20

Infectious Diseases and the Development of Health Systems in Thailand

Visanu Thamlikitkul1, Viroj Tangcharoensathien2, and Natth Bhamarapravati3

1 Siriraj Hostpital, Mahidol University, Bangkok, Thailand 2Ministry of Public Health, Nonthaburi, Thailand 3 Mahidol University Salaya, Nakhonpathom, Thailand

HISTORY AND CURRENT STATUS with emerging infectious diseases, especially OF INFECTIOUS DISEASES HIV/ AIDS, and re-emerging diseases such IN THAILAND as leptospirosis. Several emerging infectious diseases originating in neighboring countries Infectious diseases have been a major such as severe acute respiratory syndrome public health problem in Thailand for the past (SARS), avian flu, and Nipah virus infections several centuries. Most infectious diseases in are also a threat to Thai people. Moreover, in• earlier days were food and water-borne dis• fectious diseases due to drug resistant micro• eases, vector-borne diseases, and infectious organisms e.g., drug resistant Streptococcus diseases related to poor sanitation (Wright and pneumoniae, methicillin-resistant Staphylo• Breakspears, 1903; Beek, 2001). Some infec• coccus aureus, and multi-drug resistant gram• tious diseases have now been eradicated, for negative bacilli have also been increasing. example smallpox. The last case of small• There are 47 infectious diseases docu• pox in Thailand was documented in 1962. mented in the current Thai Communicable Some diseases have been brought under con• Diseases Act. These include cholera, plaque, trol by vaccines, such as diphtheria, pertus• smallpox, yellow fever, meningococcal in• sis, tetanus, poliomyelitis, and measles. How• fections, diphtheria, pertussis, tetanus, po• ever many infectious diseases continue to be liomyelitis, measles, rubella, mumps, chicken public health problems such as acute respi• pox, influenza, encephalitis, dengue fever, ratory tract infections, acute diarrhea, tuber• rabies, hepatitis, hemorrhagic conjunctivi• culosis, dengue hemorrhagic fever, malaria, tis, food poisoning, dysentery, amoebia• endemic infectious diseases such as melioido• sis, typhoid fever, paratyphoid fever, typhUS sis, and parasitic infestation e.g., opisthorchi• fever due to Rickettsia prowazekii, scrub ty• asis. Like other countries, Thailand is faced phus, murine typhus, tuberculosis, leprosy, Y. Lu et al. (eds.), AIDS in Asia 269 © Springer Science+Business Media New York 2004 270 INFECTIOUS DISEASES AND THE DEVEWPMENI OF HEALTH SYSTEMS IN THAILAND

malaria, anthrax, trichinosis, yaws, lep• therefore be considered as a minimum esti• tospirosis, syphilis, gonorrhea, non-specific mate of what is probably the actual reality. urethritis, chancroid, granuloma inguinalae, lymphogranuloma venereum, relapsing fever, Acute Gastroenteritis acute diarrhea, chronic tropical ulcer, filari• asis, mY/AIDS, acute flaccid paralysis and Acute gastroenteritis includes acute di• SARS. Five diseases are classified as danger• arrhea, food poisoning, dysentery and severe ous diseases, namely cholera, plaque, small• diarrhea. Cholera was the major leading cause pox, yellow fever, and SARS. Any cases of of morbidity and mortality in Thailand in the the following diseases must be reported to the 1900s. An epidemic of cholera in 1890 re• local health authority: cholera, plaque, small• sulted in moving the Thai capital from Uthong pox, yellow fever, diphtheria, tetanus neona• to Krungsri Ayudaya. The morbidity rate of torum, poliomyelitis, encephalitis, rabies, acute gastroenteritis per 100,000 population typhUS fever due to Rickettsia prowazekii, an• has been increasing, from 264 in 1977 to 1800 thrax, trichinosis, meningococcal infections, in 1991, to 2000 in 2002 as shown in Figure 1. yaws, acute flaccid paralysis, and SARS. However the case fatality rate has been de• According to the official documents of creasing, from 0.5% in 1977-1978 to 0.1 % or the Ministry of Public Health (MoPH) on less since 1982. The decrease in the case fa• the Burden of Disease and Injuries in Thai• tality rate was primarily due to improvements land in 1999, infectious diseases comprised in sanitation and personal hygiene, and oral 21 % of the total of 9.6 million Disability Ad• rehydration therapy. justed Life Years (2 million DALYs) (MoPH, Acute gastroenteritis is still a common Thailand, 2002; MoPH, Thailand, 2003a). cause of morbidity and mortality in children mv/ AIDS accounted for a majority of the under age five. The common micro-organisms infectious disease burden, with 1.3 million causing acute gastroenteritis documented by DALY s, or 72% of the total infectious disease stool or rectal swab cultures in 1998 and in burden. The other major infectious diseases 1999 collected from 23 hospitals located in that contributed to the DALY s in Thailand all regions of Thailand revealed that 18%- were acute respiratory tract infections in chil• 38% were Salmonella (more than 90% were dren, and tuberculosis. Although HIV/ AIDS non-typhoidal Salmonella), 21 %-36% were has been the major infectious disease prob• Vibrio parahemolyticus, 8-12% were Es• lem in Thailand over the past decade, it will cherichia coli, 9%-22% were Shigella (most be addressed elsewhere. This chapter will fo• of them were Shigella sonnei and Shigella cus primarily on epidemiology and the cur• flexneri), 2%-5% were Aeromonas 2%-3% rent status of infectious diseases other than were Plesiomonas and 3%-5% were Vibrio HIV/ AIDS in Thailand over the past several cholerae (Ministry of Public Health (MoPH), decades, during which time a disease surveil• Thailand, 1998; MoPH, Thailand, multiple lance system has been well established. Some years). There were nine major outbreaks of major infectious diseases under surveillance cholera during 1900 to 1980, which infected will be described. Morbidity and mortality more than 80,000 patients and caused more data for most of the infectious diseases de• than 30,000 deaths. The case fatality rate de• scribed in this chapter come from the annual creased from 72% in 1918 to 3% in 1980. The epidemiological surveillance report prepared first six major outbreaks were caused by the by the Bureau of Epidemiology, Department Vibrio cholerae serogroup 01 biotype clas• of Disease Control, MoPH from 1977 to 2002. sical whereas the Vibrio cholerae serogroup It should be mentioned that the morbidity and 01 biotype El-Tor serotype Ogawa and Inaba mortality data collected by the MoPH is likely was the cause of the cholera since 1963. El to be an under-estimate, and this data should Tor cholera usually causes less severe diarrhea INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 271

-+- case/loo,OOO "0- OCFR("-) ~~~ ______~~~~--~~~0.7 2900

2'100 0.6

o-.q 2000 0.5 , 1600 . 0.4 1200 0 0.3 ., 900 0.2

'100 \. ...,0-0..""0-0. 0.1 t>.. -O" -0_--0_0..-.0. . 77 79 91 83 as 87 99 91 "'EAR.

