central level for approval

The central administration (MoPH) reviews and approves, and then notifies the provincial administration as well as delegates authority

Subcommittee on decentralization of health missions to LGOs provincial level by its secretariat (provincial public health office) notifies the approved LGOs with the date of transfer, and undertakes the transfer according to the prescribed criteria and procedures

435 2.4 Development of mechanisms and process for transferring health centres to LGOs

Consider and create mechanisms Committee on mecha- Subcommittee on and process for transferring health nisms, process, criteria mechanisms and centres to LGOs in 2 aspects: (1) and procedures for procedure for support- LGO readiness assess- ing the transfer of mechanisms and process for mak- ment for the transfer of health centres to LGOs ing decisions related to transfer and health centres (2) mechanisms and process for supporting the transfer operation.

1. Develop mechanisms, 1. Set up criteria and conditions for transferring health centres to process, criteria and LGOs procedures for LGO 2. Draw up system and mechanism readiness assessment Subcommittee on develop- for LGO readiness assessment for transfer of health ment of criteria, conditions regarding the transfer of health centres centres, and operate and mechanisms for LGO readiness assessment regard- 3. Make recommendations for re- (on a pilot scale) in ing the transfer of health vising rules, laws, and regulations localities with readi- centres to LGO as well as practical guidelines for operations as per the established ness for replication in criteria, conditions and mecha- other LGOs nism in items 1 and 2 2. Set up 3 subcommit- tees

Subcommittee on studies Undertake studies, evaluation sys- Order of the committee and development of evalua- on mechanism develop- tem design, and lessons learned tion system and lessons synthesis related to the transfer of ment No. 1/49, dated 4 learned from the pilot-scale Sept 2006 transfer of health centres health centres to LGOs to LGOs

436 2.5 Steps for the transfer of health centres at provincial level

1. Create policy and administrative guidelines re- lated to the transfer of health centres to LGOs. Provincial subcommittee 2. Endorse the transfer of health centres to LGOs on promotion of health for those that have passed the assessment criteria. mission transfer to 3. Monitor, follow up, evaluate and report to the LGOs (18 members) central and national levels. 4. Appoint subcommittees to carry out tasks as assigned. Appointed by the 5. Provide comments on local health personnel Committee on Decentrali- zation to LGOs, per administration regarding: Section 13 of the - Transfer, accepting transfer, position establish- Decentralization Act and Section 6.5.3 of the ment, staffing pattern, staff advancement and Decentralization Plan welfare - Allocation of quotas for scholarship students, workforce distribution, and development for Working group on LGOs LGO readiness 6. Establish performance standards for public health assessment programmes and services at health-care facilities (9 members) under LGOs, based on those for central facilities. 7. Specify public health missions of LGOs. 8. Approve public health plans of LGOs regarding those requiring budget from MoPH. 9. Assist support and enhance the capacity of LGOs to carry out transferred health mission efficiently. 10. Perform other tasks as assigned by the Decen- tralization Committee. 11. Appoint working groups to carry out tasks as assigned.

1. Assess readiness of LGOs and health centres according to established criteria and procedures 2. Evaluate achievements of the Decentralization Plan and Action Plan

437 2.6 Criteria and procedures for LGO readiness assessment: 5 elements and 8 indicators

Element Indicator

1. Experience of the LGO in managing or taking 1. Time period that the LGO has managed or par- part in public health activities ticipated or supported public health activities until the year of assessment. 2. Results of public health activity implementation. 3. Community participation in LGOûs public health activities. 4. Promotion and support for health centres before applying for taking the transfer such as resources, technical affairs activities, and others. 2. Preparedness plans for public health manage- 5. Having a strategic plan, programmes, projects or ment of the LGO, showing preparedness in various activities, or referral system development plan, aspects that are suitable for the types and models preparedness plan for emergency and epidemic of public health management situations, and/or plan for developing a control, monitoring and examination system leading to the confidence in the management of standard health system. 3. Public health administration and management 6. Procedures for public health administration and procedures management. 4. Allocation of budget for public health 7. Proportion of budget (including general subsi- dies and loans, excluding specific subsidies from the government) for public health on average for the past three years. 5. Peopleûs and stakeholdersû opinions on TAOûs 8. Opinions of the people and stakeholders in the readiness in public health management LGOûs jurisdiction on its readiness for public health management.

438 2.7 Criteria for passing the readiness assessment on LGOûs public health management and features of public health management as assessed

Average score Readiness level Recommendations on LGOûs public health management

Less than 50% Low - Continue to participate in public health management to be better prepared in the future. - May join other LGOs in public health management. - MoPH assists the LGO to be prepared for the transfer. 50› <70% Medium - Be allowed to provide disease control and health promo- tion services. - May join other LGOs in public health management. - MoPH assists the LGO to be prepared for the transfer. ≥70% High - Be allowed to receive the transfer of health centre and undertake all four dimensions of public health missions, namely disease prevention and control, health promotion, medical care, and rehabilitation.

439 Figure 11.2 Steps for LGOûs readiness assessment on public health management

MoPH transfers health centres to LGOs for public health management

Pass 6. PPHO prepares and submits summary * Review/revise/prepare report on readiness assessment * Ask for re-assessment Not pass 5. LGO taking readiness assessment Participation in public health management; undertake the management or join other 4. LGO prepares documents and LGOs in public health evidence for readiness assessment management

3. Provincial governor appoints a working group on readiness assessment * Before asking for the readiness as- sessment, the LGO should review the 2. LGO submits an application for criteria and conditions of the assess- readiness assessment to PPHO / ment; and then submit the request relevant agencies whenever it is ready for assessment.

1. LGO prepares policy, plan, and budget request for submission to LGO Council for approval on public health assessment

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary, MoPH

440 2.8 List of LGOs and 28 transferred health centres

Province LGO, district Health centre (HC) 1 Lampang 1. Lampang Luang TAO, Ko Kha 1. Lampang Luang HC 2 Tak 2. Wang Man TAO, Sam Lao 2. Wang Wai HC 3 Kamphaeng Phet 3. Wang Khaem TAO, 3. Wang Khaem HC Khlong Khlung 4. Bo Thong HC 4 Uthai Thani 4. Hat Thanong TAO, Mueang 5. Hat Thanong HC 5 Buri Ram 5. Nong Waeng Municipality, 6. Nong Ta Yao HC Lahan Sai 7. Nong Wa HC 6 Udon Thani 6. Naphu TAO, Phen 8. Naphu HC 7 Ayutthaya 7. Bang Nomkho, Sena 9. Bang Nomkho HC 8 Phathum Thani 8. Buengyitho Municipality, 10. Buengyitho HC Thanyaburi 9 Lop Buri 9. Khao Samyot Municipality, 11. Khao Samyot HC Mueang 10 Kanchanaburi 10. Wang Sala Municipality, 12. Wang Sala HC Tha Muang 11 Sumut Songkhram 11. Ban Prok TAO, Mueang 13. Ban Prok HC 12 Chanthaburi 12. Ko Khwang TAO, Mueang 14. Ko Khwang HC 13 Ratchaburi 13. Dan Thaptako TAO, Cham Bueng 15. Dan Thaptako HC 14. Ban Khong Municipality, Photharam 16. Ban Khong HC 14 Phetchaburi 15. Ban Mo, Mueang 17. Ban Mo HC 15 Sa Kaeo 16. Phra Phloeng TAO, Khao Chakan 18. Na Khanhak HC 17 Khlong Hinpun TAO, 19. Khlong Tasut HC Wang Nam Yen 20. Khlong Hinpun HC 16 Nakhon Si Thammarat 18. Pak Phun, Mueang 21. Ban Sala Bang Pu HC 22. Ban Pak Phun HC 17 Kalasin 19. Thung Khlong TAO, Kham Muang 23. Ban Duea Kao HC 18 Chiang Mai 20. Suthep Municipality, Mueang 24. Suthep HC 21. Tha Pha TAO, Mae Chaem 25. Ban Pa Daet HC 22. San Nameng TAO, San Sai 26. Ban San Na meng HC 23. Don Kaeo TAO, Mae Rim 27. Don Kaeo HC 19 Surat Thani 24. Ko Phangan TAO, Ko Phangan 28. Ban Chalok Lam HC

441 2.9 Evaluation. The MoPHûs Committee on Health Decentralization assigned HSRI to evaluate the transfer of health centres to LGOs, from the beginning stage until the transfer of all 28 health centres was complete. In such an undertaking, HSRI had academics from Khon Kaen University conduct the evaluation 3 months, 6 months and 1 year after the transfer. In addition, other agencies including the CDL and the MoPHûs Bureau of Policy and Strategy also followed up, and conducted the evaluation. The evaluation results are briefly presented in the table below.

Analysis of the monitoring and evaluation of the transfer of health centres to LGOs by 3 agencies HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs 1. Personnel 1.1Advantages (1) The personnel (1) The personnel (1) Personnelûs were adequate, taking were very knowledgeable morale was enhanced as good care of service re- about the transfer, crite- they receive more cipients in a transparent ria and guidelines of bonuses. manner. transfer, benefits, profes- sional practice at health centres (reviewing un- changed). 1.2Issues that should to be resolved (1) In the case of (1) The number of (1) If the number of - At the meeting on transferred personnel, transferred personnel transferred personnel transfer prepared- not all are coming as was too small, not con- was smaller than before ness, issues clarified expected and some were sistent with the workload; and the transfer was de- included the direct from other areas; they so, they had to work layed, the efficiency and payment for medical needed some time to harder. quality of work would be services; LGOs had adjust themselves and lower. been requested to learn about the new con- (2) During the transi- (2) The transferred make advance pay- text and how to work tional period, health per- personnel were inad- ments for personnel with the new partners or sonnel lost the chance equate. and their family networks. for promotion and members with changing positions. chronic diseases. So, (3) Eligibility for (3) There was no MoPH and relevant

442 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs welfare for transferred career advancement for agencies need to hold personnel was unclear. staff; for instance, they a meeting on this were ineligible for level matter every time promotion under the before the transfer. health centre restructuring of MoPH. (4) Former agency of (4) The right to direct - Public health person- transferred personnel payment for medical nel are still eligible to did not support their services was lost. get reimbursements operations, resulting in of medical expenses the lack of capacity build- like civil servants, but ing and the chance to they have to make participate in MoPHûs advance payments meetings as before first. (5) Some LGOs did (5) The personnel were not fairly give the annual afraid that they would not salary increase. get technical support from MoPH after the transfer, which affected their morale. (6) LGOs still had in- adequate health person- nel. (7) LGOs lacked expe- rience in public health management. (8) Lack of clarity in the practices related to personnel after transfer. - Request the Depart- ment of Local Ad- ministration to issue clear guidelines for all LGOs. 443 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs 2. Budget, supplies and equipment 2.1Advantages (1) Give a chance for - LGOs understand community organizations and participate in the to take part in the man- management of agement of funds allo- programmes on cated from NHSO with health promotion, LGOûs matching funds. disease prevention (2) Health centres and rehabilitation for receive additional budget the people with from LGOs, making them better coverage. run health activities more efficiently with better qual- ity for better benefits for the people. (3) Medicines and - The benefits are medical supplies can be delivered directly to the obtained from the hospi- people; they received the tals with convenience and services that are not dif- flexibility. ferent from those pro- vided by MoPHûs health facilities. 2.2Issues that should to be resolved (1) In a subdistrict (1) Financial regula- (1) Lack of clarity of - The Department that has more than one tions were unclear, espe- LGO regulations such as of Local Administration health centre but not all cially for self-generated on budget. should draw up a train- were transferred to the revenue; the revision has ing curriculum on finan- LGO, there was some not been finished. cial administration for confusion in operations (2) Some LGOs (2) Lack of clarity in LGOs and support staff such as budget and lacked the knowledge budgetary procedures af- training. resources. and understanding of ter the transfer. criteria for budget allo

444 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs cation to health centres; - MoPH has no bud- some were unaware of get to be allocated to such criteria. LGOs; there is only capita- (3) The budget (3) Lack of budget tion budget from NHSO. received is too little. for public development - If the transfer is under- as no budget had been taken before the annual earmarked for such pur- budget preparation pe- poses. riod, LGOs will prepare (4) Procedures for their annual budget managing different funds regulations on a timely were unclear. basis. (5) Public health per- sonnel lack the knowledge and understanding about the financial management of LGOs; and there are no clear guidelines for accounting, financing and financial reporting. 3. Operations 3.1 Advantages - The Department of Lo- (1) For the transfer (1) Work can be cal Administration has of health centres, when done faster with more prepared a curriculum all personnel have been flexibility and local prob- on LGO financial ad- transferred, they will co- lems can be solved on a ministration; all public operate and assist each timely basis. health personnel at all other in doing their work levels should be sup- as they have known each ported to attend the other before; at the com- training. munity level, there are VHVs coordinating the activities for unity in the operations.

445 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs (2) Specific space has (2) Contacts for co- been provided for health- operation with executives care delivery with mod- of LGOs can be done ern equipment and an with more recognition opportunity for modern- and friendliness. ization. (3) The service and (3) Patient referrals referral systems have are more efficient as been better. LGOs can provide an ambulance and person- nel when making a referral. (4) LGOs can partici- (4) The people are pate in health satisfied with cleaner programme planning facilities. with the people; so, prob- lems can be discussed, their causes are analyzed; evaluations can be under- taken and achievements of such programmes or projects can be pre- sented. (5) It is more conve- nient for the people to seek health care with health providersû atten- tion. (6) Public health per- sonnel agreed than the transfer helps the people to get better services and the health centreûs pre- mises will be improved. 446 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs 3.2 Issues that should to be resolved (1) Personnelûs (1) The administra- (1) Health centre - The staffing pattern unconfidence in LGOs tive systems of MoPH staff want to get support together with justifi- causing management and LGOs are different; from LGO executives in cation for health cen- problems in the first there are no common terms of adequate staff- tres should be pro- phase. operating guidelines. ing, supplies and equip- posed to the Provin- (2) In the some local- (2) There is no sup- ment as well as continu- cial Local Administra- ity with only some health port for certain opera- ing education opportuni- tion Committee. centres transferred to an tions; that seems like ties and technical - To date the Depart- LGO, resulting in confu- being cut off from support. ment of Local Ad- sion in the operations, MoPH. ministration has is- supervision, referrals and sued the Regulation cooperation between on Use of Revenue MoPH and LGO of LGOsû Health agencies. Centres, B.E. 2552 (3) The partial trans- (3) Operations and (2009), which re- fer of health centres and revision of rules and placed the MoPHûs personnel has resulted in regulations are slow. regulation on this unsolidarity of opera- (4) Too little has the matter. tions as the policy of doctor come to provide each agency is different; medical services at health the working periods are centres; there are no also different, resulting dental services in some in disparities in opera- localities. tions. (5) Not all kinds of services are provided; no dental services in some areas. 4. Management 4.1 Advantages (1) The LGO and the (1) Having a faster (1) Policies can be set health centre have good management mechanism for working beyond the

447 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs working relations as with a shorter line of frame set by MoPH, some staff may be rela- command and more in- which can respond to tives and from the same dependent management. peopleûs needs more to locality. the point. (2) The LGO and the (2) Having career ad- (2) Referral system health centre have com- vancement within their for patients is more effi- mon experience and line of work, which can cient as LGOs can pro- faiths in operations. be changed more easily. vide an ambulance and staff for such purposes. (3) The budget ap- (3) Health centres proval process is shorter have been improved in resulting in faster opera- terms of structure, sup- tions and increased effi- plies and equipment. ciency. 4.2 Issues that should be resolved (1) Management (1) The government - At present, only Ko regulations are still un- should set a clear policy Phangan TAO has clear especially those re- and guidelines for the not establish a Public lated to personnel and transfer. Health Section; so, budget. public health and en- (2) The linkages of (2) MoPHûs policy on vironmental activities networks, operations and the transfer of the re- have to be handled by services between MoPH moving health centres is the Office of the and LGO agencies are unclear; some provinces TAO Chief Adminis- unclear. do not support the trans- trator. As the TAO is fer, resulting staffûs a special area as a unconfidence. tourist destination on (3) Former parent (3) Some LGOs have an island, it is hard agencies (under MoPH) not established a Public to recruit personnel did not give any support Health Division or Sec- and 40% of the TAO as before as the trans- tion to get prepared for budget is spent on ferred health centres the transfer. personnel, the estab

448 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs have got the budget from lishment is deferred. the receiving LGOs. - The guidelines for (4) Guidelines for re- (4) LGOs lack the LGO readiness assess- source management of readiness in management ment were actually MoPH and LGOs are dif- as they have no experi- prepared jointly by ferent. ence in this matter. MoPH and LGO net- (5) Revision of relevant (5) The criteria for works and approved rules and regulations are LGO readiness assess- by CDL. slow and unclear. ment are difficult and complicated. (6) Executives of some (6) Personnel lack the LGOs do not understand understanding of rules the work of MoPH as ex- and regulation for opera- pected. tion especially for bud- get and personnel. (7) Executives of some LGOs have little partici- pation in the management and operations of health centres. 5. Clientsû satisfaction 5.1 Advantages (1) The people are sat (1) Better service sys- (1) Most people in the - The benefits of the isfied with the standard of tems, faster services with locality are aware of the transfer go directly to health centres with better accuracy and coverage; transfer of health centres the people, who also health services, such as more supplies of to LGOs and agree on help monitor local referral systems, service medicentres and equip- the transfer. health activities. equity (queue card), daily ment; more services form services, home visit, den- physicians and dentists at tal service, lab service, health centres. faster service, emergency care within and outside office hours.

