UN Resident Coordinator ResCor Thailand

Political, socio-economic, environmental, technological, demographic and epidemiological changes now taking place are posing unprecedented health challenges for Thailand. The most recent political reform movement has resulted in a new ‘people's version’ constitution. This constitution not only places health, as a basic human right high on the national agenda, but most important of all, it allows for capacity building, empowerment, and creation of enabling environments for local communities to play active and constructive roles in health and overall socio-economic development.

Thailand's past economic growth was achieved mainly through rapid development of manufacturing industries at the expense of agricultural industries. This rapid industrialisation, especially during the past decade, also drew in more than 1 million migrant workers from Myanmar, and Southern China, some carrying re-emerging infectious diseases like Filariasis.

However, the end of this rapid economic growth came abruptly in mid 1997, with the rapid devaluation of the baht, the shrink in economic growth, unemployment, and the reduction in public budget allocations including the health budget. The current economic crisis poses great challenges and opportunities for the health sector. The main issue is how to reserve the safety net for vulnerable groups, especially women, the young, the aged, and the poor. Economic development was achieved with resultant socio-environmental deterioration. Wide spread prostitution facilitated the spread of HIV. Urban air pollution as well as pollution of major rivers remain as unsolved problems. There are also higher incidences of crimes, violence, drug addicts, and suicidal attempts, especially since the abrupt economic downturn.

This CCA health cluster explored the comparative advantage of UN agencies in taking on a catalytic role in engaging new partnerships in health development. Issues were selected that lend themselves to co-operation, need the participation of a wide range of players, and have the potential for successful implementation with distinctive products. Our aim was to focus attention sequentially on selected issues with the intent of developing a shared agenda of concern among participating agencies, both international and local. The paradigm of health development in Thailand has shifted from the routine needs of a developing country to the multi-dimensional concerns of an advancing developing country.

An integral part of that shift have been very real success stories in the general area of health. Thailand has more than met all the basic targets for reproductive health, mortality and fertility reduction that have been set through the UN’s Global Agenda. Contraceptive prevalence rates are among the highest in Asia even if the gender balance of responsibility still leaves much to be desired. There have been significant advances in nutrition too over a relatively short period. Despite the very real progress that has been achieved in these areas, there is no room for complacency and the crisis brings the danger for retrogression. Nevertheless, the Health cluster chose to focus on those key challenges that remain while bearing in mind the importance for continued vigilance in those challenges that have already been met. Those concerns are reflected in the issues selected for this cluster group: emerging and re-emerging health problems, health care financing, quality use of drugs, and narcotics and substance abuse.

Emerging and Re-emerging Health Problems

The emergence and re-emergence of diseases and health problems is now prominent on the health agenda of virtually all countries and international agencies. Major diseases such as malaria and tuberculosis are making a deadly comeback in many parts of the world. At the same time, diseases such as plague, diphtheria, dengue, meningococcal meningitis, yellow fever and cholera have reappeared as public health threats in many countries, after many years of decline. The appearance of new diseases, such as Human Immunodeficiency Virus (HIV) and the new strain of cholera (cholera 0139) have raised serious concerns worldwide. Other emerging and re-emerging health problems include non-communicable diseases (e.g. heart disease and cancer), mental illness, accidents and injuries, violence and health consequences of environmental degradation. The spectrum of these health problems is changing rapidly in conjunction with dramatic socio-economic and ecological changes. Environmental degradation, combined with uncontrolled urbanisation, population movement, increased industrialisation, mutation of infectious agents, together with vector-resistance to insecticides, all are factors contributing to the increase of diseases.

Although there have been certain important successes in controlling the incidence of HIV infection in Thailand, the large reservoir of asymptomatic infections, nearly 1 million, gives rise to serious concern for the future incidence of AIDS. As of June 1998, the number of AIDS cases reported was 86,210. The TB problem in Thailand was thought to be under control until the advent of the AIDS epidemic in the country. TB is the most common opportunistic infection associated with AIDS. The number of newly detected TB patients reported in the six upper-northern provinces show a steady upward trend since 1991, along with a mortality rate of approximately 30 percent among HIV infected TB patients. Multi-drug resistance is now appearing with alarming frequency. The TB Division of the Ministry of Public Health is expanding the number of provinces using DOTS (Directly Observed Therapy, Short Course) in an effort to ensure proper dosage treatment for TB patients.

The problem of malaria was considered diminished in Thailand, but in the past two years the number of cases has again increased. The main endemic areas are along the Thai-Myanmar and Thai-Cambodia borders. In 1997 alone, there were 99,676 malaria cases reported among Thai citizens and 66,222 cases among foreigners, most of who were illegal immigrant labourers. Other communicable and non-communicable diseases continue to pose a threat to public health in Thailand. Examples include dengue haemorrhagic fever, lymphatic Filariasis, heart disease, etc. Protective and preventive measures undertaken to control vector borne diseases include distribution and use of impregnated bed nets and repellents in highly endemic areas.