FIGURE 1. Morbidity and case fatality rate (CFR) for acute gastroenteritis (Ministry of Public Health, Thailand, 1997-2002) with a much lower case fatality rate than clas• cholerae serotype Ogawa was susceptible to sical cholera. Vibrio cholerae serotype Ogawa tetracycline and co-trimoxazole prior to 1996. was a predominant serotype during 1993- Since 1996, more than 70% of Vibrio cholerae 1994 epidemic, whereas serotype Inaba has serotype Ogawa have been resistant to co• been the most common serotype ever since. trimoxazole. Resistance to tetracycline was The cholera epidemics during 1992 and up to 50% in 2000 and then declined to 10% 1994 were caused by Vibrio cholerae non-Ol in 2002. Most strains of the Vibrio cholerae (0139) and since that time this strain of Vib• serotype Inaba were still sensitive to tetra• rio cholerae has been found only rarely. Di• cycline and co-trimoxazole. Vibrio cholerae arrheagenic E.coli strains isolated from pa• 0139 was usually resistant to co-trimoxazole tients with acute diarrhea in 1998 were en• but still sensitive to tetracycline. Almost teropathogenic E.coli (86%), enteroaggrega• all strains of Vibrio cholerae were sensitive tive E.coli (11 %), enterotoxigenic E.coli (2%) to fluoroquinolones. Antibiotic susceptibil• and enteroinvasive E.coli (1 %). Less than ity profiles of Vibrio cholerae, non-typhoidal 50% of Shigella isolated from stools was Salmonella ShigellaAeromonas against ampi• sensitive to ampicillin, tetracycline and co• cillin, tetracycline and co-trimoxazole may trimoxazole whereas 40% to 75% of non• vary according to geographical areas and typhoidal Salmonella was sensitive to ampi• species of the organism. Vibrio parahemolyti• cillin and co-trimoxazole. Nearly all strains of cus is almost always sensitive to tetracycline, non-typhoidal Salmonella and Shigella were co-trimoxazole, and fluoroquinolones. sensitive to fluoroquinolones and third gener• Studies of acute gastroenteritis in chil• ation cephalosporins (MoPH, Thailand, 1998; dren have elucidated many trends and charac• MoPH, Thailand, 1999; Isenbarger et al., teristics of the disease. Campylobacter jejuni 2002). Susceptibility of Aeromonas to ampi• was isolated in 27% of children present• cillin, co-trimoxazole and norfloxacin were ing with dysentery at Children's Hospital in 10%, 70%, and 85% respectively. The Vibrio Bangkok during 1998-2000. Campylobacter 272 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND

' -0' 0.. _l00.000chl~""""'~Y'"

2100 .----~------__, 7 .0

6.~ l!1OO o·--·~.. 6.0 p . ' ~.~ 1700 " 5.0 1~ •• 15

• . 0 l.3OO , 3.5 , 3.0 1100 '0_ -0 2 . ~

!IOO ~------~----~----~290 91 93 00 01 . 0

FIGURE 2. Morbidity and mortality rate for acute respiratory tract infections in children under 5 years (Ministry of Public Health, Thailand, 1997-2002) jejuni was also a causative agent in a small through twelve. The incidence of pneumo• outbreak of acute diarrhea in US troops de• nia in children under age five was 1%-1.9% ployed to Thailand in 1994 and it was the during 1990 and 2001 as shown in Figure 2. most common pathogen of acute dysentery The death rate per 100,000 children under age in children (Bodhidatta et al., 2002; Murphy five due to pneumonia during the same pe• et al., 1996). Most of the Campylobacter iso• riod decreased from six deaths in 1990 to 2.6 lates were resistant to ciproftoxacin but some deaths in 2001 as shown in Figure 2. This were resistant to macrolides. Rotavirus ac• data indicated that the morbidity of pneumo• counted for 6%-7% of acute diarrhea in chil• nia in children under age five has not changed dren attended Children's Hospital in Bangkok while mortality has decreased. The causative in 2000 & 2001, and it was the third most agents of ARI in Thai children are bacteria and common cause next to Aeromonas (13%) viruses (MoPH, Thailand, 1981; Sunakom et and Salmonella (10.5%) (Children's Hospi• al., 1990; Suwanjutha et al., 1990; Suwan• tal, 2000 and 2001). Rotavirus was found in jutha et al., 2002; Siritantikom et al., 2002; 27% to 34% of cases of acute diarrhea in Vathanophas et al., 1990). Otitis media and young children and G 1 was the most preva• sinusitis are caused by Streptococcus pneu• lent serotype followed by G2, G4 and G3, re• moniae and Haemophilus injluenzae, whereas spectively (Maneekarn and Ushijima, 2000). Streptococcus pyogenes is found in patients Toxins produced by S.aureus, E.coli, Bacillus with pharyngitis and tonsillitis. Pneumonia cereus, Clostridium peifringens in addition to and empyema may be caused by Staphy• enteric bacteria, cause food poisoning. lococcus aureus, Streptococcus pneumoniae, and Haemophilus injluenzae. Nasopharyngeal Acute Respiratory Tract Infections (ARI) swabs obtained from children under age five in Children under Age Five with upper respiratory infections (URI) and pneumonia during 1993 and 1994 revealed Acute respiratory infections are the most that S. pneumoniae was recovered in 37% common illnesses in childhood, comprising of URI patients and 31 % of pneumonia pa• approximately 50% of all illnesses in children tients, and H. injluenzae was recovered in under age five and 30% in children ages five 40% of URI patients and 37% of pneumonia INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 273 patients (Bamrungtrakul et al., 1994). Thirty• respectively (Sriyabhaya et al., 1993). These seven percent of S. pneumoniae isolates were observations showed a significant reduction resistant to penicillin (MIC ::: 0.1 I-lg/ml) in the TB burden in Thailand. However the and 26% to co-trimoxazole. Twenty-one per• annual morbidity rate of tuberculosis since cent of H. injluenzae isolates were resistant 1992 has increased from 20,000 cases (35 to ampicillin and 24% to co-trimoxazole. per 100,000 population) to more than 30,000 Most penicillin resistant S. pneumoniae be• cases (50 per 100,000 population) in 1999 longed to the Spanish pandemic clone 23F and thereafter, as shown in Figure 3. Based and Spanish-French international clone 9V on prevalence and incidence rates, it is esti• (Dejsirilert et al., 1999). The prevalence of mated that 80,000 to 100,000 people are in• penicillin resistant S. pneumoniae in Thailand fected with tuberculosis every year. has been increasing to 56% in 1997 and 61 % The primary reasons for this reemer• in 2000. The overuse of antibiotics is a major gence of tuberculosis in Thailand are HIV contributing factor to this high prevalence of infections, and the influx of migrants and il• antibiotic resistant S. pneumoniae. Between legal workers from neighboring countries. A 30% and 60% of children with upper res• strong association between HIV infection and piratory infections that were usually caused a rapid increase in TB cases has been ob• by viruses have been treated with antibiotics. served (Siriarayapon et al., 2002). The TB Chlamydia trachoma tis is also a causative registry data from a hospital in northern Thai• agent of lower respiratory infections in chil• land showed that the annual number of TB dren (MoPH, Thailand, 1998). The common cases nearly doubled between 1990 and 1994 cold, bronchitis, bronchiolitis and pneumo• and the prevalence ofHIV-seropositive TB pa• nia are caused by viruses, especially the tients rose from 1.5% of all TB patients in respiratory syncytial virus (RSV), influenza, 1990 to 45.5% in 1994 (Yanai et al., 1996). parainfluenza, and adenovirus (MoPH, Thai• The prevalence of HIV infections in new land, 1981; Sunakornetal., 1990; Suwanjutha cases of TB at the Chest Hospital in cen• et al., 1990; Suwanjutha et al., 2002; Siritan• tral Thailand was 22% during 1995 and 1996 tikorn et al., 2002; Vathanophas et al., 1990). (Punnotok et al., 2000). The clinical man• ifestations of TB in HIV infected patients Thberculosis (TB) on initial presentation included a low-grade fever, cough, weight loss, lymphadenopa• Prevention and control of tuberculosis in thy with pancytopenia, and lung infiltrates Thailand was officially endorsed by Prince (Putong et aI., 2002). The prevalence of pri• Mahidol in 1920. Tuberculosis was the sec• mary drug resistance to TB during 1996 ond most common cause of death in Thais and 1998 at a hospital in northern Thailand after malaria at the end of the World War II. was 13.2% to isoniazid, 10.8% to rifampicin, The anti -TB society and hospitals for TB were 15.6% to streptomycin, 5.8% to ethambutol; established later. TB centers were founded in and multidrug resistance (MDR) , i.e., resis• various parts of the country. The three national tance to at least both isoniazid and rifampicin, surveys of tuberculosis done in 1962, 1977, was observed in 6.3% of cases (Yoshiyama and 1991 revealed that the morbidity rate di• et al., 2001). HIV infection was found to be a agnosed by chest x-ray was 2.1 %, 1.4%, and risk factor for infection with resistant M. tu• 1.01 %, and the infectious case rate was 0.5%, berculosis (Yoshiyama et al., 2001). A study 0.31 %, and 0.24% respectively (Sriyabhaya conducted in 1995-1996 demonstrated that et al., 1993). The infection rate of children 0- HIV-positive patients with first-episode TB 14 years of age was found to be 15.2% in 1977; were more likely to have resistant Mycobac• 8.9% in 1983; and 5.18% in 1987, making the terium tuberculosis strains when compared to annual risk of infection 4.9%,2.3%, and 2.0% TB patients without HIV infection (Punnotok 274 INFECTIOUS DISEASES AND THE DEVEWPMENT OF HEALTH SYSTEMS IN THAILAND