449 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs (2) Specific places have (2) More support for (2) Most people are been designated for each public health from LGOs. satisfied with the better activity; service areas are cleanliness of health suitable with modern centres. equipment readiness to provide services and development of modern services. (3) Personnel are ad- (3) Better health cen- (3) The services are equate with proper atten- tres with regard to struc- more convenient and tion to clients, spending ture, supplies and equip- faster with more atten- more time on service de- ment. tion from staff. livery and working with transparency. (4) Services (medical (4) Equipment, tools care) and referral systems and medicines are ad- are suitable which changes equate for health-care towards betterment. delivery. (5) The people partici- (5) Opportunities are pate in creating health open to the people to development plans, rais- participate in undertak- ing problems and jointly ing public health activi- analyzing causes of prob- ties. lems. (6) The people are satisfied with the cleanli- ness of the premises. (7) The people get health services with con- venience and attention of health personnel. 5.2 Issues that should be resolved

450 HSRI Bureau of Policy and Committee on Analysis and Strategy, MoPH Decentralization to recommendations LGOs 6. Opinions of LGO executives 6.1Advantages (1) LGO executives - The transfer is car- are enthusiastic about re- ried out smoothly; ceiving the transfer of the support for pub- health centres with visions lic health is accept- and experience in public able to local person- health. nel as the transfer directly provides maximum benefits for the people. 6.2Issues that should be (1) LGO executive - MoPH (through resolved would like to have officials PPHO, district health of transferring agencies offices and commu- continue to provide sup- nity hospitals, are cur- port for LGOs for some rently providing good time as well as budgetary support for the trans- and technical assistance fer of health centres. for LGOs and health per- However, only some sonnel, and facilitate the district health officers transfer of staff who wish (DHO) misunder- to move to LGOs. stood that they were not supposed to over- see the transferred health centres. And in the future, DHO is still a member of the District Health Coor- dination Committee.

451 In 2010, the last year of the Decentralization Plan (No. 2) of 2008, 173 LGOs submitted a request for LGO readiness assessment for receiving the transfer of health centres; 35 of which passed the assessment criteria and at least 50% of health centre staff are willing to move to LGOs. Meanwhile, another 8 LGOs and 8 health centres in 6 provinces are awaiting MoPHûs approval of the transfer. 3. Conclusion The health decentralization operations over the period of almost 10 years have not progressed as expected, mainly due to MoPHûs concept of retaining centralized authority over subdistrict health facilities. Thus, there has been no continuity in the operations together with unclear direction and policy on such effort. As a result, the LGOs that do not want to wait for such a transfer have set up their own health-care facilities, which is a redundant investment. Besides, in connection with the linkages for operations between state and local agencies after the transfer, state agencies still have to duties to monitor their operations and provide technical assistance, as a supporter for local agencies. But, apparently there have been no cooperating mechanism or thinking process in a clear manner and LGOs have to help themselves, which has negatively affected the people.

452 Chapter 12 Support for Access to Essential Drugs and Compulsory Licensing of Drugs

1. Introduction The Thai patent law that is now being enforced is the Patent Act, B.E. 2522 (1989), and its amend- ment No. 2 of B.E. 2535 (1992) and amendment No.3 of B.E. 2542 (1999). The Act authorizes compulsory licensing or government use of patents on any patented products including patented drugs in two instances, one by any ministry, sub-ministry or department of the government according to Section 51 and the other by the Prime Minister with the Cabinetûs approved during a state of war or emergency in accordance with Section 52. The exercise of power for both instances mentioned above is in accordance with Article 31 of the Agreement on Trade-Related Aspect of Intellectual Property Rights (TRIPS Agreement), which was adopted by the Doha Declaration on TRIPS and Public Health by members of the world trade Organization (WTO) at the WTO ministerial conference held in Doha, Qatar, on 14 November 1999. There were efforts to urge the government to exercise such a right in Thailand in 1999 by a group of HIV-infected people led by Mr. Jon Ungphakorn, requesting that MoPH issue a compulsory licence for antiretroviral drug çddIé, but did not succeed. That was because the government was afraid that such a practice would affect the trade relationships in regard to the Generalized System of Preferences (GSP) and that a trade retaliatory action might be taken according to Article 301 of the U.S. trade law. As a result, Thailand had to bear the burden of unreasonably high prices of such a drug under the patent law, especially the Patent Act, Amendment No.2 (1992), which also covered pharmaceutical products, whereas the previous law covered only a manufacturing process. Such a law amendment in Thailand was undertaken 8 years before the time frame specified by WTO and 13 years before least-developed countries, including India. But finally, Thailand had a pressing need to exercise the compulsory licensing from late-2006 until early 2008 for a total of seven patented drugs, of which two were antiretroviral, one for heart disease and four for cancer treatment. 2. Background In the 1997 Constitution of Thailand, there were two sections directly on public health as follows: Section 52: A person shall enjoy an equal right to receive standard public health service, and the indigent shall have the right to receive free medical treatment from public health centres of the State, as provided by law.

453 The public health service by the State shall be provided thoroughly and efficiently and, for this purpose, participation by local government organisations and the private sector shall also be promoted insofar as it is possible. The State shall prevent and eradicate harmful contagious diseases for the public without charge, as provided by law. Section 82: The State shall thoroughly provide and promote standard and efficient public health services. In the 2007 Constitution of Thailand, which is the first constitution of the country that passed a public referendum and is currently enforced, also contains the two sections on public health with some modifications as follows: Section 51: A person shall enjoy an equal right to receive standard public health service, and the indigent shall have the right to receive free medical treatment from Stateûs infirmary. The public health service by the State shall be provided thoroughly and efficiently. The State shall promptly prevent and eradicate harmful contagious diseases for the public without charge. Section 80: The State shall act in compliance with the social, public health, education and culture policies as follows: Ç(2) promoting, supporting and developing health system with due regard to the health promotion for sustainable health conditions of the public, providing and promoting standard and efficient public health service thoroughly and encouraging private sector and the communities in participating in health promotion and providing public health service, and the person having duty to provide such service whose act meets the requirements of professional and ethical standards shall be protected as provided by law. Basically, according to the intent and provisions of the 1997 Constitution, the Parliament passed the 2002 National Health Security Act aimed at providing universal health care for all Thai citizens on an equitable and efficient basis with high quality. In particular, Section 5, paragraph 1 of the Act prescribes that çThe Thai population shall be entitled to health services with such standards and efficiency as prescribed in this Acté. Besides, the Royal Decree on Criteria and Procedures for Good Governance, B.E. 2546 (2003), specifies that state agencies have to implement their respective functions to achieve seven goals as per Section 6 of the law as follows: (1) Resulting in maximum benefits for the people. (2) Resulting in achievements of state missions. (3) Being efficient and worthwhile for state missions. (4) Not having too many operating steps other than essential ones. (5) Modifying state missions in accordance with changing situation in a timely manner. (6) Being convenient for the people and responsive to their needs. (7) Having performance evaluations on a regular basis.

454 To achieve the goals prescribed in the Constitution, the National Health Security Act and the Royal Decree on Good Governance, the National Health Security Commission and the National Health Security Office (NHSO) have decided to use the capitation financing method as the most economical capitation rate can be calculated. In the beginning, the rate was 1,202 baht per capita per year, which was the lowest, compared with the capitation rates under the Social Security Fund (SSF) and the Civil Servant Medical Benefit Scheme (CSMBS). With the capitation budget, NHSO has been able to manage and achieve the objectives quite effectively. However, one of the big problems hindering peopleûs access to essential drugs or medicines is the drugsû high prices especially patented drugs with monopoly and arbitrarily set prices of drugs. Thus, unavoid- ably, there was a need for the government to issue compulsory licences on certain essential patented drugs according to the Thai patent and international rules. 3. Procedures for Operation The first drug, according to the countryûs needs, that would be considered for compulsory licensing was an antiretroviral drug (for HIV infection). According to the 2002 National Health Security Act, the eligible persons will have access to drugs in the National List of Essential Medicines (NLEM) except for antiretrovirals in the first year of the universal healthcare scheme due to budgetary constraints. But in the following year, the government issued the policy on access to antiretrovirals for all, beginning on 1 October 2003, according to the humanitarian principles and the provision of the Constitution: çEvery person shall enjoy equal rights to receive appropriate and standard public health servicesé. For the universal access to antiretrovirals policy to be implemented in an economical and efficient manner, it is necessary to use the cheapest drug regimen, i.e. GPO-VIR of the Government Pharmaceutical Organization (GPO) which contained nevirapine, a antiretroviral that could not be tolerated and cause adverse drug reactions among a number of patients. So, the regimen had to replace the drug with another expensive patented drug efavirenz. Besides, a certain number of patients would naturally develop drug resistance and another expensive patented regimen would have to be used instead, i.e. a combination of ritronavir and lopinavir. Efforts were made continually to negotiate with drug patent-holders after MoPH had issued Order No. 360/2548 (2005) appointing an ad hoc working group on negotiations of patented drug prices, chaired by the Secretary-General of the Food and Drug Administration and comprising representatives of non-MoPH agencies including the Patent Office and the Internal Trade Department of the Ministry of Commerce. The negotiations were undertaken on 3 antiretrovirals, i.e. efavirenz of Merck Sharp and Dohme (MSD), ritronavir/ lopinavir of Abbott Laboratory and atazanavir of Bristol-Myers Squibb (BMS) Company. But, according to the working groupûs report, çthe negotiations with the drug companies were preliminarily not successful, no cooperation was received from the companiesÇ.é

455 Before that, the Department of Disease Control sent a letter No. MoPH 0424.4/7/6673, dated 16 November 2004, requesting price reduction for drug efavirenz of MSD and another letter No. MoPH 0424.4/ 7/6692 on the same date for drug ritronavir/lopinavir of Abbott Laboratory. But the requests were rejected. Later on, NHSO issued Order No. 4/2549, dated 19 April 2006, appointing a Subcommittee on Government Use of Patented Drugs and Medical Supplies, chaired by the Secretary-General of NHSO and comprising representatives of health professionals, AIDS and cancer patients, the Office of the Council of State and the Intellectual Property Department of the Ministry of Commerce. The subcommittee later made a recommendation on the government use of patents on all the patented drugs, which were later on under compulsory licenses, with the endorsement of NHSB prior to submission to MoPH. It is noteworthy that the compulsory licensing actions at a later date were reviewed by relevant agencies and taken after considerable negotiations with the patent-holders. 4. Announcements of the Government Use of Patents for the First 3 Drugs The announcements or notifications of compulsory licensing or government use of patents of the first three patented drugs, including two antiretrovirals (efavirenz, ritronavir/lopinavir) and one cardiovascular drug (clopidogrel), were undertaken pursuant to Section 51 of the Patent Act. The announcements for the antiretrovirals were issued by the Director-General of the Department of Disease Control on 29 November 2003 and 24 January 2007, while the one for clopidogrel was issued by the Permanent Secretary, MoPH, on 25 January 2007. In addition to issuing the announcements and notifying the patent-holders, the notification was also made to the Director-General of the Intellectual Property Department. And the import of all the three drugs was undertaken by the Government Pharmaceutical Organization. The justification for compulsory licensing of the three drugs was clearly stated in the three an- nouncements. For example, in the case of efavirenz, the justification includes legal authority and resources/ necessity and conditions as follows: It is generally accepted that the HIV/AIDS epidemic is one of the most grievous public health problems. Approximately, more than one million Thai people have been afflicted with the HIV. More than 500,000 of this number are still alive and eventually need long-term uses of HIV antiretroviral drugs to maintain their productive lives. The budget allocated for health services of the people who have been infected with HIV as well as AIDS patients under the national health security system for the fiscal year 2006 is only 2,796.2 million baht for the target group of 82,000 patients. Even now there are many effective HIV antiretroviral drugs which are capable of extending life span of HIV-infected persons and the Royal Thai Government has launched, since 1 October 2003, a policy to promote access to HIV antiretroviral drugs for all HIV-infected persons and has also allocated budget for this purpose, but the accessibility to some kinds of HIV antiretroviral drugs which are effective and having low level of side-effect is still difficult in spite of an inevitable necessity for the HIV-infected persons. This due to the fact

456 that all those antiretroviral drugs are under patent protection in accordance with the law on patent which enables the patent-holders to dominate market without competition. The prices of such antiretroviral drugs are, as a result, very high and a hindrance for the State to acquire the drugs for distribution to all HIV-infected persons. Efavirenz has already been proved so far to be one of highly effective and safe antiretroviral drugs with very low side effect. It has also been placed in the National System for Secured Accessibility to Antiretroviral Drugs. This antiretroviral drug, however, is subject to patent protection which deters the Government Pharma- ceutical Organization or other manufacturers from manufacturing and importing this specific drug for sale in the market. The price of efavirenz in Thailand is twice the price of the same drug which is generic drug in India. The budget allocated by the government is therefore sufficient to provide only some patients with efavirenz, while the rest has to use non-patent drugs with higher level of side-effect than efavirenz because of their lower prices. According to the Doha Declaration on the TRIPS Agreement and Public Health, each member country has the right to protect public health, in particular, to promote access to medicines for all in case of emergency and for public benefit, especially accessibility to those relating to HIV/AIDS, tuberculosis, malaria, and other epidemics. In this regard, the Thai law on patent empowers ministries, sub-ministries and depart- ments to exercise the right under any patent without prior authorization of the patent-holders so as to provide public service as mentioned above.

Therefore, the Department of Disease Control, the Ministry of Public Health, hereby notifies, by virtue of section 51 of the Patent Act, B.E. 2522 (1979), as amended by the Patent Act (No. 2), B.E. 2535 (1992) and the Patent Act (No. 3), B.E. 2542 (1999), that it is now exercising the right under drug patent of the drug under trade name çStocriné (generic name: efavirenz). In this regard, the Department of Disease Control entrusts the Government Pharmaceutical Organization to exercise the right in its name in accordance with section 36 paragraph one of the Patent Act, B.E. 2522 (1979), as amended by the Patent Act (No. 2), B.E. 2535 (1992) and the Patent Act (No. 3), B.E. 2542 (1999), subject to the following conditions: (1) the right shall be exercised from now on through 31December 2011; (2) the exercise of the right is limited to annual provision of drug having the aforesaid generic name to not exceeding 200,000 patients who are entitled persons under the 2002 National Health Security Act and the insured persons under the 1990 Social Security Act, and persons entitled to medical benefits for civil servants and government employees scheme; (3) a royalty fee of 0.5 per cent of the total sale value of drug having the aforesaid generic name by the Government Pharmaceutical Organization shall be paid to the patent-holder.

The Department of Disease Control, Ministry of Public Health, shall notify the patent-holder and the Department of Intellectual Property for information without delay.