Thailand has an effective disease surveillance programme to monitor the status of disease epidemics. Cases are reported on a weekly basis. Certain diseases, such as those that are internationally notifiable or those that have epidemic potential, are reported more frequently. A system is being designed to recognise, investigate and identify new, emerging and re-emerging diseases. International agencies’ support is needed to enhance the country’s capacity to respond to various global diseases, in particular emerging and re-emerging health problems, as well as to strengthen the scientific capability for disease research and disaster preparedness at the national level.

Quality Use of Drugs

Essential drugs, those that are cost-effective and widely used to tackle major health problems, are a critical and integral component of health care; drugs are not developed, produced, supplied or used in isolation. The national drug system is closely linked with the overall national health and socio-economic systems. Programme identification of the quality use of drugs is in conformity with the WHO Executive Board priority area covering Essential Drugs and Vaccines.

Thailand has since 1981 been implementing a national drug policy that includes activities ranging from availability of essential drugs, strengthening of drug legislation and regulatory control, quality assurance and systematising drug supply. The current changing trends of pharmaceutical and global markets signifies the need of health care providers and the public to become more aware of the rational use of drugs. Consideration of this area would complement the national drug policy and focus on the proper selection and use of pharmaceuticals, the prescribing practices of physicians and the sale and trade of pharmaceutical products. It is unfortunate that the profit potential of pharmaceutical products is a powerful determinant of their misuse, e.g. underuse of essential drugs, misuse of antibiotics, and over-sell of high profit drugs.

Over 30,000 drug products are registered for use in Thailand. Of this amount, 85% are categorised as modern drugs, 13% as traditional drugs, and 2% as psychotropic and narcotic substances. The percentage of drug expenditure in proportion to total health expenditure is estimated at 35%, which is rather high when compared to neighbouring (Philippines, Indonesia) and developed countries, which range from 8 to 20%. Besides the prescribing and selling of pharmaceuticals in hospitals and clinics, drugs are available in over 12,000 registered drugstores (pharmacies) and at over 300,000 village groceries, the latter category selling primarily household remedies.

The above scenario poses a heavy burden for control and monitoring. The drug information system is not fully developed and needs to be further updated for monitoring and decision making purposes on the part of medical practitioners and consumers. A number of areas should be addressed to provide equitable access to safe, good quality and effective drugs. Selection of drugs at the national, institutional and household levels can be improved by strengthening use of generic name drugs, increasing the efficiency of the drug registration process, and revising the list of designated household remedy formularies. Improvements in quality determination for imported drugs and R&D and GMP situation for locally produced drugs should be implemented. There is a need for monitoring of the pharmaceutical procurement, storage and distribution management systems. This would include re-examination of drug pricing and marketing mechanisms as well as policies and practices on commissions.

There should be a reorientation of prevailing practices concerning drug prescriptions and sales to reduce pharmacy or drugstore prescriptions and to reduce sales of drugs by doctors at clinics and hospitals. Thai traditional and herbal medicine should be developed in terms of R&D, industrial production and international marketing.

Health Care Financing

The Thai health care financing system is complex in terms of fund flows and role of the government. During the past three decades there were movements and policies towards more collective financing and social welfare for labourers, the poor, the elderly and children. Some form of health insurance, mainly public insurance, covers greater proportions of the people. At the same time, health expenditures are increasing at a higher rate than the economic growth. The proportion of health expenditure to GDP rose from 3% in the 1970's to 4.6 % in 1983 and showed a further increase to 5.9% of total GDP in 1992. With the recent economic crisis and predicted negative economic growth over the next two years, the estimated share of 8% of GDP on health in the year 2000 is quite possible. The macro picture of health care financing raises many critical questions: whether Thailand spent too much or too little on health; whether the government has increased or decreased its share of total health spending and; whether there is an increase in universal coverage indicating that the government is concerned with equity of access to, and use of, health services.