___ case/lOO.OOO . -0- OCFR(%)

ro.-~------~----~~--~~------~----~----~---.5.0

55 '1.5 so '1.0 'IS 3.5 40 3 .0

2 .5

25 2 .0 20 1.5 1S 1.0 10 '0 5 0.5

77 79 81 83 as 87 89 91 93 95 97 99 01 'tEAR

FIGURE 3. Morbidity and case fatality rate (CFR) for tuberculosis (Ministry of Public Health, Thailand, 1997-2002) et al., 2000). The prevalence of drug re• HIV infected patients with a previous expo• sistance in patients with HIV infection as sure to M. tuberculosis, this preventive mea• compared to patients without HIV infection sure has a limited use in Thailand due to a waslO.9% vs 3.5% for isoniazid, 9.4% vs low predictive value in detecting M. tuber• 2.9% for rifampicin, and 5.2% vs 0.4% for culosis infection in HIV-infected persons by at least isoniazid and rifampicin (multidrug• tuberculin skin test and a high prevalence of resistant TB). A study on drug resistant M. primary drug resistance (Yanai et at., 1997). tuberculosis in a university hospital in north• Tuberculosis is not only a threat to patients eastern Thailand between 1995 and 2000 with HIV infection but also to the general revealed the prevalence of 8.2% resistance public who come in contact with the patients, to rifampicin, 4.2% to isoniazid, 4.3% to especially health care workers (Yanai et al., ethambutol, 3.7% to streptomycin, 3% to 2003). kanamycin, 2.3% to oftoxacin, and 2.4% to at least isonazid and rifampicin (Reechaipi• chitkul, 2002). The factors associated with Rabies drug resistant tuberculosis were HIV infec• tion and having a history of prior treatment. The first report of a victim of human ra• A high prevalence of MDR TB, 19.5%, was bies in Thailand was a Thai princess who was reported in 154 consecutive tuberculosis pris• bitten by a rabid dog in 1912. She did not oners in central Thailand in 2000 (Pleumpanu• receive any post-exposure treatment since ra• pat et at., 2003). bies vaccine and rabies anti-serum were not Treatment of drug resistant TB in HIV available in Thailand at that time. She de• infected patients was costly and the outcome veloped rabies and died three months after was unsatisfactory (Yanai et al., 1996; Putong being bitten by the dog. Her death resulted et al., 2002; Reechaipichitkul, 2002; Kamol• in the establishment of the Queen Sauvabha ratanakul et al., 2002). Although TB chemo• Memorial Institute. Since that time, a diag• prophylaxis had been found to be beneficial in nostic laboratory for rabies and rabies vaccine INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 275

CIIse/lOO,OOO 0.6.------,

O.S

0.4

0.3

0.2

0.1

o.o~-~------~-----~-~------~ 7? 79 8 1 93 as 87 B9 9 1 93 9S 97 99 01 YEAR.

FIGURE 4. Morbidity rate for rabies (Ministry of Public Health, Thailand, 1997-2002) production has been established in this Rabies vaccinations have been given to dogs institute. Since 1967, there have been 250 to since 1956. The rate of rabies in dogs has 300 cases of human rabies per year, a rate of decreased yearly since 1993, from 52 per 0.6-0.7 per 100,000 population (MoPH, mul• 100,000 dog population in 1993 to 21 in 1999 tiple years). During 1977 to 1991, approxi• (Panichabhongse, 2001). mately 200 cases of human rabies per year, a Submission of 4000 dog brains for ra• rate of 0.5 per 100,000 population, were iden• bies virus detection revealed a positive rate of tified. Since 1992 the number of human rabies 33% in 1997; the rate has decreased to 29% has been decreasing, from 113 cases (0.2 per in 2001 (Kingnate et al., 1997). Dogs are the 100,000 population) in 1992 to 28 cases (0.05 main reservoir species for rabies and are re• per 100,000 population) in 2002 as shown in sponsible for 96% of human deaths. Cats are Figure 4. responsible for 3%-4% of human deaths and Rabies in humans is more common in other animals and wildlife for 1%. Dogs with• males than females and is more common in out an owner were 2.2 times more likely to children aged 10 years old and under. Human have rabies than dogs with an owner. rabies has been reported in all regions of Thai• land, year round, with a slight increase from Acute Pyrexia of Unknown Origin (PUO) November to March. The continuous decrease in human rabies cases is primarily due to Fifty to eighty thousand cases of pa• post -exposure treatment with vaccination and tients with acute pyrexia of unknown origin immuno-prophylaxis. Rabies post -exposure were reported during 1977 and 1979 (MoPH, vaccinations were given to 35,000; 70,000; multiple years). The number increased from 130,000; 160,000; 200,000 and more than 100,000 to 200,000 cases between 1980 and 300,000 dog bite patients in 1967, 1981, 1993, 1984, and to over 200,000 cases per year since 1994,1999 and 2001, respectively (Panichab• 1985. The annual rate has been about 400 per hongse, 2001). This observation implies that 1000,000 population since 1984, as shown in the number of dog bite victims has been in• Figure 5. However, the case fatality rate was creasing and rabid dogs are still prevalent. less than 0.1 %, as also shown in Figure 5. 276 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAIlAND

-+- c:.eJ'l.OO,OOO .-0- OCFR(~) 800 r------~------~~------~------_,O.6

700 0.5 o'<.? 600 .. . 0.>4 500 ,. «Xl . 0.3

300 0.2

200 ,, \ ,0 '0 0.1 1.00 0" -'00'0--0 '0' '0.-0 ,"0 ____ ._0--0 .-0'-0-_0_-0. 0.'0_ o M 77 79 81 83 85 f11 89 91 93 GIS W 99 01 'I'EAA

FIGURE 5. Morbidity and case fatality rate (CFR) for acute pyrexia of unknown origin (Ministry of Public Health, Thailand,1997-2oo2)

Several attempts have been made to de• 2003). Several other studies have also shown termine the cause of fever in these patients. A that leptospirosis, rickettsioses including the study of 294 acute pua cases during 1966- spotted fever group and arbovirus infections 1968 revealed arbovirus infections in 16.3%- were causes of acute pua (Silpapojakul et ai., 18.7%, scrub typhus in 9.7%-14.2%, lep• 1993; Sirisanthana et ai., 1994; Silpapojakul tospirosis in 2.2%-5.8%, murine typhus in et aI., 1991; Watt and Jongsakul, 2003; Endy 0.7%-1.2%, and brucellosis in 0.6%. A study et ai., 2002). Q fever was recently found to be of1218 patients with acute pua during 1991- the cause of fever in nine patients with acute 1992 revealed that the cause was known in pua (Suputtamongkol et aI., 2003). Acute 38.7% of cases. The causes of acute pua were pua continues to be a common public health scrub typhus 7.5%, influenza 6%, dengue problem and further research on its epidemi• 5.7%, murine typhus 5.3%, bacteremia 3%, ology and causes are still needed. enteric fever 1.9%, chikungunya 1.1%, lep• tospirosis 1.1 %, melioidosis 0.9%, Japanese Dengue Hemorrhagic Fever (DHF) Encephalitis virus infection 0.6%, and un• known in 61.3% of cases (Leelarasamee, The first case of D HF in Thailand was re• 2000). ported at Siriraj Hospital in 1951. There was A recent study during 2001-2002 re• an epidemic ofDHF in Bangkok and Thonburi vealed that 31.1 % of PUa cases were asso• in 1958. This epidemic affected 2418 patients ciated with leptospirosis, 20.7% were associ• with 240 deaths. Since 1958, there have been ated with rickettsioses which included scrub epidemics of DHF every other year or every typhus, murine typhus and the spotted fever several years, and the number of cases have group, 2.4% were bacterial infections, 3.9% increased as more areas of the country ex• were associated with miscellaneous causes, perience epidemics. DHF has become an en• and 41.9% were unknown (Yupin Suput• demic disease in Thailand with periodic epi• tamongkol, personal communication, June demic outbreaks. The endemic mode of DHF INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAIlAND 277