457 5. Procurement of Drugs under Compulsory Licenses As Thailand was forced to amend its patent law to cover pharmaceutical products in 1992, ever since no drug companies have invested in research and manufacturing of generic drugs whose patents are still valid. So, the purchase of such drugs had to be made from other countries, especially India which has been manufacturing a lot of generic drugs with good quality and low prices. In India, the patent lawûs provision on drug manufacturing process was observed especially with regard to the timeframe established by WTO; until 2005, the law was amended to also cover pharmaceutical products. Over the past decade, India has developed its pharmaceutical industry on a leap scale; and it has been able to produce medicines according to the standards of WHO and other developed countries such as the USA and European countries. Pharmaceutical products can be exported to almost all over the world; and importantly, there are a lot of pharmaceutical plants that are able to produce pharmaceutical ingredients for domestic use and export at a reasonable price. Prior to the compulsory licensing for patented dugs, the Thai MoPH had examined the list of generic drugs that should be imported for use in lieu of high-priced patented drugs. After the issuance of compulsory licences on certain patented drugs, GPO has been able to procure the drugs under compulsory licenses accordingly. However, to ensure the good quality of such drugs and to follow the countryûs legal requirements, the import of the drugs under compulsory licenses have to be strictly undertaken according to the Thai FDA requirements, including drug registration and quality assurance of the Department of Medical Sciences or other foreign agencies for the case that cannot be done by the Department of Medical Sciences. So, it takes a rather long time for each imported drug to reach the patient. It is a pleasure, anyway, that the price of each imported drug is markedly lower than that of the patented drug, especially heart-disease drug clopidogrel whose patented drug price per tablet is 70 baht (approx. US$2.33), while the GPO-purchased drug was only 1.06 baht (approx. US$ 0.0353). 6. Retaliation from Patent-holders After the governmentûs compulsory licensing of patents, three patent-holders responded and retaliated in different aspects. Merck Sharp and Dohme (MSD) responded in a creative manner by reducing the price, but not to the level set by the Committee on Support for the Government Use of Patent, i.e. the patented drug should not be more expensive than the generic drug by more than 5%. This is to allow generic drug industries to compete in the procurement process for the promotion of the peopleûs better access to essential drugs. Accordingly, the compulsory licensing for efavirenz of the drug company was in effect. For Abbott Laboratory, the retaliation was rather strong with the withdrawal of seven new drugs from the FDA. Besides, there were retaliations from various agencies, blaming Thailandûs compulsory licensing measure. For example, the Pharmaceutical Research and Manufacturers Association (PReMA, Thailand), the

458 Pharmaceutical Research and Manufacturers of America (PhRMA) and the United States-ASEAN Business Council (USABC) reasoned that Thailandûs action was the impediment to research on new drugs; and there would retaliate by stopping or reducing investments on other businesses in Thailand. Moreover, the U.S. Trade Representative (USTR) also expressed its negative position on Thailandûs measure and later on raised Thailand from their Watch List to Priority Watch List in relation to trade retaliation. The then US ambassador to Thailand asked for a meeting with the Thai Minister of Public Health to express concerns and suggested ways of negotiation with patent-holders in lieu of compulsory licensing of patents even though he had known or should have known that MoPH had used the negotiation method considerably but failed to reach any satisfactory result. Later on, an agency called USA For Innovation opened a website and put advertisements on a full page of Thai and English newspapers strongly attacking the Thai government, especially, MoPH and GPO, on this matter as well as the government having been established by the 19 September 2006 military coup. But the investigation conducted by the Royal Thai Embassy in Washington, D.C., revealed that the agencyûs location did not actually exist. The foreign mass media that continually attacked Thailandûs compulsory licensing of patents was The Wall Street Journal. As for Sanofi Company, the owner of clopidogrel, its legal action was undertaken by a law firm, Tilleke & Gibbins, informing GPO and all concerned including the Indian drug company that MoPHûs issuance of compulsory licences for its patented drug was illegal and that such an action be discontinued otherwise a legal action would be taken. 7. International Perspectives The international perspectives on Thailandûs compulsory licensing of patents were all positive from individuals, agencies or organizations within and outside the USA such as Medicins Sans Frontieres (MSF, or Doctors Without Borders), the US-based Consumer Projection Technology, the William J. Clinton Foundation, and the Knowledge Ecology International (KEI). Importantly, 22 U.S. congressmen signed a letter to USTR, informing USTR not to intervene in Thailandûs compulsory licensing of patents. Later on, a legal expert of American University prepared an analysis of this matter and concluded that Thailandûs compulsory licensing of patents is legal and in accordance with Thai law and the TRIPS Agreement. And after the USTR had raised Thailand to The Priority Watch List, 35 U.S. congressmen sent a letter to USTR indicating their objection to such a matter. As for the case of Thailandûs being deprived of the GSP privileges for gold jewellery, two key congress commissioners also sent an objection letter to USTR. In other counties, the Department for International Development of the United Kingdom sent a letter, dated 22 May 2007, supporting Thailandûs compulsory licensing of patents and the European Parliament passed a resolution on the protection of developing countriesû access to essential medicines on 12 July 2007. In addition, international organizations clearly supported Thailandûs action: the Joint United National Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) sent letters of

459 support to the Minister of Public Health on 26 December 2006 and 7 February 2007, respectively. 8. Explanation of Thailand In addition to periodically answering the questions of the press by the Minister of Public Health and relevant health officials concerned, there have been public relations efforts through various tools and mecha- nisms as briefly described below: 1) Issuance of çwhite paper çoné Facts and Evidences on the 10 Burning Issues Related to the Government Use of Patents on Three Patented Essential Drugs in Thailandé. The 16-page paper contains 10 questions and answers, systematically explaining various facts and evidences in all key relevant aspects with references as appendices in a reliable manner with a simple, concise and clear language. The publication of the paper could be done within a short period of time in February 2007, only a few weeks after the issuance of the government use of patents or compulsory licences on the first three patented drugs. It is regarded as the extremely good practice of a public relations effort as, in addition to publication for a wide-scale distribution, the paper was also posted on the MoPH website. Describing the justification and righteousness of the govern- ment use of patent related to essential drugs to the general public, the paper has created a good understanding among all public health personnel throughout the country. The paper was later on translated into English with a clearer explanation on certain aspects in accordance with the changing situation; it hard copies were widely distributed and its electronic file was posted on the Internet for worldwide distribution which helped create a good understanding for Thai and global citizens, especially in efficiently counter-attacking the claims of the benefit-losers. Another white paper of this kind was prepared after the issuances of the government use of patents related to four anti-cancer drugs, entitled çThe 10 burning questions regarding the Government Use of Patents on the Four Anti-Cancer drugs in Thailandé, published in February 2008. 2) Overseas trips to the USA. Two trips was taken to build up alliances and clarify the facts on this matter; the first one was to hold a joint press conference with former president Bill Clinton at the William J. Clinton Foundation in New York City and the second one to give a briefing to relevant persons and agencies in Washington, D.C., especially those who were supportive of, or against, MoPHûs operations on this matter. The Thai delegation also met with key figures in the USA such as Congressmen, (both the government and opposition sides), the U.S. Secretary of Commerce, the Pharmaceutical Research and Manufactures of America, the U.S.-ASEAN Business Council, office of the U.S. Trade Representative, and the Office of the Washington Post. At the end of each day of the 2-day visit, a press briefing was held at the Royal Thai Embassy in Washington, D.C., where proactive public relations efforts could be effectively undertaken. Both trips to the USA were efficiently supported by the Royal Thai Embassy in Washington, D.C., which also provided excellent background information about the negotiation partners. 3) After Thailand had been put on the USTRûs Priority Watch List due to vague reasoning of Thailandûs government use of patent, the Thai Minister of Public Health bravely declared that Thailand was

460 retaliated because of the drugsû compulsory licensing, rather than being blamed for taking incorrect actions, making Thailand being in a difficult situation. On the contrary, the mass media and the general public praised the courage and were displeased with the USAûs action persecuting Thailand with its power. 4) When the USA For Innovation opened its website and issued a full-page advertisement in Thai and English newspapers, strongly blaming Thailand with true and false information, the GPO responded immediately by filing a legal action against such an agency, but not against the advertising newspapers. As a result, the newspapers discontinued the advertisement and the USA for Innovation disappeared. 9. The Second Wave of the Government Use of Patents During the late stage of the Surayud Chulanont government, despites being pressured by the US government and the Thai Ministry of Commerce, the Thai Minister of Public Health decided to issue the government use of patents for four patented anti-cancer drugs: docetaxel, letrozole, erlotinib and imatinib, with the conditions that the patent-holders agree to give one of the drugs to Thai patients under the universal healthcare scheme free of charge, but the use of the other three drugs would be in accordance with Section 51 of the Patent Act, B.E. 2522 (1979), as amended, after unsuccessful negotiations because the patent-holder agreed to reduce the prices with the conditions that were hard to follow, and thus unacceptable. The compulsory licensing or government use of the four aforementioned patented drugs began when the Subcommittee on Selection of Essential Medicines and Medical Supplies with Difficult Accessibility under the Health Insurance System submitted a letter No. NHSO 05/013521, dated 25 September 2007, to the Minister of Public Health and the Committee on Supporting the Implementation of the Government Use of Patents passed a resolution at its meeting No. 7/2550, on 2 October 2007, requesting the Minister of Public Health to issue the government use of patents as per its memorandum No. MoPH 0100/TST/special, dated 19 October 2007. After more than 10 negotiations with the drug companies conducted by the Committee on Price Negotiation of Patented Drugs, chaired by the FDA Secretary-General, the Minister of Public Health signed the notifications on the government use of patents for the four patented anti-cancer drugs, but its implementation was delayed, pending further negotiations. After another round of negotiation with Novartis (imatinibûs patent- holder), the company agreed to donate the drug to the patients under the universal healthcare scheme; and thus the MoPH notification on government use of patent for imatinib was repealed. Accordingly, a new notification with conditional government use of patents was issued instead on 25 January 2008, which also cancelled the delay in the implementation for the other three drugs. 10. Implementation of the Change in Government After the general elections on 23 December 2007, the Peopleûs Power Party won the majority seats and the new Minister of Public Health issued a policy to review the implementation of the government use of patents on patented drugs; but the move was widely apposed by the Rural Doctors Society and groups of

461 patients. In this connection, the Public Health Minister issued orders transferring the then FDA Secretary- General to another position and removing the GPO Board of Directors. In this regard, some members of the Board filed a petition to the Administrative Court and the Central Administrative Court issued an injunction reinstating all the Board members, but later on the Supreme Administrative Court reversed the order, resulting in the removal of all the Board members. Some time later, as a result of the political change, the newly appointed cabinet endorsed the reappointment of the former chairperson of the GPO Board of Directors. It is noteworthy that, during the one-year period after the general elections, there were changes in membership of the GPO Board of Directors as the post-election Cabinet had policies that were clearly different from those of the Surayud Chulanont government, especially on the government use of patents. There were criticisms that the decision had been made arbitrarily, especially for the anti-cancer drugs, taking the opportu- nity while being the caretaker government. But because there was no official order for GPO to delay the implementation of the policy directed by the Surayud government, the importation of the generic drugs under the government use of patents has been carried out continuously. 11. Results of the Operations Between January 2007 and 14 February 2011, GPO imported five generic drugs under the govern- ment use of patents, but the other two drugs were not imported; the first one, imatinib, was not imported as it is under the conditional government use of the drug patent and there had been no conditions for such importation and, for the other drug (anti-cancer erlotinib), it was not imported as there was no generic drug with the results of bio-equivalence study in the blood according to the FDA criteria. Totally, the value of drug imports during the period was 1,077.7 million baht. 12. Increase in the Access to Patented Drugs After the issuance of notifications of the government use of patents and the importations of generic drugs, it has been noted that patientsû access to essential drugs has increased considerably in both the universal healthcare and social security systems, especially for two antiretroviral drugs: efavirenz and lopinavir/ritronavir (Figures 12.1 and 12.2).

462 Figure 12.1 Use of antiretroviral efavirenz (600 mg) under the universal coverage (UC) of healthcare scheme, 2006›2010

Bottles CL 50,000 45,000 40,000 UC Scheme 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0

Jul-06

Jul-07

Jul-08

Jul-09

Jul-10

Jan-07

Jan-08

Jan-09

Jan-10

Sep-06

Sep-07

Sep-08

Sep-09

Sep-10

Mar-07

Mar-08

Mar-09

Mar-10

Nov-06

Nov-07

Nov-08

Nov-09

Nov-10

May-07

May-08

May-09

May-10

Source: Suwit Wibulpolprasert, 2011.

Figure 12.2 Use of antiretroviral lopinavir/ritronavir (200/50 mg) under the universal coverage (UC) of healthcare scheme, 2006›2010

Bottles CL 14,000 12,000 UC Scheme 10,000 8,000 6,000 4,000 2,000 0

Jul-06

Jul-07 Jul-08

Jul-09

Jul-10

Jan-07 Jan-08

Jan-09

Jan-10

Sep-06

Sep-07 Sep-08

Sep-09

Sep-10

Mar-07 Mar-08

Mar-09

Mar-10

Nov-06 Nov-07

Nov-08

Nov-09 Nov-10

May-07 May-08

May-09

May-10

Source: Suwit Wibulpolprasert, 2011.

463 13. Systematic Monitoring and Evaluation To make it apparent to the world community that the government use of seven drug patents was correct, justifiable, transparent and accountable, according to World Health Assembly resolution 60.30, MoPH requested the WHO Director-General to send a group of experts to examine and give advice on MoPHûs operations. In response, the expert team comprising representatives of WHO, WTO, the U.N. Conference on Trade and Development (UNCTAD), and the UN Development Programme (UNDP) came to review the system and procedures for the government use of patents on patented essential drugs in Thailand from 31 January to 6 February 2008. The team did not find any operation that was not transparent or inconsistent with the WTO rules. However, the team recommended that Thailand deploy the TRIPS flexibility measures for more Thais to get access to the essential drugs, particularly the pre-patenting measures that have been used effectively in India. Regarding the impact assessment, the Health Intervention and Technology Assessment Program (HITAP) conducted a study on the government use of drug patents in Thailand, but with a limited timeframe of 2006›2008, the study did not cover the four anti-cancer drugs as their patent use was imposed at a later date. The study briefly reveals the following: çRegarding health, the compulsory licensing measure has considerably increased the number of patients having access to essential drugs, particularly antiretrovirals. But for clopidogrel and the four anti- cancer drugs, during the study period there were no imports of such generic drugs, the researchers had to make an assumption that there would be the imports of such generic drugs from 2009 onwards. It was found that the numbers of patients with access to each of such drugs had increased at a high to low level for clopidogrel, letrozole, docetaxel, imatinib and erlotinib, respectively. In terms of economic impact, the measure has resulted in a greater number of patients having access to such drugs, better quality of life and, a longer lifespan, worth US$ 132 million. Even though the relation between Thailandûs compulsory licensing measure and USAûs revocation of GSP on three Thai products was unclear, the study has revealed that such a trade retaliation ùhas no impact on the countryûs overall exports and investorûs confidence in the short runû. However, there should be a further study to monitor the impacts of such a policy in the long term. In assessing the socio-psychological impact, data collection has done using a questionnaire for Thai and foreign respondents; most of them agreed to the compulsory licensing measure for antiretrovirals. The positive impacts that most Thai and foreign respondents agreed to was the cheap prices of drugs. As for the negative impact, most Thai respondents viewed that technology transfer from developed to developing coun- tries would decline, while most foreign respondents said that the major negative impact was the blame on Thailand by the international community. Under this study, the researchers have proposed six factors for use when selecting patented drugs if the compulsory licensing measure has to be deployed in the future; and there are needs for the development of an information system for the health system, the health insurance project and intellectual property right

464 protection; the dissemination of knowledge and the creation of correct understanding for the general public particularly in relation to the flexibility according to the TRIPS Agreement and compulsory licensing; and the selection of measures for resolving the problem of inaccessibility to essential drugs in a suitable manner, based on empirical evidence.é 14. Conclusion The government use or compulsory licensing of patents for seven essential patented drugs is the correct operation in accordance with all principles and justifications: humanitarianism international rules, the countryûs law and good governance. The operations, including the preparation, have been undertaken with prudence and step-by-step procedures, with the participation of all relevant persons, and by the agencies directly responsible for this matter, not deferring it for cabinetûs consideration. Wherever there were retalia- tions or objections from the benefit-losers, there were systematic and adequate clarifications at the national and international levels. The implementation of such a measure has resulted in the significant reduction of unsuitable expenses as such patented drugs are unreasonably expensive. The major target has been achieved, i.e. the substantially increased number of patient with access to essential drugs; and there has been no impact on international trade as expected. In the future, there should be studies and preparation on using other measures to increasingly improve patientsû access to essential drugs such as pre-patenting measure recommended by WHOûs team of experts.