Sources of Thai health care financing can be classified into five major groups: (a) Ministry of Finance (MOF) provides funds to Ministry of Public Health (MOPH), other ministries, and local governments and also acts as the financing agency responsible for the Civil Servant Medical Benefit Scheme (CSMBS); (b) State enterprises which act as both ultimate source and financing agencies providing fringe benefits to their employees and dependants; (c) Employers contribute to the Social Security Scheme (SSS) and Workmen Compensation Scheme (WCS) and also provide medical benefits to their employees; (d) Households act as both ultimate source and financing agencies; and (e) Donor organisations play a minor financing role through the MOPH and other ministries. In 1994 there was a total budget of 141,818 million Baht available for health, largely financed by households (49.3%) and MOF (45.7%). In total, 12 financing agencies were responsible for the total health expenditure which was 128,305.11 million Baht in 1994 (with an unspent budget of 13,512.96 million). Seven agencies are classified as public source, while five are classified as private sources. In 1994, 84.07% of total health expenditure (or 3,00% of GDP) was spent on consumption expenditures while 15.93% (or 0.57% of GDP) was spent for capital formation. Of the total health expenditure of 128,305 million Baht in 1994, households paid 44.38%, MOPH 28.56%, CSMBS 7.76%, local government 4.34%, other ministries 3.8%, and Social Security 2.7%, respectively. Overall, the ratio of private and public sources of funding in the total health care budget changed from 32:68 in 1983 to 46:54 in 1994. With high proportions of out-of-pocket payments, the coverage of health benefits in Thailand is not universal. In 1991, the first national survey on health benefits by the National Statistical Office (NSO) showed that two-thirds of the total population were not covered by any benefit scheme. Five years later, about one-third of the population was not covered. This was the result of the increases in coverage under the Low Income Card Scheme (LICS), the Voluntary Health Card Scheme (VHCS) and the Social Security Scheme. The coverage under the LICS increased again in 1997, however the budget per capita for the LICS remained unchanged despite low cost recovery.

Information on health expenditures is crucial for health care financing policy development and monitoring. The National Economic and Social Development Board (NESDB) of Thailand is the major data collector on health care financing. There is a concern over the validity of NESDB indirect estimation methodology in using the drug and non-drug approach, and its inability to produce useful breakdowns of expenditures which are important in a pluralistic health care system. In addition, data on insurance coverage from the National Statistical Office Household Socio-Economic Survey (SES ) showed discrepancies when compared with the NESDB data on expenditures and sources of finance. To improve data quality for health care financing monitoring, planning and policies, sustainable National Health Account development and utilisation is preferred. Inefficiency in the Thai health care system can be explained partly by the over-compartmentalisation of sources of finance. The government itself runs 5-6 big health-related insurance and welfare schemes under various organisations with different benefit packages and levels of public subsidy. In addition, all levels of public hospitals and health centres are financed from the government budget to cover their operating costs, capital investments, and various health programmes. Too many sources with different subsidised levels of finance create duplication and inequity. Different payment mechanisms of insurance and welfare schemes together with an unclear criteria of resource allocation for health services result in varying incentives for providing care to different insurance coverage groups and less incentives for improving their performance. New financing schemes developed within the last decade have been designed to extend coverage to needy populations by using public resources, thus creating additional flows in the financing system. However, household out-of-pocket payments are still the major part of total health expenditure, which reflects the need for the government to link critically the fundamental issues of health care financing.

Reproductive Health

The new Reproductive Health Policy of Thailand, was announced as a grouping of 10 elements in July 1997, but has not yet been implemented in terms of the delivery of an integrated and holistic package of reproductive health services. Although Thailand has achieved remarkable success in population and family planning (Population Growth: 1960s = 3.5 per cent, 1998 = 1.1 per cent. Total Fertility Rate: 1984 = 3.5 children per woman, 1998 = 1.98 per woman), several reproductive health challenges remain.

The Contraceptive Prevalence Rate (CPR) among married couples is about 75 per cent. However, since services have traditionally been directed towards married women, there is an unmet need for family planning and other reproductive health services among single women, men, adolescents, youth and other under-served population groups. Male methods of contraception are not widely used, with condoms and vasectomies accounting for only 0.5 per cent and 1.9 per cent, respectively, of total contraceptive use. These figures indicate that a better understanding is required of the cultural, social and economic factors that underlie gender differences and their impact on reproductive health.

The unmet needs in reproductive health are further reflected in the high incidence of teenage pregnancies, which account for14.7 per cent of births. The number of abortions is also high. The Foundation for Women in Thailand has estimated the number of unwanted pregnancy terminations at 200,000-300,000 per year or about 1 for every 3 live births. Finally, the HIV/AIDS infection among youth is high with 50 per cent of the cases of HIV/AIDS falling into the 15-25 age group. The number of HIV infected pregnant mothers is also alarming at 1.8 per cent with an estimated 6,000 new AIDS orphans each year. The percentage of Sexually Transmitted Disease (STD) cases in the reproductive age group (15-44 years) usually accounts for more than 90 per cent of all STD cases with about 40 per cent of these cases found in the 15-24 years age group. Among this percentage, male cases outnumber those of their female counterparts. Commercial sex workers comprise the largest group of diagnosed STD cases.

Adolescents and youth comprise nearly 28 per cent of the population, however, their access to reproductive health information and services is very limited. There is an urgent need to improve sex education and family life programmes including counselling in schools starting from late primary to secondary levels. Timely and accurate data on teenage pregnancies and abortions is required. Thus increasing equitable and widespread access to information and services, and improving the quality of reproductive health care, are important challenges that need to be addressed in Thailand.