___ case/UXl,OOO .-0. OCFR('No) 2 .0

9 2.4 ," : ,. 2.2 270 . 2.0 240 1.8

1.0

VI 1.2

1.0

0 .9

0.6

0.4

0.2

0 .0 n 7Q 91 93 as 97 99 Ql 93 gs g] 9iI 01 'rEAR

FIGURE 6. Morbidity and case fatality rate (CFR) for dengue hemorrhagic fever (Ministry of Public Health, Thailand, 1997-2002) corresponds to the cyclic seasonal pattern, periods. In many provinces a 2- to 4-month with incidence reaching its peak during the hot interruption was observed during the dry and and rainy seasons (May-October). The epi• cold seasons, the incidence decreasing to demic mode is a non-cyclic pattern and cor• the "normal" level, followed by a short re• responds to important non-seasonal rises in emergence (lasting 2-3 months) of the epi• the incidence of DHF. Major epidemics over demic pattern. the past several decades occurred in 1977, Most of the DHF cases have been in 1980, 1984, 1985, 1987, 1989, 1990, 1993, children under 15 years old. DHF is char• 1995,1997, 1998, 2001, and 2002, as shown acterized by fever, bleeding diathesis with in Figure 6. During 1958 and 1963, the num• thrombocytopenia, and a tendency to develop ber of cases per year was 1,000 to 4,000. Since hypovolemia due to vasculopathy. Primary 1964, the number of cases for each epidemic dengue infection is usually less severe than has been over 10,000 cases. The 1987 epi• a secondary infection. Preexistent dengue im• demic was the worst, with 152,840 cases and munity is a risk factor for developing dengue 785 deaths (Ungchusak and Kunasol, 1987). hemorrhagic fever. The risk of developing A retrospective study of spatial and tem• dengue shock syndrome (DSS) is greatest fol• poral variations ofDHF incidence in Thailand lowing an anamnestic dengue infection, par• during1983 and 1995 revealed that 52.4% of ticularly if the most recent infection was with DHF cases occurred during epidemic months the dengue 2 virus. Only 1% to 3% of patients (Barbazan et al., 2002). From 1983 to 1990, with dengue fever develop DSS. Most of the three major epidemics lasting 10-12 months infected patients are mildly symptomatic and occurred at 10- to IS-month intervals and af• the early symptom complex of acute dengue fected almost the entire country simultane• virus infection is protean and difficult to dis• ously (50-70 provinces). From 1991 to 1995, tinguish from other causes of febrile child• epidemics did not affect as many provinces hood illnesses (Endy et al., 2002). simultaneously (less than 30), and were less Unusual manifestations of DHF, espe• differentiated than during the inter-epidemic cially cerebral and hepatic manifestations 278 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND were not infrequently observed (Nim• Further research and development on a mannitya et al., 1987; Pancharoen and safe and efficacious dengue vaccine is ur• Thisyakorn, 2001). Classical HLA class I alle• gently needed. DHF continues to be a heavy les were associated with the clinical outcome health burden in terms of high morbidity and of exposure to dengue virus in previously ex• huge socioeconomic impact (Kantachuves• posed and immunologically primed individ• siri, 2002). The goals of the Thai National uals (Stephens et a!., 2002). An increased Dengue Prevention and Control Plan (ND• dengue disease severity was correlated with PCP) for DHF are to reduce the morbidity rate a high viremia titer, secondary dengue virus of dengue infection to 50 or less per 100,000 infection, and DEN-2 virus type (Vaughn popUlation, and the case fatality rate to 0.2% et al., 2000). DHF was caused by Dengue or less; and to reduce the mosquito breeding virus type 1, 2, 3, 4. DEN-3 was the most places measured by the Breteau index to be• frequent serotype in primary dengue, DEN- low 50 and the container index to below 10. In• 2 in secondary and in dengue hemorrhagic terventions aimed at achieving the aforemen• fever (Nisalak et al., 2003). The predominant tioned goals have been employed. In addition dengue serotype varied by year: DEN-l from to DHF, a disease caused by the chikungunya 1990-92, DEN-2 from 1973-86 and 1988- virus, which has similar clinical manifesta• 89; DEN-3 in 1987 and 1995-99; and DEN-4 tions and transmission, was observed to be from 1993-94. Oilly DEN-3 was associated prevalent in Thailand (Thaikruea et al., 1997). with severe outbreak years. The case fatality rate of DHF has decreased from 10% to 3% Malaria during the 1960s, to 2% in the 1970s, to 0.7% in the 1980s, and to 0.3% orless since1991 as Malaria was first documented in Thai• shown in Figure 6. land in 1660 and it remains a significant in• Prevention and control of DHF depends fectious disease leading to morbidity and mor• on control of the female Ades mosquito vector tality in Thailand. In 1947, there were 52,000 and vaccine. Currently the only effective way deaths due to malaria, with a death rate of to avoid dengue infection in areas where the 297 per 100,000 popUlation; the number of disease is endemic or epidemic is to avoid be• malaria cases was 3.8 million in 1949 (Bum• ing bitten by infected Ades egypti mosquitoes rasnaradul, 1967). The morbidity rate was through the use of personal insect repellent higher than 200 cases per 100,000 population and other insect barriers. There is no dengue during 1980 and 1990 and decreased to less vaccine currently available for widespread than 100 since 2000 as shown in Figure 7. public health use. Thai researchers have de• However, the morbidity rate in 1998 and 1999 veloped a dengue tetravalent live-attenuated increased to more than 100 per 100,000 pop• vaccine (Sabchareon et al., 2002). A study of ulation due to imported cases along the in• the safety and immunogenicity of two doses of ternational borders and a reduction in vector vaccine in flavivirus-seronegative Thai adults control during the economic crisis in Thailand showed that the first dose was the more re• (Chareonviriyaphap et al., 2000; Wiwanitkit, actogenic and 58% of the recipients sero• 2002). converted against 3 or more serotypes; 35% Malaria occurs more frequently in the seroconverted against all four. After the sec• summer and rainy seasons (March to Septem• ond dose, seroconversion was 76% and 71 %, ber). Males are more affected, and the dis• respectively. All subjects seroconverted to ease affects all age groups, though it is found serotype 3 after one dose. Serotype 4 elicited more frequently in those aged 15 to 44. All the lowest primary response but the highest in• four human malaria parasites cause diseases in crease in seroconversion after the second dose Thailand. Plasmodium jalciparum and Plas• (Sabchareon et al., 2002). modium vivax account for more than 95% of INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAIlAND 279