465 466 Chapter 13 Economic Dynamics and Health

Economy and health are interconnected as statistics in the past have shown that the economic crises had both positive and negative impacts on peopleûs health as well as the health-care system. This chapter aims to show the statistics during the two previous economic crises in 1997 and 2008, by presenting the impacts on health status, health service utilization and medical expenses as well as measures implemented to cope with both crises. 1. The 1997 Economic Crisis: Background and Pattern1 The opening of the liberal financial market through international banking facilities in 1993, while the monitoring and control system was not strong, coupled with the fixed exchange rates, was the key factor leading to the 1997 economic crisis. With the financial liberation, large mounts of low-interest foreign loans were brought in for low-return investments or speculations without any real demand such as private hospital and real property businesses. During 1995›1996, it was found that foreign loans were as high as US$ 100 billion, while the fixed exchange rates resulted in an overvalued baht currency affecting the countryûs competi- tiveness and export slowdown, resulting in the trade deficit of US$ 14.7›16.1 billion and a current account deficit at 8% of the gross domestic product (GDP). The baht value protection measure in early through mid-1997 resulted in a large loss of foreign reserves, leading to the adoption of the managed float policy and baht devaluation on 2 July 1997. That was the beginning of the economic crisis and the rapidly rising amounts of external debts, including the large amounts of bad debts for the financial and banking institutions and bankruptcies of numerous businesses. Meanwhile, the remaining businesses had to make great efforts to restructure themselves and take cost-cutting measures. The crisis also resulted in higher unemployment rates, high inflation rates, and peopleûs decreased incomes, leading to lower spending on consumer goods and decreased state revenue. As a result, the government budget and public services had to be decreased, which directly and indirectly affected the people.

1 Suwit Wibulpolprasert. Chapter 9, Economic dynamics and health implications in Thailand Health Profile 2001-2004, 2005.

467 1.1 The 1997 Economic Crisis and Health Impact 1.1.1 Impact on Health Status

The apparent impact on health status was the nutritional conditions among the poor and unemployed; the malnutrition rates in 1997›1998 were higher than that for 1996. The prevalence of malnutri- tion (low weight for age) among primary schoolchildren rose from 10.5% in 1996 to 12.2% in 1997/98, the prevalence of low-birth-weight newborns (<2,500 gm) rose from 8.2% to 8.5% and 8.6%, and the prevalence of anaemia among pregnant women rose from 12.9% to 13.% and 13.9%, respectively over the same period. The child death rate (for children under 5 years of age) also rose, so did the incidence of infections diseases, but the death rates did not increase for such diseases as malaria, paediatric diarrhoea, and dengue haemorrhagic fever. The physical health problems had an improving tendency especially those related to occupa- tional health, road traffic accidents, there was a decline in the peopleûs smoking rate and amounts of alcohol sales. However, the drops in smoking and alcohol consumption rates were noted for only a few years, but they rose again afterwards. Regarding mental health, the prevalence of stress and suicide ideation among the unemployed was higher than that for the general public and employed people. 1.1.2 Impact on Health-seeking Behaviour During the 1997 crisis, Thailand had not launched the universal health-care scheme; so, 30% of Thai citizens had no health security coverage and they had to seek medical treatment with lower expenses. It was found that the proportions of people seeking self-medication and government health services were higher than before. According to a survey conducted by the National Statistical Office, the household health spending at health facilities dropped by 23%, while the self-medication spending rose by 12.2%. Other surveys revealed that the number of outpatient visits at state hospitals rose by 6›15%. 1.1.3 Impact on Health Spending and Health Budget The health spending or expenditure actually declined; its real value dropped by 9.3% while the drug spending dropped by 17.3% and the state health spending dropped at a faster rate than that for the private sector. The MoPH budget in real value decreased from 67,574 million baht in 1997 to 61,097 million baht in 2001, a 9.6% drop, primarily for the investment budget. The proportion of investment budget dropped from 11.5% in fiscal year (FY) 2000 to 8.8% in FY 2001, to maintain the level of operating budget. However, the rate of increase in the health spending at present value was higher than that for GDP, resulting in the proportion of total health expenditure to GDP rising from 5.97% in 1998 to 6.1% in 1999. 1.1.4 Impact on Private Health Facilities The impact on private health facilities was twofold: the increases in both expenditures and debts. A survey conducted by MoPH in December 1997 found that, overall, private hospitalsû debts increased

468 by 10 billion baht, while their revenues dropped due to income elasticity resulting from lower household incomes and lower health-care spending at private facilities. Other surveys conducted in 1999 revealed that the numbers of outpatients at private hospitals dropped by 20›70%. As a result, private hospitals had to urgently undertake a restructuring or downsizing measures such as cutting the number of beds, reducing personnel salaries and remuneration, and/or cutting the number of personnel. In such efforts, more generic drugs had to be prescribed and hospital marketing mechanisms had to be deployed to seek new groups of clients by participating in providing medical services under the Social Security Scheme and providing health service packages and health tourism. With regard to hospital debts, there were debt restructuring measures and many foreign investors began to become major shareholders of some private hospitals. 1.2 Strategies for Resolving the Impact of the 1997 Economic Crisis 1.2.1 Strategy 1: Creating an equitable health system The promotion of an equitable health system received more support, after the 1997 economic crisis, with the social safety net development concept. It was noted that even though the overall budget for MoPH during the crisis was reduced, the budget for the medical services for the poor programme actually increased by 25.3% in real value. But due to the problems of efficiency of services system for specific popula- tion groups which was later changed as the universal health-care system for all Thai citizens. The government launched the universal health-care scheme around the end of 2001 and got the National Health Security Act enacted in 2002. Besides, emphasis was placed on the promotion of equitable health-care financing and universal access to health services. The increased production of physicians for rural residents project has been continuously implemented since the pre-crisis period; the project was expanded in 1999 and has helped ease the problem of physiciansû inequitable distribution, although many health personnel moved from the private sector to the public sector, resulting in the drops in the proportion of personnel in the private sector. It was noted that the proportion of physicians in the private sector dropped from 23.7% in 1995 to 18.7% in 1999. However, after the economic recovery had been on a positive trend, there was a reverse brain drain of physicians from the public to the private sector, resulting in the rising proportion of physicians in the private sector after 1999 to 21% in 2002. 1.2.2 Strategy 2: Creating an efficient health system After the economic crisis, the efficiency of the health system was enhanced in many aspects related to the system management and resources distribution as follows: First, reforming drug management systems in all MoPH hospitals at all levels by reducing the number of drug items, giving more importance to the use of drugs on the National List of Essential Medicines, the pooled procurement of drugs at the provincial level from GMP-certified drug manufacturers, the systematic drug quality assurance, and the establishment of a drug information database with the information on the names of purchasers and drugs that can be purchased, which can be easily accessed.

469 Second, reforming the Civil Servant Medical Benefit Scheme (CSMBS) with particular atten- tion on reducing the number of bed-days in hospital, limiting the use of private hospitals and using the drugs on the National List of Essential Medicines. Third, establishing autonomous state hospitals under the supervision of the government under the Public Organization Act, B.E. 2542 (1999), focusing on enhancing flexibility, efficiency and public participation in hospital management; to date only one has been established, i.e. Banphaeo Hospital. With regard to the enhancement of efficiency in resources distribution, more importance was given to disease prevention and health promotion in various modes. During the economic crisis, the people were encouraged to exercise regularly, eat suitable or nutritious food, quit smoking, drive motor vehicles responsibly, and practise safe sex. In late 2001, the Thai Health Promotion Foundation Act was promulgated, establishing the Health Promotion Fund with the money specially collected from 2% additional excise taxes on tobacco and alcohol sales. Besides, during such a crisis, the level of budget for disease prevention and control was still maintained. 1.2.3 Strategy 3: Developing service quality In parallel with the service efficiency improvement, the Hospital Accreditation System was established in 1997 and implemented by the Institute of Quality Improvement and Hospital Accreditation (HA). Later on, efforts have been made to improve all hospitals under the universal health-care system to get HA certification. 1.2.4 Strategy 4: Promoting social empowerment Under the 1997 Constitution, which was generally endorsed by the people, there were regulations and law related to health enacted, namely the Prime Ministerûs Officeûs Regulations on Health System Reform, B.E. 2543 (2000), and the National Health Act, B.E. 2550 (2007), which serves as a statute of national health containing important strategies, i.e. knowledge creation and social mobilization to establish a sustainable health system development mechanism in the future through the participation of all sectors in society. 2. The 2008 Economic Crisis: Background and pattern The global economic crisis in 2008›2009 originated in the USA, in a similar manner as what happened in Thailand in 1997, because large amounts of loans were taken for speculative purposes in the real property sector, regarded as subprime, or low-quality loans. The inefficient examination of financial institutions and innovative financing mechanisms had transformed such subprime loans into various forms of financial products. So, when the returns on investments were not as expected, such loans became bad debts, leading to the financial institution and economic crisis in the USA as well as other countries all over the world. For Thailand, the economic crisis was clearly apparent in the second half of 2008 until the third quarter of 2009, causing a negative economic growth for five trimesters. The GDP growth for 2008 was very low and contracted to ›2.2% in 2009.

470 The GDP per capita dropped from 143,568 baht in 2008 to 142,625.5 baht in 2009. Thailandûs financial sector was slightly affected by the US financial crisis as the Thai financial status was in a much better condition than that during the 1997 crisis. But the export-dependent manufacturing sector was directly affected due to the slowdown of consumption and imports in the USA and other European countries. So, it was a problem for related industries and they had to take several adjustment measures such as decreasing working hours. In this connection, the unemployment rate was rising, leading to reduced consumption and investments, which were the prime movers for the economy, resulting in the negative growth in 2009. 2.1 The 2008/09 Economic Crisis and Health Impact 2.1.1 Impact on Health 1) Physical health Statistics from the Bureau of Registration Administration, Ministry of Interior, showed that there were fewer births over a period of several years. In 2009, the number of births was approximately 780,000 and the proportions of low-birth-weigh (<2,500 gm) newborns were 8.2%, 8.6% and 8.3% in 1996, 2008 and 2009, respectively, while the proportions of childbirths among teenage mothers (aged 11›19) had a rising trend from 12.5% before 1996 to 16.08% in 2009. In certain parts of country, such problems had been quite serious and chronic for a long time, but in some localities the problems became more serious over the past one or two years (Report on economic crisis and health system in Thailand, Office of the International Health Policy Program › Thailand, 2010). Besides, epidemiological data for Thailand showed that the HIV infection rate was not declining in 2009; most of the newly infected cases were youths, resulting from factors related to changes in social values and lifestyles. The infection rates were high among vulnerable groups, especially injecting drug users with the rate of 34.98% in 2009. Over the past several years, the government has given more importance to prevention and medical care for HIV-infected persons, primarily with in-country funding and resources. The economic crisis had no impact on the national budget for AIDS as the budget level was not so high; the AIDS- care spending was not higher than 2% of the national health expenditure. As for the antiretroviral therapy project, for 2009 the budget rose by 54%, compared with that for 2008, due to the greater number of HIV/ AIDS patients receiving the second drug regimen. 2) Mental health Overall, the mental health status of Thai people did not deteriorate after the 2008 economic crisis. A mental health survey among Thais revealed that their mental status during the second half of 2009 was better than that for October 2008 (Table 13.1). It was found that the proportion of respondents with mental health risks dropped from 17.8% to 14.7%, except for those in Bangkok, whose mental health was worse. An in-depth analysis found that, in addition to informal indebtedness, job and income security was an important factor affecting their mental health especially during the economic crisis, while farmers gave more importance to the possession of farmland. Besides, after the economic crisis, there was no increase in the

471 suicide rate. According to the death certificate data of the civil registration system, the suicide rate per 100,000 population was 5.96 and 5.67 in 2008 and 2009, respectively (Figure 13.1). The non-increase in suicide rate for 2009 might be the result of pro-active vulnerable case detection and suicide prevention compaigns in commu- nities, based on the lessons learned from the previous economic crisis, which recorded a higher rate probably as a result of a timing factor. Statistics in the past showed that more suicides would be committed 1 or 2 years after the crisis. So, the suicide surveillance together with proactive measures has to be intensively continued.

Table 13.1 Comparison of mental health scores, 2008 and 2009

Item Question Score, % 2008 2009 First dimension: Mental status 1 You are satisfied with life 64.3 64.9 2 You feel happy 64.8 63.5 3 You feel bored/disheartened with daily life 18.9 18.5 4 You feel disappointed with yourself 12.6 12.2 5 You feel that your life has a lot of sufferings 13.5 14.6 Second dimension: Mental capacity 6 You are able to accept and ready to solve difficult problems (if any) 56.7 60.2 7 You are confident that you can control your emotion in critical situations 58.7 61.0 8 You are confident that you can encounter the serious situation that 59.3 61.5 has happened in your life Third dimension: Mental quality 9 You feel sympathetic with other peopleûs suffering 63.5 68.4 10 You feel happy to have helped resolve other peopleûs problems 68.1 70.2 11 You have helped others whenever you have a chance 61.7 67.0 12 You are proud of yourself 68.2 70.5 Fourth dimension: Supportive factors 13 You feel secure when living with the family 78.6 82.1 14 If you are seriously ill, you believe that your family will take good care of you79.9 82.8 15 Your family members love and care for each other 81.4 84.3 Source: Report on Economic Crisis Impact on Health System in Thailand, International Health Policy Programme › Thailand, 2010.

472 Figure 13.1 Suicide rate per 100,000 population, Thailand, 1998›2009

Rate per 100,000 population 9 8.5 7.9 8.2 8 7.7 7.5 7.1 6.9 7 6.31 6 5.77 5.96 5.96 5.67 5 4 3 2 1 0 Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Bureau of Policy and Strategy, MoPH.

2.1.2 Impact on Health-care Utilization 1) Utilization of medical services According to the health and welfare surveys conducted by the National Statistical Office, the number of outpatient visits (visits/person/year) at health facilities rose from 3.2 in 2005 to 3.8 in 2009, especially at state health facilities (community and regional/general hospitals), while the number dropped slightly for private hospitals (Table 13.2). For inpatient services, based on the same dataset on household survey, the hospitalization or hospital admission rate (admissions/person/year) dropped from 0.091 in 2005 to 0.065 in 2009 for all categories of hospitals. However, changes were made in the method of asking for such information for the 2006/07 survey; so, there was limitation in the comparison of the results with those from other survey periods; and the interpretation should be carefully made.

473 Table 13.2 Rates of outpatient and inpatient services at various levels of hospitals, 2004›2009

Year Average outpatient visits (visits/person/yr) Health centres Community Regional/general Private health Total hospitals hospitals facilities 2004 1.12 0.85 0.45 0.96 3.38 2005 1.07 0.79 0.45 0.89 3.20 2006 0.51 0.58 0.35 0.80 2.24 2007 0.50 0.49 0.35 0.79 2.14 2009 1.05 1.06 0.89 0.80 3.80 Year Average hospitalization rate (admissions/person/yr) Health centres Community Regional/general Private health Total hospitals hospitals facilities 2004 n/a 0.040 0.040 0.013 0.094 2005 n/a 0.038 0.039 0.013 0.091 2006 n/a 0.036 0.035 0.012 0.083 2007 n/a 0.036 0.036 0.013 0.086 2009 n/a 0.025 0.031 0.009 0.065 Source: Report on Economic Crisis Impact on Health System in Thailand, International Health Policy Programme › Thailand, 2010.

Meanwhile, the health service statistics collected from health facilities under the MoPHûs Office of the Permanent Secretary between 2005 and 2009 (79% of all hospitals) (Table 13.3) showed that the number of outpatient visits rose on average by 4.5›6.1%, or 5% for the 2007/2008 period.