Narcotics and Substance Abuse

All countries are affected by the devastating consequences of narcotics and substance abuse. Rapidly changing social and economic circumstances and the global availability of, and rising demand for, illicit drugs have been major contributing factors to the increasing magnitude of this global problem. According to UNDCP's estimates, annual illicit drug consumption is likely to involve 3.3 - 4.1 per cent of the world's population, making the illicit drug industry worth US$ 400 billion per year - nearly double the revenues of the global pharmaceutical industry.

In Thailand, the situation continues to be serious for both the demand and supply sides. The 1996 provincial data collection showed that almost half of the villages/communities throughout the nation faced drug problems where metamphetamine, marihuana, volatile substances and heroin have been the major drugs of abuse (see figure 1).

While truck drivers, agricultural labourers and workplace employees remain the major groups of drug abusers, in-school and out-of school youth have been increasingly engaged in drug use and now become the new but most vulnerable group in society. Results of urine testing of 118,375 school students nation-wide by the Ministry of Education and the Office of narcotics Control Board (ONCB) in 1996 revealed that 1,375 (i.16 per cent) were using amphetamines. Records of drug treatment centres also indicate a high number of students among other patients (see figure 2).

On the supply side, despite remarkable success in the decrease of poppy cultivation in the country, heroin and metamphetamine have continued to be smuggled in from neighbouring countries. It was estimated that 100 million tablets of metamphetamine were smuggled into Thailand in 1997 and that only 20 per cent of them were seized (see seizure record in figure 3).

Regarding drug trafficking, Thailand has been an important trafficking route of illicit drugs to regional and international markets. Apparently, owing to the economic downturn, the country has observed an increase in drug use and trafficking. People suddenly faced with unemployment and few income-earning opportunities have turned to drugs either as an escape or as a means to earn extra income. Migrants who have experienced drug use may aggravate the problem when they return to rural areas. On the other hand, Thailand also affords a relatively attractive location for financial operations that is conducive to money laundering by drug traffickers.

While concerns over narcotics and substance abuse have become more widespread, the subject has not yet been fully integrated in the mainstream development agenda. Neither has it been directly addressed under the Eighth National Economic and Social Development Plan. The country has implemented several programmes to combat drug problems including active participation in sub-regional and international co-operative activities. National level plans, implemented by various agencies and co-ordinated through the ONCB are designed to integrate enforcement, treatment, public awareness and demand reduction programmes. The challenge ahead would thus be whether the current approach and resource availability are capable of handling this critical problem effectively. Some priority aspects requiring greater efforts and proper attention of all agencies concerned would include the following:

There are currently limited data and documentation that can provide a comprehensive picture of the drug situation, resulting in more difficult and less effective planning and implementation of drug control efforts. The most frequently referred data/information compiled by the Thailand Development Research Institute (TDRI) in 1993, has become outdated and therefore less reliable. A systematic and comprehensive study as to the type of drugs, the type and number of users, the extent and patterns of drug use as well as the place of sale/use, will need to be conducted and updated periodically. Good monitoring systems will also have to be developed to keep tract of the extreme/ rapid mobility and flexibility of drug trading networks.

Number of provinces applying Directly Observed Therapy, Short Course (DOTS) for TB patients
Degree of compliance with generic labelling/advertising
Total health expenditure (Total Baht, per capita, % of GDP, and private/public mix)
Types of health expenditures
Health cost inflation rate in relation to other sectors
Proportion of births attended by trained health personnel
Number of seizures and total quantity of seized controlled drugs per annum
Estimated number of drug abusers by sex, age, occupation, and main drugs of abuse

Impact of the various diseases on the socio-economic situation of the country as reflected in the number of work-days lost and in the costs of treatment and care
Coverage of distribution of impregnated bed nets and repellents
Updated national essential drugs list
Number of factories employing Good Manufacturing practices (GMP)
Volume of prescription drugs distributed through hospitals, clinics, pharmacies and other centres
Registration of traditional medicine practitioners
Sources of finance for the health sector
Total health benefit coverage
Classification of seized controlled drugs by type, price and purity

UN Common Country Assessment
Thailand,1997-1998

Chapter 4 : Health

Contents

Introduction

Emerging and Re-emerging Health Problems

Quality Use of Drugs

Health Care Financing

Reproductive Health

Narcotics and Substance Abuse

Dated: 26Jan1999

UN Common Country Assessment Thailand,1997-1998

Chapter 4 : Health

Contents

Introduction

Emerging and Re-emerging Health Problems

Quality Use of Drugs

Health Care Financing

Reproductive Health

Narcotics and Substance Abuse

Dated: 26Jan1999

UN Common Country Assessment
Thailand,1997-1998