...... Case/lOO,OOO . <>. OCFR("-)

r-~--~------~-- ~~~~ ~ ~~ ~ ,1.4 400 ______

350 1.2

300 0 , 1.0 '0 2SO , 0 .8

200 0.6 150 \>-0 , "0-.0.. O ~ • '0' ..0 • (>. _ ., 100 " 0------.. -0 ____...... , .0, "0--0' "0--0, so '0' 0.2

o M n 79 81 83 a:5 87 89 91 93 95 97 99 01 'tEAR

FIGURE 7. Morbidity and case fatality rate (CPR) for malaria (Ministry of Public Health, Thailand, 1997-2002) the cases whereas Plasmodium malariae and nowadays is to be used in combination with Plasmodium ovale are very rare. During 1978 artemisinin derivatives. Resistances to qui• and 1985, P Jaiciparum accounted for 60%- nine and artemisinin derivatives are consid• 80% of cases, but after 1985 until 2002 P Jal• ered uncommon and both drugs are still ciparum was responsible for 40%-60% of in• very effective if they are used in combina• fections. tion with another anti-malarial. P. Jalciparum Drug resistant malaria has posed one of resistant to more than two operational an• the most difficult problems in malaria con• timalarial compounds of different chemical trol over the past decades (Wongsrichanalai classes (multi-drug resistance) is common et al., 2002). Chloroquine resistant Plasmod• at the Thai-Myanmar and Thai-Cambodia ium Jalciparum was first reported in Thai• borders. land in 1961 and chloroquine is no longer The factors that have contributed to effective for falciparum malaria. Resistance widespread drug resistance in Thailand in• to sulfadoxine-pyrimethamine was first noted clude wide availability of drugs, poor com• on the Thai-Cambodian border and more pliance, inappropriate therapy and self• than 90% of P. Jalciparum were resistant treatment. Multidrug-resistant P. Jalciparum after this drug replaced chloroquine for a is being controlled within the framework decade (Wongsrichanalai et ai., 2002). Mefto• of a general malaria containment program quine had been effective for therapy of fal• i.e., rapid case detection and treatment, and ciparum malaria until the late 1980s when vector control in areas where transmission resistance was first observed near the Thai• occurs. The currently effective regimen for Cambodian border. Meftoquine alone is no therapy of falciparum malaria in Thailand, longer effective on the Thai-Myanmar and especially in the area with multi-drug re• Thai-Cambodian borders, although it is still sistance, is artesunate plus meftoquine or moderately useful in some endemic areas in quinine plus tetracycline for uncomplicated and around Thailand. The role of meftoquine falciparum malaria and intravenous quinine 280 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND

-- ca../lOO,OOO .-0. OCFR("'> ~r------~----~~~----~~~--~~~------~------~--, 14 24 22 12 20 10 19 .,, ? 16 . ., .... 9 14 : ~ : ' 12 . ,, ., 1\ 10 . , 9 6 '0 4 6 '.. : '\ ,~ .. 2 2 6 OL------A=-=*~~~~~~~~~~~~~~ __~~ 0 77 79 91 93 es 97 99 91 ga Q5 97 99 01 'lEAR

FIGURE 8. Morbidity and case fatality rate (CFR) for leptospirosis (Ministry of Public Health, Thailand, 1997- 2002) or artemisinin derivatives in cases of severe to be an important strategy in the fight against malaria. The cloroquine-primaquine regimen malaria in Thailand. is still effective for therapy of vivax malaria (Congpuong et ai., 2(02). Leptospirosis The mortality rate of malaria in 1930 was greater than 400 cases per 100,000 popula• Leptospirosis was first reported in Thai• tion. The mortality rate per 100,000 popula• land in four patients who developed the dis• tion has been steadily decreasing to nearly ease during the flood in Bangkok in 1942; 300 cases in 1947, 14 in 1975, 8 in 1980, two patients died (Yunibandu, 1943). Prior 2.3 in 1990 and 1.3 in 1997. The case fatal• to 1996, there were fewer than 200 cases of ity rate has been decreasing from 1% in 1977 leptospirosis per year, and more cases were to 0.2% in 2002 as shown in Figure 7. Fa• usually observed after flooding. The num• tality is usually due to cerebral malaria and ber of leptospirosis patients has increased to severe and complicated malaria. The reduc• 14,285 (23 cases per 100,000 population) in tion of morbidity and case fatality in malaria 2000, as shown in Figure 8. This is clearly a is partly due to programs using chemical in• reemerging disease. Geographic variability in secticide to spray inside houses, promotion the distribution of cases has been noted, i.e., of bed-nets often impregnated with perme• more than 80% of cases were localized to the thrin, establishment of a surveillance and con• northeastern region. The demographic pro• trol system through more than 500 malaria files of leptospirosis cases during epidemics clinics and more than 15,000 malaria village remain unchanged. The disease is usually di• volunteers, and the availability of more pow• agnosed during August to November. A high• erful antimalarials such as artemisinin deriva• risk group was found to be male farmers tives. Biological control and environmental aged 15 to 45 years old. Risk factors for ac• management to control malaria vectors have quiring leptospirosis are walking through wa• also been attempted. Vector control remains ter, applying fertilizer in wet fields for more INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 281

<:ase/lOO,OCJO .<>- OCFR( .. 0 ...... · 0.4 2 , , , . .0 , , A 0.2 . 0' • 'I:r ,0,-0 ~ 0.0 77 79 81 93 85 87 99 91 93 95 97 99 01