474 Table 13.3 Volumes and averages of health services at hospitals under MoPHûs Office of the Permanent Secretary, fiscal years 2005›2009 Number of services Health services 2005 2006 2007 2008 2009 Outpatient (visits) 70,136,878 69,124,701 73,319,828 76,593,156 80,601,118 Inpatient (visits) 4,593,268 4,678,082 4,783,887 4,879,483 4,854,181 Total bed-days (days) 18,087,910 18,494,357 18,718,540 18,936,090 18,629,036 Health promotion and disease 2,461,738 17,897,699 18,427,570 18,973,942 19,188,128 prevention (visits) Average outpatient visits per hospital (visits) 107,407 105,857 112,282 117,294 123,432 Average inpatients per hospital (admissions) 7,034 7,164 7,326 7,472 7,434 Average bed-days per hospital (days) 27,700 28,322 28,665 28,999 28,528 Source: Report on Economic Crisis Impact on Health System in Thailand, International Health Policy Programme › Thailand, 2010. Note: *Analysis of data from 653 hospitals with complete datasets.

2) Medical care expenditure During the economic crisis in 2008, Thailand had implemented the universal health-care scheme since 2002, which was regarded as a safety net for the people to access health services. The quarterly statistics from the household socio-economic surveys conducted by the National Statistical Office for 2009 compared with those for 2008 revealed an increase in the overall household expenditure of 1.59%, while the food and medical expenditures rose by 2.31% and 12.33%, respectively, but the educational expenditure dropped by 4.05%; the expenditure for alcohol dropped by 5.79% and for tobacco rose by 2.44% due to the tobacco tax hike (Table 13.4).

475 Table 13.4 Changes in household income, debt/income ratio, and expenditures by quarter, 2007 and 2009 Percentage of change Income & expenditure Quarter 1 Quarter 2 Quarter 3 Quarter 4 Average Comparison between 2007 and 2009 income and debt Income 13.68 1.47 5.24 10.89 7.82 Debt/income ratio 6.04 5.28 -4.99 3.47 2.45 Comparison between 2007 and 2009 expenditures Total expenditure 0.07 2.05 1.76 2.47 1.59 Food expenditure 4.73 1.86 1.62 1.03 2.31 Health expenditure 15.81 9.23 19.89 4.40 12.33 Educational expenditure -1.99 -7.80 -5.41 -0.99 -4.05 Alcohol expenditure -14.82 0.39 -6.80 -1.94 -5.79 Tobacco expenditure -4.88 0.17 7.40 7.09 2.44

Source: Report on Economic Crisis Impact on Health System in Thailand, International Health Policy Programme › Thailand, 2010.

In considering the economic status of this matter, it was found that the health spending increased the most for the rich and the richest groups by more than 20%, while the educational spending dropped a lot for the poorest, the middle income and the rich groups by more than 10%, while the tobacco spending rose the greatest in the poorest group at 12.8%, and the alcohol spending dropped in all income groups, except for the poorest group whose spending on this item remained unchanged between 2008 and 2009. When considering the ratio of household health spending to income, it was found that the richest group (decile 1) had such a ratio lower than that for the poorest group (decile 10). Besides, between 1992 and 2009, such a ratio had a declining trend for most groups, but for the period 2006›2009, the ratio for 2009 was lower than that for 2006 except for the rich group whose health spending for 2009 was higher than that for 2006 (Figure 6.85). Regarding the proportion of household catastrophic health spending (health spending at 10% or more of all household spending), overall, the proportion had a declining trend, dropping from 3.85% in 2006 to 3.29% in 2009, but for the richest group, their proportion rose from 4.95% in 2008 to 5.41% in 2009 (Figure 6.86).

476 2.2 Measures for Dealing with the 2008/09 Economic Crisis 2.2.1 Government Measures Faced with the problems of oil price hike and rising cost of living, on 15 July 2008, the government issued six measures for easing the hardship, namely cutting oil excise taxes, delaying the cooking gas (LPG) price increase, providing a certain amount of free water supply and electricity for domestic use, and providing some free bus and train services for six months beginning on 1 August 2551, except for the oil tax cut which was effective on 25 July 2008. Later on, when the economic crisis became apparent, the following government continued such measures with some modifications. Later on, in January 2009, the government issued an economic stimulus policy to minimize the impact of the global economic crisis for the general public and the private sector in two phases as follows: 1) Economic Stimulus Package 1 (SP1) This package includes four programmes, namely: (1) Restoring and boosting economic confidence (2) Generating income and developing the quality of life and social security (3) Managing emergency or necessary situation (4) Repaying the treasury reserve The 4 programmes were divided into 18 sub-programmes with the budget of 116.7 billion baht plus an agricultural product price guarantee scheme with a budget of 123.6 billion baht and the tax measures policy for 40 billion baht, totalling 280.3 billion baht. All the above-mentioned programmes aimed to drive the economy in four aspects, namely internal consumption, public sector spending and investments, private sector investment, exports and tourism. Regarding public health, there were two programmes, i.e. proactive support for 830,000 village health volunteers (VHVs) by giving monthly allowance/remuneration and the upgrading of 2,609 health centres across the country as subdistrict or tambon health promotion hospitals. 2) Economic Stimulus Package 2 (SP2) Even though the government had launched the SP1 to minimize the impact of the global economic crisis on Thailand, the Thai economy began to have signs of recovery but not so strong. In April 2009, the government initiated additional measures on a medium- and long-term basis, commonly known as çThailand: Invest for Strength to Strength 2010›2012, or Thai Khem Khaeng Projecté. The measures were approved on 6 May 2009 with a budget of 1,431.3 billion baht including the government budget of 1,110.2 billion baht and state enterprisesû investment funds of 321.2 billion baht, with the achievement indicators in the following seven programmes: (1) Creating food and energy security, conserving the environment, and enhancing the efficiency of the agricultural and industrial sectors. (2) Improving basic public services to raise the quality of life and business capability. (3) Improving the educational quality. (4) Reforming public health system standards.

477 (5) Building the potential of tourism. (6) Generating new income from creative economy. (7) Creating occupations for the better quality of life at the community level. Under this scheme (2010›2012), MoPH was allocated a budget of 86,688 million baht for 14 projects with the objectives of investing in health-care system development, improving the health-care structure, especially durable articles, land and construction (due to the continuous budget decrease after the 1997 economic crisis, despite the implementation of the universal health-care scheme), developing human workforce and service networks, and developing health conditions in specific localities (such as southern border areas) and other relevant issues, such as food safety (Figure 13.2). At present, MoPH has received 11,508.67 million baht under the SP2, and the rest will be included in the budget request for FY 2011, under which MoPH has been allocated an investment budget of 13,943.62 million baht (totaling 23,798 million baht if the FY 2012›2013 commitment is included; Bureau of Policy and Strategy, MoPH). Figure 13.2 Targets of investment on public health service system development

Thailand Investment from Strength to Strength Plan of Action, 2010 - 2012 Medical and health personnel (Numbers to be additionally Ministry of Public Health produced: 1,620 doctors; 2,500 12 health products demonstration & professional nurses; 400 dental EC exhibition centres (17 million baht) nurses; 750 health technical 40 heart centres; 7 health products manufacturing and officers; 6,000 nurse assistants. 26 cancer centres and processing facilities (7 million baht) Capacity building: continuing 51 trauma centres education at masterûs and (10,376 million baht) Food safety at tourist sites (4,800 busi- doctoral degree levels in country 1 TTM center (395 million baht) ness places, 12 million baht) and abroad; 5,870 million baht) Public health development in Tertiary care southern border areas 115 tertiary care hospitals (26 regional, 68 general (5 provincial public health and 21 DMS hospitals: 20,796 million baht) offices, 6 regional/general 2 geriatric centres (76 million baht) hospitals, 37 community Secondary care hospitals; 2,659 235 community hospitals (13,499 million baht) million baht) Primary care 9,762 subdistrict health promotion hospitals (14,763 million baht) Public health service support system Referral system (18 coordinating centres; 616 million baht) Health information system (1 system and network; 2,974 million baht) Support for operations of service networks at all levels (1,100 housing units, 195 office units, 355 motor vehicles; 14,625 million baht) Investment in Health, MoPH (86,688 million baht) Source: Report on projects under the Thailand Investment from Strength to Strength 2012 (SP2), Bureau of Policy and Strategy, MoPH, 24 September 2009.

478 2.2.2 Measures Undertaken by Non-MoPH Agencies In implementing public health activities, non-MoPH agencies involved are the following: 1) The First National Health Assembly passed resolution 1.14 on economic crisis and Thaisû well-being protection on 26 December 2008, essentially requesting that: (1) The government implement social protection measures by providing adequate bud- get for the universal health-care scheme and others. (2) Relevant agencies, particularly the Ministry of Public Health, the Health Systems Research Institute, the Thai Health Promotion Foundation, the National Health Security Office, and the Social Security Office undertake the following: ● jointly implement social protection measures; ● improve and develop the health information system; ● improve the efficiency of the health service system especially at the primary care level; ● develop policies and measures to deal with risky behaviours leading to poverty; ● improve the collaborative working process between the National Health Security Office and the Social Security Office. (3) The Secretary-General of the NHCO support the establishment of a unit for moni- toring health consequences during economic crisis and report the results to the Second National Health Assembly in 2009. In this connection, on 17 June 2009, the Cabinet endorsed the NHAûs resolution and assigned relevant agencies to take further action. It was noted that, while the overall budget for 2010 dropped by 12%, the universal health-care budget rose by 9%. 2) The MoPH appoint the Committee on Monitoring Health Consequences during Economic Crisis on 19 January 2009. 3) On 27 March 2009, the Thai Health Promotion Foundation established a Subcom- mittee on Monitoring the Operations Related to Health Consequences during Economic Crisis using six strategies as follows: ● Managing knowledge and information ● Creating skills for coping with the crisis ● Improving the quality of life ● Strengthening the capacity of business enterprises and communities ● Resolving serious social impacts ● Making commitment towards sustainable development

479 3. Conclusions The context of economic crisis is important particularly during the past three or four years as Thailand has encountered a number of major events such as social, political, and environmental crises, series of protests by various groups with different opinions, the energy crisis between 2004 and 2008 resulting in the high prices of agricultural products, and the spread of pandemic influenza H1N1 2009. The consequences of such events and crises could not be isolated from the 2008/09 economic crisis. Besides, the data obtained were the aggregate results of the crisis and the impact resolution efforts. Thus, it is difficult to clearly point out what the direct impacts of the economic crisis are. Overall, the data have shown that the 2008/09 economic crisis caused a less severe impact on Thailand than the one in 1997 due to differences in the causes and natures. With the countryûs strong financial status during 2008›2009, the government could allocate adequate budget for the universal health-care scheme, implement six economic stimulus measures during the first phase, including free public utilities and increasing peopleûs income with some living allowance. Subsequently, the government adopted the SP2 policy, giving more importance to investments on infrastructure and public health, especially the capacity building for all health facilities from the primary to tertiary levels, in terms of physical structure and human resources. In addition to the aforementioned government measures, in 2009, there were several mechanisms for easing the impacts of the crisis, which have been implemental since 1997. For example, the universal health- care scheme, which has been carried out for over half a decade, has served as a social safety net by greatly reducing the financial risk related to peopleûs illnesses as they could have access to essential health services. The National Health Assembly is a participatory mechanism with the involvement of various sectors; and the Thai Health Promotion Foundation has got a flexible process for formulating strategies for relieving health and social impacts resulting from the crisis together with various civil society organizations; all such efforts are supplementary measures for preventing the impact on the publicûs health and the health system. The existing secondary data do not indicate a clear impact of the economic crisis on health and the health system. Certain health problems such as low birth weight, teenage pregnancy, and HIV infection are those that had occurred before the 2008/09 economic crisis, partly due to social and behavioural changes. Regarding the data per se, somes are lacking such as those on peopleûs health and child malnutrition. Some of the collected data are process indicators such as health-care utilization, medical expenses; such data may not reflect the health outcomes. Therefore, the development of data or information to reflect the health status of Thai people has to be supported continuously for the data to be available as a long series of dataset during both normal and crisis situations. Such a health dataset that is linked to the socio-economic status should also be developed and supported so as to identify the problem for each economic status that will also provide better data on equity.

480 Chapter 14 Creation of Universal Health Security in Thailand

1. Importance of Universal Health Security Thailand began to have a health security or insurance for all or Universal Coverage of Healthcare (UC) Scheme when the Royal Thai Government issued a policy on such a matter in 2001 and the National Legislative Assembly passed the National Health Security Act, B.E. 2545(2002). The Actûs intent is to set up a health-care system that provides essential health services for the people to have good health and live a decent life with good quality. According to the law, the National Health Security Office (NHSO), an organization governed by the Board comprising representatives of the public and popular sectors, has the duties to ensure that approximately all 47 million Thai citizens (or 75% of the Thai population) under the UC scheme, not under the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Security scheme (SSS), are eligible to receive standard health services according to Sections 52 and 82 of the Constitution of Thailand, B.E. 2540 (1997). The evaluation and situation of the health insurance system in Thailand before 2002, when the UC Scheme was launched, are as summarized below: 1.1 The Situation before 2002 If the 1972 Workmenûs Compensation Fund, established by the Announcement of the Revolutionary Council No. 103 and the 1975 policy on free medical services for the poor are taken into consideration, Thailand has spent about 30 years on expanding the health security coverage from certain groups of people (such as workersû illness due to work-related cause and the poor) to the social security system in 1990, children and the elderly in 1994, and the universal healthcare scheme in 2002 (Table 14.1). The strategy used by Thailand on this matter was the creation of health security coverage for various groups of people, beginning from the free medical services for the poor by the Kukrit Pramoj government in 1975. Later on, a royal decree on CSMBS was enacted in 1980 to provide medical-care privileges for civil servants and their dependants and in 1981, the Low-Income Health Card (LIHC) Scheme was launched to provide free medical services for low-income people followed by the Voluntary Health Card (VHC) Scheme in 1983›1984 for those who were not eligible under the LIHC scheme for the poor or underprivileged. A success was noted when the Social Security Act, B.E. 2533 (1990), was enacted to create health insurance for workers who are ill or disabled or die from non-work-related causes. In the initial stage, the law was applicable only to business enterprises, each with 20 employees more; later on, the scheme was

481 expanded in 1994 to cover all enterprises with 10 employees or more each and then to all enterprises each with 1 employee or more in 2002. And finally, the UC Scheme was launched in 2002 according to the National Health Security Act, B.E. 2005 (2002).

Table 14.1 Major events related to health insurance in Thailand, 1972›2002 Health insurance system Year Event State Workplaceûs Compul- Voluntary welfare welfare sory 1972 Workmenûs Compensation Fund established as X per Announcement of the Revolutionary Council No. 103, dated 16 March 1972 1975 Policy on free medical services for the poor X 1978 Private health insurance companies began X operations in Thailand 1980 Royal Decree on Civil Servant Medical Benefit X Scheme, B.E. 2523 (1980) 1981 Free medical service cards first issued under the X LIHC scheme 1983 Voluntary Health Card Project: Phase 1, X Maternal & Child Health Fund 1984 Voluntary Health Card Project: Phase 2, for all X family members 1990 Social Security Act, B.E. 2533 (1990) for business X enterprises each with 20 employees or more 1992 Extension of free medical services to elderly X persons 1993 Motor Vehicle Victims Protection Act, B.E. 2535 X (1992) 1994 Expansion of social security coverage to X enterprises each with 10 employees or more 1994 Workmenûs Compensation Act, B.E. 2537 (1994), replaces the Announcement of the Revolutionary X Council No. 103 1994 Voluntary Health Card Project: Phase 4, with X state subsidies for health insurance, reinsurance policy, and use of the cards outside designated areas

482 Health insurance system Year Event State Workplaceûs Compul- Voluntary welfare welfare sory 1994 Expansion of the Voluntary Health Card Scheme X to cover community leaders and village health volunteers with government subsidies 1994 The coverage of the free LIHC scheme was X extended to children under 12 years of age 1998 Revision of co-payment procedures for certain X medical services under CSMBS after the 1997 economic crisis 2000 The Social Security Scheme is expanded to X cover old age pension and medical services for the employeeûs children 2001 The Royal Thai Government declares the UC X healthcare policy 2002 The Social Security Scheme is extended to cover X enterprises each with one or more employee 2002 National Health Security Act, B.E. 2545 (2002), X and establishment of the National Health Security Office (NHSO)

Source: Modified from Thai Health Security System (2002). Note: Compulsory means compulsory health insurance required by law; voluntary means voluntary health insurance.

The evolution of various health insurance schemes in Thailand before the 2002 UC Scheme was launched has resulted in the establishment of a segregated health insurance system consisting of several health insurance systems, each for a different target groups. As a result, Thailand has various health insurance schemes with different objectives, benefit packages, sources of financing, target groups and methods of payment to health facilities as shown in Table 14.2.

483 Table 14.2 Key features of various health insurance schemes prior to 2002

Scheme LIHC Voluntary CSMBS Social Security Motor vehicle Private health Health Cards Scheme victims insurance* Feature protection law Feature of State welfare Voluntary State welfare Compulsory Compulsory Private health health insurance insurance for insurance insurance insurance with state vehicle owners subsidies Target groups Low-income People without Civil servants, Employees in Victims of General and LIHC or other state enterprise private sector vehicle public underprivileged kinds of employees and and temporary accidents persons insurance dependants employees in public sector Population 30% 23.4% 8.5% 7.8% All victims 1.2% coverage (2001) Benefit State State (MoPH) State/private State/private State/private State/private packages Outpatient services Inpatient State State (MoPH) State/private State/private State/private State/private services Registration at Required Required Not required Required Not required Not required health facilities Benefit 15 cases 15 cases - 15 cases Not exceeding Diseases packages 15,000 baht exempt exception Childbirth Covered Covered Covered Covered None Covered Physical None None Covered None None Dependent on checkup insurance conditions Special room None None Covered None Covered Covered Health Govt. budget Govt. budget Govt. budget Employee, Vehicle Household financing and household employer and owner Source of govt. financing

484 Scheme LIHC Voluntary CSMBS Social Security Motor vehicle Private health Health Cards Scheme victims insurance* Feature protection law Method of Govt. budget, Capitation, Performance- Capitation, Performance- Performance- payment to global performance- based performance- based based health facilities based based Co-payment The amount exceeding entitlement Major problem Not covering Lack of risk Rapidly and Covering while Redundant Risk selection the really poor, distribution constantly being employed eligibility inadequate rising costs only and slow budget disbursement

Note: *Health insurance in addition to state-funded health insurance.

1.2 Lack of Health Security and Inequitable Access to Health Services In 2000, 30% of the Thai population had no health security coverage. A study conducted by the Consumer Protection Foundation in 1999 revealed 15 instances of people being unable to get access to essential health care. Even though specific group healthcare schemes, such as the LIHC Scheme, had been trying to modify their approach to reach the target groups, there was inefficiency in reaching the real ones. A study conducted by Sukanya Kongsawat and colleagues in 2000 among 2,093 low-income households in 6 provinces found that only 17% of them had received LIHCs while among the 1,003 LIHC-holders, only 35% were really poor, and the rest did not meet the eligibility requirements (Table 14.3).

Table 14.3 Proportions of low-income and non-low-income households that had received LIHCs, 2000

Card-holding Low-income households Non-Low-income households Total No. Percent No. Percent No. Percent - Having received LIHCs 353 17 650 12 1,003 13 - Not having received LIHCs 1,740 83 4,942 88 6,682 87 Total 2,093 100 5,592 100 7,685 100 Source: Sukanya Kongsawat et al. (2000).

485 1.3 Inequities and Catastrophic Household Health Expenses The household socio-economic surveys conducted between 1992 and 2002 by the National Statistical Office (NSO) indicate inequities in health spending between the poor and rich households. In 1992, the poorest 10% of households (decile 1) spent 8.17% of their total income on health care, while the richest households (decile 10) spent only 1.27% on their health care, a 6.4-fold difference. The inequities in health had a positive trend as, in 2002, the health spending dropped to only 2.77% among the poorest households but rose to 1.71% among the richest households, the disparities dropping to only 1.6-fold. Such a positive trend was the result of the governmentûs extension of the health insurance policy to various groups, especially the poor, the underprivileged, the disabled as well as labourers, between 1992 and 2002, including the UC policy in 2002. The NSO surveys conducted between 1996 and 2000 revealed a decline in the number of households with catastrophic medical expenses from 4.9% in 1996 to 4.4% and 3.8% in 1998 and 2000, respectively (Table 14.4). In summary, before the launch of the UC Scheme, more than 600,000 Thai house- holds (or 3.8% of 16.7 million households across the country) were faced with high health-care costs.

Table 14.4 Proportion of households with different levels of health to total (excluding food) expenditures, 1996›2000

Proportion of householdûs health to total Households (%) (excluding food) expenditures 1996 1998 2000 0›0.5 % 31.9 33.2 34.5 0.5›10 % 51.3 51.5 50.8 10›25 % 11.9 10.9 11.0 25›50 % 3.5 3.6 3.1 >50 % 1.4 0.8 0.7 Total 100.0 100.0 100.0

Source: Analysis of data from Household Socio-Economic Surveys, 1996›2000.

486 1.4 Other Environmental Factors Related to Universal Health Security Policy One of the important factors that was supportive of the creation of the universal healthcare policy in 2002 was the 1997 Constitution of Thailand, Section 52, which prescribed that Thai people shall enjoy an equal right to receive standard public health services and the indigent shall have the right to receive free medical treatment from state health facilities thoroughly and efficiently; and in addition, Section 82 provided that the State shall thoroughly provide and promote standard and efficient public health services. Based on such constitutional provisions, there were continued movements of the popular and academic sectors in creating and advocating such a policy prior to 2002. Besides, Thailandûs public health system development was based on the National Public Health Development Plans, which were part of the National Economic and Social Development Plans. The First 5-year National Public Health Development Plan focused on investment on infrastructure, especially the construction of provincial hospitals throughout the country. In the Second and Third Plans, the government gave more attention to rural health investment, producing more health personnel and beginning the provision of free medical services to the poor. As for the Fourth and Fifth Plans, the focus was placed on the primary health care policy aimed at achieving the goal of Health for All by the Year 2000, with the training of village health volunteers (VHVs) across the country and the construction of district hospitals (which were later changed to community hospitals) in all districts for the whole country as well as the accelerated production of doctors and nurses to be distributed to such rural health facilities. Later on, during the periods of the Sixth and Seventh Plans, all subdistrict (tambon) health centres across the country were developed in support of the primary health care programmes; and there were also other important events, i.e. the enactment of the Social Security Act, B.E. 2533 (1990), and the extension of the LIHC Scheme to cover elderly persons aged 60 years and over as well as children under 12 years of age. According to the policy on development of all levels of health facilities, accelerated produc- tion and distribution of health personnel, and primary health care development over the past two decades, the countryûs public health service system has been strengthened and become the significant foundation for the success in the establishment of the UC Scheme in 2002. 2. The Impacts of Universal Health Security After the implementation of the UC Scheme, beginning in 2002, 95% of Thai people are covered by one of the three major health insurance schemes, namely UC or Gold Card, CSMBS, and Social Security. All the three schemes have different features related to the benefit packages, healthcare financing, matching fund payments, co-payments of beneficiaries, and methods of payment to health facilities. Empirical evidence and results of studies have reflected the impacts on the UC Scheme as follows:

487 2.1 Coverage of Health Security Since the launch of the UC Scheme in 2002, the percentage of Thai people without any health insurance has dropped steadily from 29% in 2001 to 5.1% and 2.6% in 2003 and 2009, respectively (Figure 14.1); and 74% of the population were covered by the UC Scheme, 12% by the Social Security System, and 9% by CSMBS. Figure 14.1 Coverage of various health security systems, 1991›2009

Percent 100

80 14.2 27.9 52.3 74.7 73.5 72.2 74.3 73.6 76.1 60 66.5 54.5 40

20 29.0

0 5.1 5.7 4.9 4.0 3.7 2.6 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 20012002 2003 2004 2005 2006 2007 2009 Year No insurance coverage LIHC Scheme UC Scheme Social Security CSMBS Others

Source: Analysis of data from Household Health and Welfare Surveys, 1996›2007, National Statistical Office.

When classifying Thai people into five groups (quintile) based on their income ranging the first 20% poorest group to poor, moderate, rich and the last 20% richest groups, it was found that, in 2004, approximately 50% of the Gold Card holders (under the UC Scheme) were in the poorest and poor quintiles, while 49% of insured persons under the Social Security Scheme, and 52% of the eligible persons under CSMBS were in the richest quintile (Figure 14.2). The findings show that the UC Scheme is the important health security system for the poor. Besides, as analysis of the residences of the eligible persons under all the three health insurance schemes reveals that most of those under the UC Scheme are rural poor residents.

488 Figure 14.2 Proportion of eligible persons in the three health insurance schemes by their economic status

Percent 100 10 80 52 49 17

60 23

40 26 31 25

20 11 14 25 7 5 0 4 1 CSMBS SSS UC

Q1(poorest) Q2 Q3 Q4 Q5(the richest)

Source: Analysis of data from Household Health and Welfare Surveys, 2004, National Statistical Office.

2.2 Access to Health Services and Benefits from Government Health Resources An analysis of data from the Household Health and Welfare Surveys, 2001›2003, on the utilization of outpatient (ambulatory) services revealed that the average number of outpatient visits of the poorest quintile increased from about 3 visits/person/year in 2001 to about 5 visits/person/year in 2003›2005 (Figure 14.3), especially for the services at subdistrict health centres and community hospitals which are primary and secondary care facilities where rural residents can access quite conveniently.

489 Figure 14.3 Utilization of outpatient (ambulatory) services of people by income quintile, 2001›2005

6 2001 2003 5 0.7 4 0.4 0.6 3 0.3 1.8 0.4 0.4 0.7 0.4 0.6 2 0.6 1.3 0.3 0.7 0.7 0.6 0.7 0.5 0.4 0.7 0.6 1.9 0.9 0.6 1 0.4 1.3 0.7 0.3 Ambulatory visits per cap per year 1.2 1.0 0.6 0.7 0.2 0.7 0.6 0.3 0 0.5 0.2 0.2 Q1 Q2 Q3 Q40.1 Q5 Q1 Q2 Q3 Q4 Q5 Income quintiles Health centres Community hospitals Provincial and regional hospitals Private clinics Private hospitals

600 2004 2005 500 0.7 400 0.6 0.4 0.4 300 0.6 0.6 1.5 0.4 0.4 0.7 1.5 0.6 200 1.1 0.3 1.0 0.4 0.7 0.6 0.8 0.7 Ambulatory visits per cap per year 100 0.3 0.6 0.3 2.0 1.9 1.4 0.6 1.4 0.5 0.3 0.9 0.6 0.2 0.9 0.5 0.3 0.2 0 0.2 0.3 0.2 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Income quintiles

Health centres Community hospitals Provincial and regional hospitals Private clinics Private hospitals University hospitals Other public hospitals

Source: Analysis of data from Household Health and Welfare Surveys, 2001›2005, National Statistical Office.

490 When analyzing data on inpatient services (hospitalization or hospital admissions) for 2001› 2005, it was found that the average admission rate for each year for the poorest quintile was not much different, ranging from 0.09›0.10 admission/person/yr, but the type of health facilities that the poor and poorest quintiles used the most changed from regional/general hospitals in 2001 to community hospitals in 2003›2005 as such health facilities could be more easily accessed (Figure 14.4).

Figure 14.4 Utilization of inpatient services (hospital admissions) of people by income quintile, 2001›2005

District hospitals Regional/general hospitals Private hospitals 0.10 0.09 0.01 2001 2003 0.01 0.00 0.08 0.01 0.07 0.01 0.02 0.01 0.03 0.06 0.05 0.01 0.05 0.05 0.03 0.05 0.01 0.04 0.02 0.06 0.02 0.03 0.05 0.02 0.03 0.05 0.02 0.04 0.03 0.03 0.01 0.02 0.02 Hospital admission per cap per year 0.01 0.01 0.01 0.01 0.00 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Income quintiles

Community hospitals Regional /general hospitals University hospitals Other public hospitals Private clinics Private hospitals

0.14 2004 2005 0.12 0.01 0.00 0.00 0.00 0.10 0.01 0.00 0.04 0.01 0.01 0.04 0.00 0.01 0.08 0.00 0.01 0.03 0.01 0.03 0.02 0.06 0.03 0.01 0.02 0.03 0.01 0.02 0.04 0.01 0.01 0.07 0.03 0.07 0.03 0.06 0.05 0.02 0.04 0.02 0.04 0.02 Hospital admission per cap per year 0.02 0.02 0.02 0.00 0.01 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5

Source: Analysis of data from Household Health and Welfare Surveys, 2001›2005, National Statistical Office.

491 Based on data on health service utilization of various population groups and the costs of services at various levels of health facilities, the analysis of benefits from government health resources obtained by the people with different economic status in 2001 before the launch of the UC policy and after the UC policy was implemented between 2003 and 2007 showed that the proportion of people in the poorest quintile (quintile 1) benefiting from the state health services rose from 28% in 2001 to 31%, 28%, and 29% in 2003, 2006 and 2007, respectively, and the proportion in poor quintile (quintile 2) rose from 20% to 22%, 26% and 24% respectively, over the same period, while those for the rich and richest quintiles (quintiles 4 and 5) dropped after the UC policy was implemented (Figure 14.5).

Figure 14.5 Comparison of benefits from state health resources received by population groups with different economic status, 2001›2010

OP&IP 29 2420 14 12

2007

OP&IP 28 26 20 14 11

2006

OP&IP 31 2215 16% 15

2003

OP&IP 28 2017 17 18

2001 Percent 0 20 40 60 80 100

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Source: Prakongsai P. The Impact of the Universal Coverage Policy on Equity of the Thai Health Care System. PhD dissertation. London School of Hygiene and Tropical Medicine, 2008; and How Thailand achieved pro-poor health service utilization and government subsidies? IHPP, 2010.

2.3 Household Health Expenditure and Equity in Healthcare Financing An analysis of household health expenditure or spending in relation to income of households with different economic status (decile) for 1992›2008 revealed that the proportion of health spending as a proportion of household income in the poorest decile (decile 1) dropped from 8.17% in 1992 to only 2.77% in 2002; and after the UC Scheme was launched, the proportion dropped to only 2.05 in 2008 (Figure 6.68), while that for the richest decile (decile 10) ranged from 1.1% to 1.7%.

492 With the UC Scheme, the household healthcare costs for catastrophic illnesses have been steadily declining. An analysis of data from the Household Socio-Economic Survey revealed that the proportion of households with catastrophic health spending dropped from 5.7% in 2000 to only 3.3% in 2009 (Figure 6.70). Such a drop that was significant for the households in the poorest quintile (quintile 1) ranged from 5.2% in 2000 to only 1.9% in 2007 and 1.4% in 2009 (Figure 6.27). A comparative analysis of the householdûs overall consumption spending in relation to health spending after the UC Scheme had been implemented revealed a significant decline in the proportion of householdsû impoverishment due to catastrophic medical expenses, for both outpatient and inpatient services. In particular, for the proportion of impoverishment dropped from 3.8% in 2000 to only 1.5% in 2004 due to outpatient services and from 11.9% to 2.6% due to inpatient services for the same period. The above data have show that, in addition to increasing the coverage of essential medical and health services, the UC Scheme has resulted in the decline of household health spending; and a large number of households have been relieved from catastrophic medical expenses. 2.4 Impacts on Health Facilities Besides the positive impacts mentioned above, the UC Scheme has increased the medical care workload of state health facilities, especially primary care units (subdistrict health centres) and secondary care units (community hospitals) as shown in Table 14.5. It is noteworthy that the number of outpatient visits at health centres rose from 37.2 million in 2001 to 63.9 million in 2009. Similarly, the rise is noted for both outpatient and inpatient services at community hospitals while the number of state health personnel has not much increased, resulting in increased workloads at health centres and community hospitals.