FIGURE 9. Morbidity and case fatality rate (CFR) for scrub typhus (Ministry of Public Health, Thailand, 1997- 2002) than 6 hours a day, plowing in wet fields for Marked differences in rodent population den• more than 6 hours a day, pulling out rice sity and number of infected animals between plant sprouts in wet fields for more than 6 epidemic and non-epidemic sub-districts have hours a day, and traveling on potholed roads been found. Serological studies in rodents within 2 weeks (Tangkanakul et al., 2000; trapped in urban and rural areas in Thailand Tangkanakul et ai., 2001). revealed that pyrogenes. sejroe and bataviae Current clinical manifestations are not were predominant serovars (Wangroongsarb significantly different from cases recognized et al., 2002; Kositanont et al., 2003). The lep• prior to 1996. Yet, pulmonary complications tospires isolated from 14% of the rodents dur• seem to be more frequent and pulmonary hem• ing 1999 and 2000 were mostly bataviae and orrhage is the leading cause of death. Mi• pyrogenes serovars (Phulsuksombati et al., croagglutination test of serum samples from 2001). Leptospires were also isolated from patients revealed that the common serovars cows and buffaloes from the rice-fields. Re• were bratislava. sejroe and pyrogenes which search and development on rapid diagnostics were different from icterohaemorrhagia and and prevention and control ofleptospirosis are bataviae which were reported serovars in the being actively carried out in Thailand. past (Tangkanakul, 2002). However the most common serogroup of the leptospires iso• Scrub Typhus lated from patients' blood was autumnalis (Y. Suputtamongkol, personal communica• Scrub typhus is the most common rick• tion, June 2003). The case fatality rate varied ettsial infection in Thailand. It was first re• from 1% to 20%. The case fatality rate dur• ported in Thailand in 1952 (Thainua, 1952). ing epidemics has been 1% to 10% as shown Prior to 1984, less than 100 cases were re• in Figure 8. Penicillin G and doxycycline are ported annually. The number of patients with still the first line antibiotics used for ther• scrub typhus has been increasing steadily apy. Ceftriaxone has been demonstrated to be since 1985 as shown in Figure 9. This efficacious as well (Panaphut et ai., 2003). was due to an increased awareness and an 282 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND improvement in laboratory diagnosis. It is capita was 6132 US$PPP (purchasing power likely that many cases of scrub typhus prior parity). Income distribution and poverty to 1984 were reported as acute pyrexia of un• alleviation were among major government known origin. It should be emphasized that policies. Poverty reduction (in terms of the scrub typhus is a common cause of acute number of poor households) has been quite pyrexia of unknown origin, as mentioned ear• successful, but there has not been much lier. Cases were reported from all regions but achievement in improving income distribu• more cases have been observed in the north• tion. The discrepancy gap of income between eastern region, especially from the areas close the richest 10% to poorest 10% was 11.6. Data to Cambodia and in the central region; this ge• from the United Nations Development Pro• ographic distribution is similar to that of lep• gram's Human Development Report shows tospirosis. The disease usually peaks during that the gap between the richest 20% to poor• the rainy season of June and October. Most est 20% was 7.6, with a slowly improving of the cases are among male farmers. Clini• GIN! index of 41.4. In 2000 and 2001, per cal features of scrub typhus are protean, and capita GD P dropped to the level of 1992 (1846 eschar (scab) is found in 0-55% of the pa• USD). GDP growth in 1997 and 1998 was mi• tients (Sirisanthana and Poneprasert, 1989; nus 1.7% and minus 10.8%. The economic Supparatpinyo et al., 1990; Silpapojakul et al., recession had major negative consequences 1991). for all sectors of Thai society, including Some patients with unrecognized scrub the health sector (Tangcharoensathien et al., typhus may develop complications such 2000). as pneumonia, encephalitis, and meningitis. Since 2002, there have been promising Doxycycline has been the antibiotic of choice signs of economic recovery. GDP growth in for treating scrub typhus with a rapid clin• 2002 was 3.5% and was expected to increase ical response. However Orientia tsutsuga• to more than 5% in 2003. The economic cri• mushi is probably resistant to doxycycline; sis had a major impact on the social sector but this has been observed in patients living in a lesser impact on the health sector despite the northern part of Thailand (Watt et al., government fiscal constraints (Tangcharoen• 1996). Macrolides such as azithromycin could sathien et aI., 2000). be an alternative to doxycycline for treat• Thailand has achieved a medium human ing scrub typhus (Watt et al., 1999). The development level, as measured by Human case fatality rate over the past 6 years has Development Index (HDI), of 0.757 in 1999. usually been less than 0.5%, as shown in According to the UNDP's Human Develop• Figure 9. ment Report, there was a steady increasing trend of the HDI over the past two decades, rising from 0.603 in 1975 to 0.749 in 1995. DEVELOPMENT OF HEALTH Thailand achieved the rank of 74 in the global SYSTEMS IN THAILAND league table of HDI for 2001, with an index of 0.768. Life expectancy at birth in 2001 was The Socioeconomic and Health Context 68.9 years, the adult literacy rate was 95.7, the combined primary, secondary, and tertiary Thailand, classified by the World Bank gross enrollment ratio was 72, and GDP per as a lower-middle income country, had a re• capita US$PPP was 6400 (United Nations De• markable economic achievement during the velopment Program, 2003). 1980s to the mid 1990s. Gross Domestic Prod• Health achievement over the past two uct (GDP) per capita increased from 861 USD decades has also been also remarkable. A con• in 1986 to a peak of 3060 USD in 1996. The sistent reduction in total fertility rate (TFR) 1997 financial crisis in Thailand triggered the has been observed. The average TFR for Asian economic crisis. In 1999, the GDP per 1995-2000 was 1.9, with a contraceptive INFECTIOUS DISEASES AND THE DEVEWPMENT OF HEALTH SYSTEMS IN THAILAND 283 prevalence rate of 72% (Population Refer• adequate and sustained provision of financial ence Bureau, 2000). A health status pro• and human resources. Since the early 1980s, file indicated an infant mortality rate of the government has invested enormously in 26/100,000, an under five child mortality rate construction of 10 to 90 bed district hospitals of 30/100,000, and the maternal mortality rate in all districts. Subsequent policy also focused in 1980-99 was 44/100,000. The measles im• on full coverage of sub-district health centers munization rate for children aged one was as to adequately provide care to local popula• high as 94% and was sustained at this level tions of about 5000 Thais. By the 7th National for more than 10 years, while the percentage Socio-Economic Development Plan (1991- of births attended by skilled health staff in 1996), healthcare infrastructure accomplished 1995-99 was 95% (United Nations Develop• a very high geographical coverage (Ministry ment Program, 2003). of Public Health, 2001). By 2001, there were In terms of health care resources, there 92 hospitals in 75 provinces outside Bangkok were an average of 24 physicians per (25 regional and 67 general hospitals), 720 100,000 population for 1990-99. In 1998, the district hospitals in 795 districts (91 % cov• total health expenditure indicated that public erage), and 9738 health centers in 7255 sources comprised 1.9% of GDP, while pri• sub-districts (100% coverage). These infras• vate sources comprised 4.1 % of GDP (notably tructures served as important hubs for the household out of pocket). Per capita health ex• provision of integrated healthcare services penditure was 349 US$PPP. In 1999, the num• including prevention, promotion, and cura• ber of People Living with HIV / AIDS aged tive services throughout the country. Sub• 15-49 was 2.15%, along with 305,000 women sequently, these hubs also enabled social and 13,900 children 0-14. The adult infection mobilization towards good health. rate declined to 1.8% in 2001 (United Nations The public sector played a major role Development Program, 2003). in healthcare provision. In 2000, 67% of to• tal hospitals were owned by MoPH, 26% by Healthcare Delivery System the private sector, and 7% by other ministries. Some 64% of total hospital beds were owned Thailand has a pluralistic healthcare de• by MoPH, 22% by private sector, and 14% livery system. Though the public sector, no• by other ministries especially teaching hos• tably the Ministry of Public Health (MoPH), pitals. Private hospital bed share increased played a very key role in healthcare provision, from 13% in 1991 to 22% in 2000 due to the private sector, notably for-profit providers, increasing demand for private medical care. also played an increasing role especially Demand for private medical care was income in the urban cities. Private hospital sector elastic, and affected by the economic bust in growth has been significant due to increased 1998. Private healthcare market shrank signif• demand for private care among the mid• icantly after the crisis, and a shift of utilization dle classes, especially during the economic from private to public hospitals was observed boom. (Putthasri et ai., 2003). Since the five-year National Socio• It should be noted that local elected Economic Development Plan of 1981-86, governments (especially municipalities) were successive governments have placed a high comparatively weak in terms of healthcare importance on the development of the health• service provision, leaving the MoPH to play care system, especially in the rural areas at a significant role. A Devolution Act was district and sub-district level. A policy frame• promulgated recently to increasingly trans• work was laid out to achieve full coverage fer healthcare service responsibility to local of district hospitals in all districts through• elected governments, but local governments' out the country in three successive five-year readiness and capacity to handle healthcare plans. The policy was implemented through services remains in question. 284 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND

Private hospitals have expanded their AZT, and breast milk substitution. This re• services in more affluent areas, such as provin• flected the system's resilience to successfully cial cities and metropolitan areas. A symbiotic accommodate new programs in a short period. relationship between public and private hos• In 2003, district and provincial hospitals were pitals has been observed. Public doctors are major hubs for the provision of universal anti• allowed to have private practices during off• retroviral treatment. hours either in their own private clinics or in Healthcare services were organized in private hospitals. three levels to promote rational use of re• Since 1972, the government has enforced sources and to foster effective referral sys• a three-year mandatory rural service among tems. At the primary level, health centers pro• new medical, nursing, pharmacist, and den• vide primary care, and focus on prevention tal graduates. Young graduates are posted and promotion services, no hospitalization in district hospitals all over the country. services are available. At the second level, dis• Positive incentives are included, such as a trict hospitals, staffed by several general prac• hardship allowance, and non-private practice titioners, pharmacists, dentists, and a cadre incentives. Financial fines are levied against of professional nurses provide secondary care violators. This has significantly improved ac• including ambulatory, basic surgery, and hos• cess to quality medical services by the vast pitalization services. At the third level, provin• majority of Thailand's rural population. cial general hospitals staffed with special• District health systems, typically com• ists provide more sophisticated tertiary and prised of district hospitals and 8-10 sub• sub-specialty medical services. MoPH re• district health centers, contributed to the gional hospitals and teaching hospitals mostly remarkable achievements of the Thailand provide super-specialty care through referral National Family Planning policy in the last 25 systems. years, as evidenced by the low TFR and a very high contraceptive prevalence rate. Nurses, Human Resources for Health midwives and doctors were trained to pro• vide temporary and permanent methods of The government finances the education contraception through static clinics and mo• of most categories of health professionals bile campaigns. District health systems also including physicians, dentists, pharmacists, contributed to the achievement of high im• nurses and other paramedics, through general munization coverage, significant reduction of tax revenue. Student's tuition fees are low and vaccine preventable diseases, and mortality do not reflect the true cost of education. Pri• among children under age five. District health vate nursing colleges play a very minor role systems also serve as a major hub for disease in producing nurses. One difficulty is a na• surveillance, integrated control of diseases, tional policy that fails to understand the de• and primary health care implementation. mand for manpower in the private sector. In District health systems have played a sig• addition, there is neither a clear national pol• nificant role in mv/ AIDS control and pre• icy toward private sector growth nor a strong vention, voluntary counseling and testing, pri• regulatory capacity to steer and maximize the mary prevention, safe sex campaigns, and contributions of the private sector. As a result, treatment of opportunistic infections. It took there has been an internal brain drain of well• only one year to scale up the Vertical Trans• trained public Thai healthcare professionals mission Prevention Program of HIV through• toward the private sector, especially during out the country in 200 1. Success factors were the economic and private hospital boom pe• high antenatal care coverage, geographically riods. The heavy workload and relatively low accessible health centers, medical teams who pay scale and incentives in the public sector, provide counseling services, distribution of contrasted with lower workload and higher INFECTIOUS DISEASES AND THE DEVEWPMENI OF HEALTH SYSTEMS IN THAILAND 285