493 Table 14.5 Utilization of outpatient and inpatient services at various levels of health facilities, 2003›2009

No. of visits or admissions (in millions) Type of services and facilities 2003 2004 2005 2006 2007 2008 2009 Outpatient visits Health centres 37.21 38.14 38.44 50.84 52.88 56.09 63.92 Public health centres - - - 0.45 0.71 1.03 1.96 Community hospitals 35.82 32.26 34.22 43.63 44.99 47.65 51.49 General/regional hospitals 9.88 11.32 11.18 16.55 16.96 17.69 17.78 University hospitals 0.73 1.30 0.76 0.05 0.14 0.32 0.38 Other state hospitals 4.35 2.38 1.81 1.60 1.70 2.36 2.55 Private clinics 19.66 22.92 21.90 0.27 0.28 1.15 0.17 Private hospitals 4.29 4.16 3.32 1.42 1.63 2,46 2.44 Total 111.95 112.49 111.64 114.77 119.29 128.76 140.70 Inpatient services Community hospitals 2.24 2.20 2.24 2.36 2.45 2.55 2.56 General/regional hospitals 1.16 1.30 1.44 1.94 1.98 2.10 2.13 University hospitals 0.06 1.09 0.13 0.14 0.14 0.16 0.17 Other state hospitals 0.39 1.87 0.18 0.18 0.19 0.21 0.22 Private hospitals 0.45 0.36 0.36 0.12 0.12 0.15 0.19 Total 4.30 4.16 4.34 4.73 4.88 5.17 5.28

Sources:1.Utilization of outpatient services at various levels of health facilities, fiscal years 2003›2005, from Household Health and Welfare Surveys, 2001, 2004, and 2005, National Statistical Office. 2. Utilization of inpatient services at various levels of health facilities, fiscal years 2003›2005, from Household Health and Welfare Surveys, National Statistical Office, and for 2006›2008 from the Inpatients Database, National Health Security Office.

494 Regarding the financial situation of MoPH hospitals, the financing and accrual accounting data have shown that, after the implementation of the UC Scheme, the MoPH hospitalsû financial situations were not so problematic, except for the hospitals located in less populous or remote localities, which had encountered a rather serious financial problem. That was evident in the fact that they had constantly rising cash balance and net working capital between 2003 and 2009 (Table 14.6). As for the financially troubled hospitals, NHSO and MoPH have helped resolve their problems by allocating additional budget for them on a special case basis.

Figure 14.6 Data on financial situations of health facilities that submitted complete data in fiscal years 2003›2009

No. of hospitals and financial status Description 2003 2004 2005 2006 2007 2008 2009 Hospitals submitting complete data 783 662 711 792 809 818 822 each year (hospitals) 1) Cash balance (million baht) 15,635 15,734 21,158 18,468 28,141 43,276 42,963 2) Inventory (million baht) 2,990 2,972 3,590 3,783 4,294 4,818 5,241 3) Liabilities (million baht) 6,938 9,513 16,672 16,054 12,316 15,825 16,626 4) Net working capital (million baht) 11,687 9,193 8,076 6,197 20,119 32,270 31,579

Source: Bureau of Policy and Strategy, National Health Security Office.

2.5 Efficiency of Health-care System and state Investment in Health According to Thailandûs national health accounts for 1994›2007, after the implementation of the UC Scheme, the national health spending, as a proportion of GDP, did not increase much, ranging from 3.5% to 4%, while the proportion of state health spending rose considerably from 56% of the total health spending in 2001 to 73% in 2007 (Figure 14.6). That means the public sectorûs level of investment in health is larger after launching the UC Scheme.

495 Figure 14.6 Proportion of health spending in relation to GDP and amounts of health investment in the public and private sectors, 1994›2007

Million baht Percent GDP 350,000 4.5 300,000 4.0 3.5 250,000 3.0 200,000 2.5 150,000 2.0 1.5 100,000 1.0 50,000 0.5 0 0.0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Public Private %GDP

Source: National Health Accounts, Thailand, 1994›2007, International Health Policy Program › Thailand.

3. Current Problems and Future of UC Scheme 3.1 Sustainability and Adequacy of Healthcare Financing In the medium and long terms, the sustainability and adequacy of the UC Scheme is the issue that health insurance policy-makers and academics in Thailand have given much importance too. However, the estimation of national health spending, compared with GDP, by experts of the International Labour Organiza- tion (ILO) and NHSO, has revealed that Thailandûs national health spending ranges from 4% to 6% of GDP over the next 5 to 15 years, most of which will be under the UC Scheme, followed by CSMBS (Figure 14.7).

496 Figure 14.7 Estimated national health spending as a percentage of GDP, Thailand, 1994›2026 Expenditure share in GDP of financing agencies: Long-term trends Percent 6.0

5.0

4.0

3.0

2.0

1.0

0.0 Year

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

MOPH OthMin LocGovet StateEnterprise CSMBS SocSec UC WCF Private TrafficIns ERBenefis PrivHH NonProfit RoW

Source: Wolfgang Scholz et al (2008) Long term financial forecast

3.2 Increase in Health Spending According to data on the burden of disease and health risk factors among Thai people between 1999 and 2004 and a study on direction of health investment under the 10th National Economic and Social Development Plan, more Thais suffer and die from chronic non-communicable diseases and risky health behaviours such as diabetes, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, depression, alcohol-related illnesses and cancer whose major risk factors are alcohol and tobacco use, accidents, consumption of food rich in carbohydrate and fat, inadequate intake of vegetables and fruit, and physical inactivity. The rising prevalence of such chronic non-communicable diseases tends to result in the rising health-care costs of the country. Meanwhile, changes in the population structure will result in a higher proportion of the elderly; and the inventions of new costly health technologies will lead to an increase in health expenditures in the future.

497 3.3 Disparities among Three Health Insurance Schemes (CSMBS, SSS, and UC) One of the major problems in the creation of the UC Scheme in Thailand is the disparities among the three health insurance systems. A comparison of the service utilization of eligible persons under the three systems revealed that the number of SSS beneficiaries using outpatient services is 1.4 times those under the UC Scheme and CSMBS. As for inpatient services, the number of CSMBS beneficiaries using such services is 1.25 times those under the SSS and the UC Scheme, adjusted for sex, age, martial status, educational achievement, domicile and chronic illness. Besides, empirical evidence has shown the disparities in medical services received under different health insurance systems. In particular, patients under CSMBS receive medicines outside the national essential drug list, imported original drugs, and high-priced drugs in markedly greater amounts than those under the UC Scheme and SSS, resulting in an increase in the overall national health spending. Moreover, the proportions of certain medical procedures are also higher such as caesarean section and laparoscopic surgery (Figure 14.8). Disparities were also noted the processes and outcomes of medical treatment for diabetic patients according to the standard practices such as lab tests for HbA1C and blood lipid and retinal examination.

Figure 14.8 Disparities in medical services among patients under the three health insurance systems

Coxibs Single source statins and new antihyperlipidemia % % 50 CS 50 CS 45 45 40 40 35 SS 35 SS 30 30 25 25 20 UC 20 UC 15 15 10 10 5 5 0 0

Jul

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Apr 20032004 2005 2006 2007 2003 2004 2005 2006 2007 %%Cesarean section Laparoscopic cholecystectomy 58 59 60 53 54 55 56 54 56 60 53 55 55 55 56 54 50 52 50 51 CS 49 51 52 50 51 51 CS 50 45 47 48 50 48 47 47 40 40 SS SS 30 26 26 26 28 27 26 30 22 30 24 22 23 23 25 24 22 18 18 20 20 21 20 19 20 27 29 28 UC 20 17 17 16 17 20 23 24 24 24 26 28 28 20 20 20 20 20 20 21 21 UC 21 22 20 22 24 10 16 16 17 17 18 18 19 10 0 0 QtrQtrQtr Qtr QtrQtrQtr QtrQtrQtrQtr Qtr QtrQtrQtr QtrQtrQtr Qtr QtrQtr Qtr QtrQtrQtrQtr Qtr QtrQtr Qtr 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 2004 2005 2006 2007 2004 2005 2006 2007

Source: Limwattananon, J.,S. Limwattanon,et al.(2009).

498 Besides, disparities were found in the hospitalization of CSMBS beneficiaries due to such illnesses as pneumonia, heart failure, ischemic heart disease, and cerebrovascular disease; their hospital lengths of stay were markedly larger than those for UC beneficiaries, even though adjusted for sex, age and illness severity. Regarding the number of bed-days for diabetic patients with acute and chronic complications under CSMBS was also significantly greater than those under the other two health insurance schemes. Meanwhile, the readmission rate within 30 days after discharge among UC eligible patients was found to be higher than that for CSBMS patients. The major causes of the differences in medical services received by CSMBS eligible patients are the method of payment to health facilities, i.e. the fee-for-service, whereby the health facility tends to provide high-cost diagnostic and treatment procedures, some time more than necessary, resulting in the rapidly and steadily rising medical expenditure under CSMBS (Figure 14.9). A matter of concern is the service quality because of the capitation payment to health facilities under the UC Scheme for outpatient services or the close-ended payment for other kinds of medical services, with a tendency for health facilities to limit the amount of services or use minimum resources if there is no efficient monitoring and control system.

Figure 14.9 CSMBS medical expenditures, 1990›2008

Short-term measures after the 1997 economic crisis Direct payment measure - Use of non-NLEM drugs had to be approved by - 2004 for chronic illnesses more than one medical specialist. - 2006 for retirees - Limit the number of bed-days in a special room, - 2007 for all diseases Million baht not exceeding 14 - Patientûs co-payment for doctorûs fee 60,000 - Services at private hospitals were not allowed except for an emergency 50,000 40,000

30,000 DRG 20,000

10,000 0 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Outpatient services Inpatient services Total

Source: Comptroller Generalûs Department, Ministry of Finance.

499 4. Future Directions of the UC Scheme in Thailand The data on the success of the UC Scheme and the equitable access to health services for the rural poor residents as well as the reduction of health-care spending for the poor households and the prevention of impoverishment due to catastrophic medical expenses are the indicators showing that the Thai government has succeeded to a certain extent in reducing health inequities after the UC Scheme is implemented. Thus, the government has to continue supporting such a policy, not just to reach the goal of implementing the populist policy. The UC Scheme has created health and social equity and enhanced the efficiency of the countryûs health system as it provides support for primary medical care, health promotion and disease prevention as well as health security for preventing risks from medical expenditure for all Thai citizens nationwide. However, the government has to allocate adequate resources for the UC Scheme, especially primary and secondary care to which the rural poor can have better access and use more frequently than tertiary care. Besides, the govern- ment needs to increase the efficiency of the health system with more investment on human resources for health, health promotion and major disease prevention. This is to cope with the rising proportion of elderly persons and chromic non-communicable diseases, which tend to result in a health-care financing burden in the long run. Regarding the increase of efficiency of resource utilization for CSMBS and the reduction of dispari- ties of the three health insurance schemes, the government has to give priority to such matters and resolve relevant problems in the next phase, as well as develop the health information system for the purpose of monitoring, evaluation and development of the UC healthcare policy on a continuous and sustainable basis.

500 Chapter 15 Thailand and Global Health

Health problems have changed rapidly over the past three decades or so due to changes in the global context such as convenience and rapidity in international transportation and communication, resulting in health problems in one country becoming problems in other countries across the globe within a short period of time. For example, the SARS epidemic in Asia became a global problem within a few days; particularly for developed countries, health issues are not only viewed for promoting the publicûs health, but also for security purposes. That is because whenever there is an epidemic in any region of the word, such an event will widely and rapidly affect the health conditions of their own populations, which may become a crisis as the forecast has shown that pandemic influenza H1N1 2009 may cause a large number of fatalities. As health problems have become more increasingly important to the world, major changes have been made to cope with them such as the increase in health-care budget from various sources, the changes in the organizational structures of various relevant agencies, and the impacts resulting from changes in develop- ing countries. Thus, it can be said that the global health system is a significant transition that all nations have to pay attention to and be prepared to respond to such changes.

1. The Transition of Health Concept: from within the country to the problem requiring inter-country collaboration and worldwide public-private sector cooperation The concept of health has changed in accordance with changes in other sectors. In the era when travel and communication were limited only in a certain area, health problems were contained chiefly within each countryûs boundary. Since the 19th century, the health concept in the çpublic healthé dimension, giving importance to disease prevention and holistic medical treatment for the people, defined çpublic healthé as the actions for making people healthy, disease prevention, health promotion, and good environmental sanitation. When there were more communications among countries, the health concept was extended to cover international health, which crossed the border of one country to another, focusing on resolving health prob- lems of developing countries, taking into account the complexity of global and local factors related to health.

501 As international transportation and communication have progressed rapidly, resulting in rapid cross- border movements of health problems and requiring more complex solutions to such problems, the health problems have got a different dimension with the concept of çglobal healthé, which means the consideration of the health needs of the people of the whole planet is to be done beyond the concerns of particular nations1 with more involvement of non-governmental mechanisms. When considering the definitions of public health, international health and global health, we can see a number of overlapping points, all giving importance to peopleûs health as a whole, focusing on disease prevention and concerns over the underprivileged. However, there are differences with respect to area cover- age: çpublic healthé deals with the problems in the national context, çinternational healthé deals with health problems beyond oneûs own country with collaboration between/among two countries or more, while çglobal healthé covers the common health problems of the entire world which require the collaboration of public and private mechanisms all over the world (Table 15.1).

Table 15.1 Comparison of public health, international health and global health Aspect Global health International health Public health Area Focus on issues directly and Focus on health issues of Focus on issues affecting health coverage indirectly affecting health other countries other than of the people within the coun- beyond the border of any oneûs own country, particu- try or community. particular country. larly developing countries. Level of Development and operations Development and operations Development and operations coopera- for resolving problems for resolving problems for resolving problems do not tion require cooperation from require bilateral cooperation. require cooperation from other several countries across the countries at the global level. world. Individual Covering both disease pre- Covering both disease pre- Primarily focusing on disease or popula- vention for the population vention for the population prevention in population tion and illness treatment for the and illness treatment for the groups. individuals. individuals. Access to The major goal is to create Focus on assisting the people The major aim is to create health care equity in health for all the with problems in other equity in health for the people in all countries countries. people within the country or throughout the world community.

1Brown et al. The World Health Organization and the Transition From "International" to "Global" Public Health. AJPH: Jan 2006, Vol 96, No 1. http://www.ajph.org/cgi/reprint/96/1/62

502 Table 15.1 Comparison of public health, international health and global health Aspect Global health International health Public health Breadth of High level of interdisciplinary Requiring some collaboration Supporting interdisciplinary technology and cross-disciplinary with other sectors, but not working approach particularly used approach with cooperation focusing on interdisciplinary in the health and social science also from non-health sectors. approach. sectors. Source:J P Koplan et al. Towards a common definition of global health Lancet 2009; 373: 1993›95.

2. Pluralistic Dimensions of Global Health For the purpose of better understanding of global health, the following five dimensions are reviewed as follows: (1) Global health as international policy. As the objectives of global health in this dimension focus on trade, economic growth, stability, democracy, and countryûs image, the high priority diseases in this group are infections diseases and HIV/AIDS; and the agencies giving importance to this dimension are, for example, international development agencies of developed countries such as the U.S. Agency for International Develop- ment (USAID) and the U.S. Presidentûs Emergency Plan AIDS Relief (PEPFAR) of the U.S. Department of State, the Department for International Development (DFID) of the United Kingdom, and the Japan Interna- tional Cooperation Agency (JICA). (2) Global health as a matter of security. Its principal goal is to fight bioterrorism, infection and drug resistance, major diseases (avian influenza, respiratory infection, multidrug-resistant tuberculosis and HIV/AIDS. The agencies recognizing the importance of this dimension are disease control agencies of devel- oped countries, such as the U.S. Centers for Disease Control and Prevention (CDC), and private agencies, such as the Nuclear Threat Initiative (NTI). (3) Global health as charity. Its principal goal is to resolve the problem of poverty which is related to droughts, famine, malnutrition, HIV/AIDS, tuberculosis, and malaria. The agencies dealing with this dimen- sion are international development agencies of developed countries as mentioned in item (1) and private charities such as the Bill & Melinda Gates Foundation. (4) Global health as investment. Its principal purpose is to enhance economic growth resulting form health development efforts in a full extent focusing on HIV/AIDS, malaria, maternal and child health, nutrition, occupational health, and health insurance, and involving such agencies as the World Bank, the International Monetary Fund (IMF), the International Labour Organization (ILO), and some private businesses. (5) Global health as public health. Its principal purpose is to make every human being on earth healthy to the full extent, dealing with the issue of burden of disease and involving agencies such as the World Health Organization, specific disease control agencies and private agencies.

503 Table 15.2 Comparison of five global health dimensions and focuses

Principle or Goal Priority diseases Lead agencies dimension Global health as Trade, economic Infections diseases International development agencies of international growth, stability, and HIV/AIDS developed countries such as USAID, policy democracy, countryûs PEPFAR, DFID, SIDA, CIDA and JICA image Global health as The fight against Avian influenza, Disease control agencies of developed security bioterrorism, infec- respiratory diseases, countries such as U.S. CDC and private tion and drug resis- MDR tuberculosis charities such as Nuclear Threat Initia- tance and HIV/AIDS tive. Global health as Ending poverty Droughts, famine, International development agencies of charity malnutrition, HIV/ developed countries and private charities AIDS, tuberculosis, such as the Bill & Melinda Gates Foun- and malaria dation. Global health as Economic develop- HIV/AIDS and The World Bank, IMF, ILO and private investment ment on the full malaria businesses extent Global health as Healthiness to the full Global burden of WHO as well as specific disease control public health extent diseases and private agencies

Source: David Stuckler, Martin McKee, Five metaphors about global-health policy, Lancet 2008; 372.

It is noteworthy that çglobal healthé has several dimensions and purposes; and participating agencies have different purposes. Thus, creating a good understanding about global health is more complicated than that for the former health issue which primarily focused on health. However, when considering certain illnesses that fall within all groups or dimensions, such as HIV/AIDS, the evolution of such common illnesses has obtained more support than other diseases, resulting in a higher investment on such efforts. Nevertheless, global health is not limited only to communicable diseases, but over the past few years, non-communicable diseases have gained more attention as their burden of disease has contributed to over two- thirds of the overall burden of disease in all countries worldwide. As a result, the NCD Summit will be held in April 2011 in Moscow and at the United Nations in September of the same year. At the meetings, there will be a specific agenda on NCDs, which requires intersectional and international cooperation for resolving such problems, including those related to alcohol and tobacco consumption, migrantsû health and global warming.

504 3. Global Health Governance As global health has several dimensions and purposes, many more agencies have given importance to such issues; several public and private global health organizations were established over the past 20 years. Such agencies include funding agencies, fund management agencies, cooperation agencies and operational agencies, resulting in the organization and mechanisms for global health governance becoming more complicated. When existing agencies such as UN agencies, bilateral organizations, foundations, private organizations and technical agencies are taken into account, all such global health agencies are numerous. When each of them tries to achieve their own objectives, they have set up their own working and performance reporting mechanisms. Despite strong efforts being made, the cooperation among such agencies has been extremely difficult.

Figure 15.1 Linkages among global health agencies providing management and financial support

Foundations such as Gates Governments of countries Foundation, Rockefeller Other private agencies providing official assistance Foundation

Fund management organiza- Multilateral organizations such as tions such as Global Fund, the World Bank and UN agencies GAVI

Through various bilateral More than 100 organizations such as cooperating agencies PEPFAR, USAID, DFID, such as Stop TB, Roll SIDA, CIDA, AusAID, JICA Back Malaria, Global Health workforce Alliance

Public sector Private sector

Source: The global health landscape.

505 4. Changes in the Roles of Global Health Agencies With the transition of health concept and global health dimensions, the roles of relevant agencies have changed. Agencies that used to be important in dealing with health issues in the world such as WHO and UNICEF have had a markedly decreasing role, in terms of policy-making and funding support. The establish- ment of new agencies, so-called Global Health Initiative, since 2000, was partly due to WHO itself, especially its management inefficiency and its budgetary system chiefly dependent on the contributions from developed countries. Thus, WHOûs operations are carried out under the influence of developed countries that make contributions with specified conditions or activities. This is apparent in the fact that in 1997, two-thirds of WHOûs budget was received from Member Statesû assessed contributions, thus being able to set its own policies. But at present more than 80% of its budget is obtained from the contributions of developed countries with specific conditions for activities of their interests. Thus, WHO lacks the independence in its operations, causing the concept of creating new agencies for dealing with global health for better efficiency in management and truly resolving global health problems. The establishment of several health agencies has resulted in WHOûs declining role. At present, there are more than 100 organizations working on Global Health Initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and the World Bank Multi-Country AIDS Program (MAP), which are major agencies having received a lot of contributions from several funding sources for health projects. According to the World Bank, funding contributions for health rose from US$ 2.5 billion in 1990 to US$ 14 billion in 2005 and many bilateral agencies also increased their contributions from US$ 8.5 billion in 2000 to US$ 13.5 billion in 2004, while the Global Fund to fight AIDS, Tuberculosis and Malaria has received contributions from various countries and agencies in a cumulative amount of more them US$ 20 billion.2 In addition to increased contributions from various governments, many private agencies have also increased their contributions for health; for example, the Bill & Melinda Gates Foundation has donated US$ 6.6 billion for projects related to Global Health. 3 As HIV/AIDS is a common problem for all dimensions of global health, the proportion of budget for HIV/AIDS is highest; for example, in 2007 of the total contribution for health of US$ 14.5 billion, US$ 5.1 billion, or 35%, was allocated for HIV/AIDS while only 5% was allocated for tuberculosis and malaria programmes.4 When considering the budget allocated to various agencies, the amount provided for UN agencies such as WHO, UNICEF, UNAIDS and UNFPA dropped from 32.3% of the total funds for health in 1990 to 14% in 2007, while the proportion donated to the Global Fund and GAVI rose from 1% of the total funds for health to 8.3% and 4.2%, respectively, over the same period. The largest expansion was noted for bilateral assistance, especially from the U.S.A. and Japan, which have given less importance to multilateral assistance mechanisms. 2http://www.theglobalfund.org/documents/pledges_contributions.xls access on March 7, 2010 3Laurie Garrett. The Challenge of Global Health, Foreign affairs. January /February 2007. 4Nirmala Ravishankar, et al. Financing of global health: tracking development assistance for health from 1990 to 2007, Lancet 2009; 373: 2113-24.

506 Figure 15.2 Investments in health of various agencies, 1990›2006

US$ billions 19 18 17 16 US NGOs 15 Other US Foundations 14 Gates Foundation 13 European Commission 12 11 UN System 10 GAVI & GFATM 9 Regional Development Banks 8 World Bank IDA & IBRD 7 Direct Bilateral ODA 6 5 4 3 2 1 0 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Source: Institute for Health Metrics and Evaluation, University of Washington, Seattle.

The much increase in the budget for global health agencies has resulted in both positive and negative impacts. On the positive side, the increased budget has helped expand the coverage of medical and health services; for example, more HIV-infected persons have received antiretroviral therapy and more bednets have been distributed for malaria prevention purposes. Meanwhile, there have been problems and the health system, i.e. inequities in health services because of the limited resources for such purposes in developing countries are allocated for the programmes on certain diseases, resulting in other important problems receiving inadequate budget and thus, decreasing the service quality in order to reach the established quantitative targets. As for the countries receiving such financial support from external sources, they might reduce their own investments on health, while the policy has been made by external funding agencies, other health problems may received a lower priority, resulting in decreased budget and personnel which may have been drawn to implement the projects with higher levels of funding. The negligence of unfunded projects and the investment on specific diseases, not the entire health system, has resulted in less development of the health system.

507 The changes in health-related organizations in Thailand are similar to those at the global level; many autonomous non-MoPH agencies with better management efficiency have been established over the past 10 years such as the Health Systems Research Institute (HSRI) in 1992, the Thai Health Promotion Foundation (ThaiHealth) in 2001, the National Health Security Office (NHSO) in 2002, and the National Health Commis- sion Office (NHCO) in 2007. With the existence of such agencies, the proportion of MoPHûs budget on health, previously being the lead agency in health, has decreased in relation to the overall national budget; and the role of MoPH in policy-making has also declined. Thus, WHO and MoPH should adjust their roles by giving more importance to technical matters to serve as the central agency in establishing standards and national health policy/direction, promoting interagency coordination, providing knowledge, and representing the country in global health forums. In this connection, the capacity building of personnel has to be urgently undertaken. 5. Thailandûs Role in Global Health Forums Thailand has played a leading role in a number of global health forums as it has got success stories about sustainable health development such as primary health care, family planning, maternal and child health, policies on national drug and national list of essential medicines, rural health-care system development, disease prevention especially against HIV/AIDS, and universal health care. 5.1 The Role in the World Health Organization 1) The Thai delegation has played a leading role in the meetings of the Regional Commit- tee of WHO/SEARO and the World Health Assembly (WHA) and has been invited to serve as a member of several major committees. The Thai delegation has played an outstanding rate at the WHA for more than 10 years, especially in preparing recommendations and making comments on numerous agenda items of the meeting, and negotiating various resolutions. Thailandûs role in the WHA is recognized by other Member States and, in many instances, was invited to chair a working group on drafting important resolutions such as resolution WHA 60.28 on sharing of influenza viruses and access to vaccines and other benefits. Besides, Thai delegates played a significant role in a meeting the Intergovernmental Working Group on Public Health Innovation and Intellectual Property (IGWG), responsible for drawing up a global strategy and plan of action in response to the development of new drugs and making drug prices affordable and accessible by the people; and a Thai delegate was appointed as vice chairperson of a committee on public health emergency under the International Health Regulations and chairperson of the Conference of the Parties to the WHO Framework Convention on Tobacco Control. 2) Pushing for the election of a Thai citizen as the Regional Director of the WHO South- East Asia Region. Dr. Samlee Plianbangchang of Thailand was re-elected as the Regional Director of WHO/ SEAR for the second 5-year term beginning on 1 March 2009.

508 3) The role in international health coordination among Member States of WHOûs South- East Asia and Western Pacific Regions. For example, serving as the coordinator of the Asia-Pacific Action Alliance on Human Resource for Health (AAAH), the Mekong Basin Disease Surveillance Network (MBDS) and the ASEAN+3 Field Epidemiology Training Program Network. In addition, Thai delegation has coordi- nated the establishment of the Asian Partnership on Emerging Infectious Disease Research (APEIR) and the Regional One Voice for WHO/SEAR Member States at global health forums, especially the WHA. 4) Framework Convention on Tobacco Control (FCTC). Thailand notified the WHO FCTC, as the 36th country out of 147 countries, which came into force on 27 February 2005, becomes a binding treaty for all FCTC parties (members). In this connection, Thailand hosted the Second Conference of the Parties of the FCTC (COP II) and a Thai delegate was elected as chairperson of COP III; and Thailand has continuously played a leading role at such an international forum. 5.2 Role in Other Global Health Forums 1) Administrators and academics from Thailand have been selected as leaders in several organizations such as: ■ The Global Fund to Fight AIDS, Tuberculosis and Malaria: A Thai delegate was selected as a member and vice chairperson of the Executive Board of the Global Fund from January 2003 to March 2004 and as chairperson of its Committee on Policy and Strategy for 2010›2011 ■ The Global Alliance for Vaccine and Immunization (GAVI). Thai delegates once served as chairperson of GAVIûs programme review committee and a member of its evaluation committee. ■ The Intergovernmental Forum on Chemical Safety (IFCS). A Thai delegate served as its President between November 2003 and September 2006. ■ Chairperson, Council on Health Research for Development (COHRED). ■ Vice chairperson of the Board, Alliance for Health Policy and Systems Research. 2) Hosting of meetings on issues related to global health Thailand has been the host of international meetings on issues related to global health, the important ones including the 2004 International AIDS Conference, the 2006 Global Conference on Health Promotion, and the 2010 First WHO Global Forum on Medical Devices, for most of which Thailand was requested by the international agencies concerned to co-host such events. The international conferences that are initiated by Thailand are getting more numerous and the one that has been held annually since 2007 is the Prince Mahidol Award Conference. The Conference is co- hosted by the Prince Mahidol Award Foundation, the Thai Ministry of Public Health, Mahidol University and several other Thai agencies as well as other international agencies invited to co-host the event such as WHO, the World Bank, the Rockefeller Foundation, and the China Medical Board. For each conference, the impor- tant topics or issues will be selected by Thai partner agencies for knowledge sharing and exchange of ideas among 300›500 participants from all over the world. Besides, in 2013, Thailand will host the 21st IUHPE World Conference, which will be the largest global health promotion conference to be co-hosted by the Thai

509 Health Promotion Foundation and the Ministry of Public Health together with other agencies. 3) Bilateral cooperation Thailand holds meetings on bilateral cooperation agreements with all neighbouring coun- tries every year, resulting in closer cooperation for the control and prevention of communicable diseases. 6. Capacity Building for Thai Personnel to Work on Global Health 1) Capacity building through attendance at international meetings. Thailand has given importance to the capacity building for Thai personnel to work on global health issues for more than 10 years. The mode of such an effort emphasizes actual practices under the mentorship of experts. Major international forums of such endeavour include the World Health Assembly, for which Thai technical officials with good potential from MoPH and other agencies are selected to attend, with the preparedness of the Thai technical team in seeking Thailandûs positions before departure for the meeting. During the Assembly, the Thai delega- tion holds meetings to establish a clear position of the country, assess other countriesû positions and determine how to conduct negotiations. Having technical officials from various agencies attend the WHA is a way of creating a working network among agencies concerned; and this capacity building mechanism is praised and adopted by many other countries. 2) Secondment of Thai officials to overseas agencies. Thailand has selected a number of officials with international working capability to work in various agencies abroad such as WHO, the World Bank, and the Rockefeller Foundation. Since 2005, 12 Thai officials have gone through this mechanism and returned to work effectively for the benefits of their respective agency and the country. 3) Training in Global Health Diplomacy. Thailand and WHO/SEARO organized a training cruse on Global Health Diplomacy to enhance the capacity of Thai officials in global health in terms of issues, mechanisms and organizations as well as negotiation skills through a series of lectures, case studies and practices at the WHA. It is hopeful that Member States of WHO/SEAR will have good capability to participate in the WHA and push for adoption of certain policies for the regionûs benefits in the future. 7. Global Health and In-country Networking The trends in global health have made many Thai agencies become interested in this matter. Many academic institutions have offered a curriculum or programme on global health as well as a short course and research. However, there has been no cooperating mechanism among them to create collaborative actions. Therefore, a network for in-country cooperation should be established so that complex problems can be jointly resolved more effectively.

510 References

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524 525 Name Agency Position 1. Dr. Suwit Wibulpolprasert Expert in Disease Prevention & Control Chairperson 2. Dr. Supakit Sirilak Director, Bureau of Policy & Strategy Vice Chairperson 3. Dr. Amphon Jindawatthana Secretary-General, National Health Member Commission 4. Dr. Pinij Faramnuayphol Health Information System Development Member Office 5. Dr. Churnrurtai Kanchanachitra Mahidol University Member 6. Mrs. Benjamaporn Jhantharapat Thai Health Promotion Foundation Member 7. Director, Economic & Social National Statistical Office Member Statistics Bureau II 8. Dr. Viroj Tangcharoensathien Director, International Health Policy Member Program 9. Dr. Phusit Prakongsai International Health Policy Program Member 10. Dr. Kanitta Bundhamcharoen International Health Policy Program Member 11. Mrs. Montira Ratchatasomboon Department of Medical Sciences Member 12. Mrs. Jutamart Molee Food and Drug Administration Member 13. Ms. Worasap Chitprasert Department of Health Member 14. Mrs. Suparp Chaiyanit Department of Medical Services Member 15. Mrs. Uthai Ketsara Department of Health Service Support Member 16. Mrs. Worawan Chutha Department of Mental Health Member 17. Ms. Pornthip Siripanumas Department of Disease Control Member 18. Mrs. Vichaya Jaidee Department for Development of Member Thai Traditional & Alternative Medicine 19. Mrs. Orapin Sublon Bureau of Policy & Strategy Member 20. Mrs. Daranee Khampera Bureau of Policy & Strategy Member & Secretary 21. Ms. Panbaudee Ekachampaka Bureau of Policy & Strategy Member & Assistant Secretary 22. Mr. Nitis Wattanamano Bureau of Policy & Strategy Member & Assistant Secretary 23. Mrs. Kitiya Ukachoke Bureau of Policy & Strategy Member & Assistant Secretary 24. Ms. Paichit Pengpaiboon Bureau of Policy & Strategy Member & Assistant Secretary

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