TABLE 1. Top Twenty Conditions that Contribute to DALY in Thailand

Rank Male DALY DALY % Female DALY DALY %

mY/AIDS 960,087 17% mY/AIDS 372,947 9% 2 Traffic accidents 510,907 9% Stroke 280,673 7% 3 Stroke 267,567 5% Diabetes 267,158 7% 4 Liver cancer 248,083 4% Depression 145,336 4% 5 Diabetes 168,372 3% Liver cancer 118,384 3% 6 Ischemic heart disease 164,094 3% Osteoarthritis 117,994 3% 7 COPD (emphysema) 156,861 3% Traffic accidents 114,963 3% 8 Homicide and violence 156,371 3% Anemia 112,990 3% 9 Suicide 147,988 3% Ischemic heart diseases 109,592 3% 10 Drug dependence 137,703 2% Cataracts 96,091 2% 11 Alcohol dependence 130,654 2% COPD 93,387 2% 12 Cirrhosis 117,527 2% Deafness 87,612 2% 13 Lung cancer 106,120 2% Lower respiratory tract 84,819 2% infections 14 Drowning 98,464 2% Low birth weight 83,879 2% 15 Depression 95,530 2% Dementia 70,191 2% 16 Osteoarthritis 93,749 2% Anxiety disorders 66,992 2% 17 Tuberculosis 93,695 2% Schizophrenia 60,800 2% 18 Deafness 93,497 2% Tuberculosis 60,643 2% 19 Low birth weight 91,934 2% Birth trauma and asphyxia 57,488 1% 20 Anemia 87,610 2% Nephritis and nephrosis 55,258 1% Total top 20 3,926,813 70% 2,457,197 62% Total national 5,600,000 100% 3,980,000 100%

Source: Ministry of Public Health, Thailand, 2003b

pay in the private sector are primarily respon• Leptospirosis comprise an unfinished agenda sible for this internal drain. So far there has of infectious diseases, while maternal and been no effective mechanism to prevent and child health and nutritional problems have mitigate this brain-drain problem. Policy so• been significantly addressed. lutions focus on a systematic analysis of part• A recent study on burden of disease time and full-time manpower arrangements (BOD) in 1999 estimated a total number of5.6 between the two sectors. However, this so• million Disabled Adjusted Life Year (DALY) lution faced very rigid bureaucratic rules and losses among men, and 4 million DALY losses regulations. among women (Ministry of Public Health, Thailand 2002). The top ten leading causes Burden of Diseases account for 52% and 44% of total national burden among men and women (Table 1). For the past 25 years, the development In 1999, the three leading causes of of Thailand's healthcare system focused on DALY among men were HIY/AIDS, traf• physical service expansions. There was an ur• fic injuries, and stroke. Among women, gent need to look at how healthcare could HIY/AIDS, stroke, and diabetes were three better cope with the changing epidemiolog• leading causes of DALY. Many of these causes ical profiles and burden of diseases. Rapid are preventable by primary reduction of risks, epidemiological transitions have occurred in notably through safe sex, effective traffic in• Thailand, as the burden of disease shifts jury prevention, and tobacco consumption from communicable to non-communicable controls. and lifestyle-related diseases. HIY/ AIDS, Tu• Three major risks contributing to Thai• berculosis, Dengue hemorrhagic fever, and land's BOD were unsafe sex, alcohol, and 286 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND tobacco among men, unsafe sex, high blood as there were no government regulations. In pressure, and overweight including obesity 1981, exemption was implemented through a among women (Ministry of Public Health, formal mechanism of means-testing for the 2003a). Alcohol was the second contribut• issuance of a free care card for low-income ing risk factor for BOD among men. It can households; an annual earmarked budget for lead to domestic violence, major economic free care to the poor was allocated to public and life loss, and disability due to alcohol health facilities. One article in the Thai Con• related injuries. Recent campaigns against stitution stipulated clearly the government's drunk driving were not particularly successful responsibility to ensure the poor access to free and tougher law enforcement was required. care when needed. Despite a decreasing trend in tobacco con• Past governments employed a "piece• sumption due to successful public campaigns meal targeting approach" to increasing cov• and tough law enforcement, the high preva• erage for specific target population groups, lence of tobacco consumption in the past starting first with a tax-financed Social Wel• decades indicates that tobacco was the third fare Scheme for the poor (Tangcharoensathien and fourth major contributing factor for BOD et at., 2003). This is a means-testing scheme in Thailand. for low-income households. In 1992, the In summary, increasing Thailand's Scheme expanded to cover all elderly Thais healthcare system capacity to effectively over age 60, acknowledging the population's cope with chronic diseases such as diabetes, lack of cash income to access healthcare. hypertension, and cardiovascular diseases is Children under age 12 were another targeted a major millennium challenge. In addition, population for expansion in 1994. Though enabling the system to provide primary local leaders participated in the means• prevention and risk reduction through social testing exercises and recommended eli• mobilization and behavior modification gible households to the district authorities, programs are further challenges, requiring a due to nepotism at the very local level, the new mix of skills, attitudes and conceptual scheme neither adequately covered the real thinking among Thai healthcare workers and poor nor effectively excluded the non-poor policymakers. from enjoying the Scheme (Tangcharoen• sathien et aI., 2003). Financing Healtbcare, Insurance Introduced in 1983, the Voluntary Health Coverage, and Recent Reform toward Card Scheme covers borderline populations Universal Coverage who were not eligible for the social welfare scheme due to their income. This scheme Early in Thailand's healthcare history, has not performed well in term of coverage user charges to patients were introduced and expansion and financing viability due to its culturally accepted by patients. In the past, structure. The voluntary nature of the scheme user charges were made on a voluntary ba• results in "adverse selection", whereby the sis through donation boxes or contribution in sick participate and the healthy opt out the kind; subsequently charges became more for• scheme. This results in financial non-viability malized as bills. Revenue generated through in spite of more than 50% government subsi• user charges is kept at facility level to im• dies. Stagnated coverage expansion has been prove services. Non-budget revenue played a observed. significant role in financing healthcare facili• Introduced in 1990, the Social Security ties. The government's policy on charging pa• Scheme (SSS) covers private sector employ• tients has been accompanied by an exemption ees. This is a tripartite (by the employee, policy for the poor. Exemption started first in the employer and the government) contribu• 1975, at the discretion of health care workers, tory scheme legislated in 1990. It gradually INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 287 expanded coverage from private enterprises the population was not covered by any health• having more than twenty workers to ten, to care policy (Tangcharoesnathien et at., 2001). five, and finally to one employee by April By October 2001, three major public schemes 2002. Unfortunately, beneficiaries are only were covering the entire 62.5 million popula• the workers; to date no serious efforts have tion, the UC, the CSMBS, and SSS. Figure 10 been made by the social security administra• depicts the relationship among the three par• tion to expand its healthcare coverage to work• ties concerned-the insurance or purchaser ers' spouses and dependents, despite huge agencies, the beneficiaries and patients, and surpluses of the social security fund. The the public-private health care providers. Flow strengths of the scheme were the application of funds and services among these three stake• of a capitation contract model. It could very holders clearly illustrates their relationship well contain healthcare costs, with simple and (Tangcharoensathien et at., 2002). low administrative costs. Decent quality of The design of the benefits package and care was provided to the social security work• magnitude of the budget subsidy endorsed ers though "cost-quality trade off" was one of the "convergence principle" of closing down the major weaknesses of the capitation sys• the existing gap of inequity among the three tem. public insurance schemes (CSMBS, SSS and The employer liability Workmen Com• UC). Table 2 shows the trend of healthcare pensation Scheme, the predecessor of the So• financing during 1995-2000 (WHO, 2002). cial Security Scheme, was designed to cover WHO referred to National Health Account the work-related illnesses, injuries, disabili• studies in 1994, 1996 and 1998 (Tangcharoen• ties, and death compensation to private sector sathien et at., 1999; Pongpanich et at., 2000), employees. Employer contributions were for• and reports on Thailand Health Profile (Min• mulated to account for the risk of each indus• istry of Public Health, 2001). Total Health ex• trylbusiness, plus an experience rate. Experi• penditure ranged 3.4% to 3.7% of GDP in ence rate was meant to be a financial incentive 1995 to 2000. Government expenditure on (and vice versa disincentive) to encourage health as percent of total health expenditure employers to introduce safety measures, but increased from 48.9% to 57.4% in this period, it was unsuccessful (Chunharas et at., 1999). as private expenditure on health declined. A tax financed Civil Servant Medical When its targeting policies were ex• Benefit Scheme (CSMBS) generously cov• hausted, Thailand boldly adopted a policy of ers current public employees, retired officials, universal healthcare coverage. With strong and their three generation dependents, includ• political will by the major party-led coali• ing spouses, parents, and three children un• tion government, Thailand adopted universal der age 20. This was a non-contributory wel• healthcare coverage (UC) in October 2001. fare scheme. Inefficiency and poor financing The UC incorporated the Social Welfare value was observed in CSMBS, as it applied a Scheme, the Voluntary Health Card Scheme, "fee for service" retrospective reimbursement and the uninsured into a single form of cover• model. age, to be financed by general tax revenue. It During the past ten years of govern• applied a low cost capitation contract model ment efforts on coverage expansion, human for ambulatory care, whereby beneficiaries resources were strengthened, experience was were required to be registered with a provider, gained in insurance management, and lessons typically with a district health system (OECD, were learned about the strengths and weak• 1994). It also applied a global budget and nesses of different provider payment methods, case-mix (diagnostic related group) for inpa• notably fee for service and capitation mod• tient services. A nominal payment (30 Baht, els. Despite efforts made during the past 20 approximately 70 US cents) per ambulatory years, prior to October 2001, almost 30% of visit or admission at point of service was 288 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND

Civil Servant Medical Benefit General tax Scheme (Min of Finance) (7 millions beneficiaries) Standard Benefit Package General tax National Health Insurance Office, (45 millions of general population) across scheme (not Tripartite achievement contribution. Social Security Office. at present) Pay roll tax (10 millions of formal private employee)

Ri.. " ."I.. t"r! --..r Private voluntary 1 contribution l insurance J

I I Capitati n Public& Private Capitation contractor network Pop ~ Primary care------Hospital care r Global budget for Patients ~ IP using ORG ~'- -

Fee for services

Fee for services -op

FIGURE 10. Model of health insurance system in Thailand. 2002 (Tangcharoensathien et al .• 2(02) introduced, and again, the poor were ex• Benefit Incidence Analysis. Several national empted from this nominal fee. databases and household interview surveys are conducted by the National Statistical Future Challenges Office to provide evidence for policy moni• toring and modification. UC might significantly change the pro• The low cost capitation contract model file of Thailand's healthcare financing from applied by both the Social Health Insurance the dominant role of household out-of-pocket plan in 1990 and more recently by the UC payment towards tax funded public health in• Scheme provided an enabling environment surance. Policy makers expect to see a dimin• towards a more efficient healthcare system ishing proportion of households facing catas• with rational use of resources. However, the trophic illnesses. However, researchers need possibility exists of a "cost quality trade• to monitor the beneficiaries of public spend• off" of providing inadequate and poor ser• ing, whether they are rich or poor, through vices, under-prescription, and postponement INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND 289

TABLE 2. National Expenditure on Health in Thailand, 1995-2000, Current Year Price

Expenditure ratios & per capita levels 1995 1996 1997 1998 1999 2000

Total Expenditure on Health (THE) % GDP 3.4 3.6 3.7 3.9 3.7 3.7 Government Expenditure on Health (GGHE) % THE 48.9 51.1 57.2 61.4 58.3 57.4 Private Expenditure on Health (PvtHE) % THE 51.1 48.9 42.8 38.6 41.7 42.6 GGHE % General Government Expenditure (GGE) 8.1 9.6 10.9 13.3 11.4 11.4 Social Security Expenditure on Health (SSHE) 26.5 27.9 30.2 25.8 26.3 26.4 %GGHE External Resources funded Expenditure on Health 0.2 0.6 0.5 0.7 0.9 0.9 (ExtFHE) % GGHE Private Prepaid Plans Expenditure on Health 7.6 7.8 8.6 9.7 9.7 9.6 (PvtPPHE) % PvtHE Net Out-Of-Pocket Spending on health (OOPS) 44.7 42.6 36.9 32.7 35.3 36.2 % THE THE per capita at Exchange rate (US$) 97 110 93 71 73 71 GGHE per capita at Exchange-rate (US$) 47 56 53 44 43 41 THE per capita at International Dollar rate ($) 210 237 242 228 229 240 GGHE per capita at International Dollar rate ($) 103 121 138 140 133 138

Source: Vasavid et aI., 2003 of elective surgeries. This threat warrants other countries as they cope with emerging prompt policy attention toward quality mon• HIV/AIDS issues. itoring, accreditation of healthcare institu• It is important to accelerate surveillance tions, and audit. However, the geographical of different phases of the disease as much as monopoly whereby consumers had no choice possible. In Thailand, the first government ap• but their local District Health System, chal• proach was one of denial of the possible con• lenges attempts for tougher measures on qual• sequences, and took about five years. Part of ity. This requires a strong grievance mecha• this time was spent performing seroepidemi• nism and monitoring of performance among ology on a handful of cases in men having sex contractors. with men (MSM). A few small-scale studies Health systems need to address prior• showed low levels of prevalence among male ity health problems indicated by BOD mea• sex workers. Later studies found high inci• surements. Social mobilization and empow• dences in female sex workers in the Northern erment of individuals and communities are province. Ideally, primary phases of surveil• the most crucial tools to increase societal mo• lance should be shortened through improve• mentum towards a healthy life style, physi• ments of the surveillance systems. cal fitness, and mental well-being. Additional A cohesive understanding of the extent to government strategies include legislation and which HIV/ AIDS can cause social, economi• law enforcement to provide a favorable, cal, ethical, legal, and international issues as healthy, and safe environment for all Thai well as medical and health problems, must be citizens. developed. Top-level policymaking is also a highly desirable objective. One mechanism may be a LESSONS LEARNED FROM AIDS national AIDS policy commission. Top politi• cians may lead this commission; in some Thailand's knowledge ofHIV/AIDS has countries, the prime minister may head this increased significantly over the course of the committee. Alternately, a Minister of Pub• epidemic. The following are some of the most lic Health or Minister without portfolio may important lessons that can be instructive to be asked to lead the commission. It is very 290 INFECTIOUS DISEASES AND THE DEVELOPMENT OF HEALTH SYSTEMS IN THAILAND important to put such a commission in place REFERENCES as early as possible. The composition of a National AIDS Barnrungtrakul, T., Sunakorn, P., Sareebutara, W, Vejab• policy commission will have to be di• huti, A., Lochindarat, S., Teeraratkul, A., Kittikhun, P., Pinyosmosorn, R., Wasanawat, S., Darnswang, verse, and include representatives of non• S.A., Chupuppakarn, S., Kusum, M., and Dejsirilert, governmental organizations (NGO), and oth• S. (1994). 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