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Phusit Prakongsai, MD. Ph.D.Walaiporn Patcharanarumol, MSc. Ph.D.

Viroj Tangcharoensathien, MD. Ph.D.International Health Policy Program (IHPP) - Thailand

Presentation to the World Bank workshop on ‘Managing Vulnerability in East Asia and the Pacific’

-2426 June 2008The Siam City Hotel

How to design and implement effective public health to prevent and mitigate

the impact of disease: experiences from Thailand and beyond

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Outline of presentation

• Burden of disease in Thailand in 2004• Two examples of public policies and disease

prevention in Thailand:– Control of tobacco consumption in Thailand– HIV/AIDS

• Health expenditure in Thailand in 2001 and 2005

• Innovative financing on health promotion• Conclusions and policy recommendations

Disability adjusted life years (DALY) loss in Thailand

by three major categories in 2004

Total = 9.9 Million DALYs (Males: 5.7 , Female: 4.2)Group I Infections, maternal, perinatal and nutritional conditions = 2.1 Million DALYsGroup II Non-communicable diseases = 6.5 Million DALYsGroup III Injuries = 1.3 Million DALYs

Male Female

Group III, 1.0

Group II, 3.4

Group I, 1.2

Group III, 0.3

Group II, 3.1

Group I, 0.9

Source: Thai Burden of Disease (BOD) Study

Top ten: DALY loss in Thailand in 2004

Top ten: DALY loss in Thailand in 2004

% of Total 52.6 42.8

Rank DiseaseDALY('000)

% %DALY('000)

Disease

1 HIV/AIDS 645 11.3 7.4 313 Stroke2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS3 Stroke 332 5.8 6.4 271 Diabetes4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease6 COPD 187 3.3 3.0 125 Traffic accidents7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer8 Diabetes 175 3.1 2.8 118 Osteoarthritis9 Cirrhosis 144 2.5 2.7 115 COPD

10 Depression 137 2.4 2.6 111 Cataracts

Male Female

DALY

Source: Thai Burden of Disease (BOD) Study

Prevalence of regular smoking in Thailand from 1991 to 2006

30.46

25.3622.47

19.47 18.94

0

5

10

15

20

25

30

35P

reva

len

ce o

f re

gu

lar

smo

kin

g (

pe

r 1

00

p

op

ula

tion

)

1991 1996 2001 2004 2006

2

2.11

2.42

2.97

4.6

36.91

37.16

42.93

49.21

55.63

0 10 20 30 40 50 60

2006

2004

2001

1996

1991

Prevalence in male (per 100 population)Prevalence in female (per 100 population)

Source: Tobacco Control Research and Knowledge Management Centre (TRC)

• Currently, Thailand has a strong comprehensive tobacco control policy

• It took almost four decades of effective tobacco control efforts• Effective interventions through the Framework Convention on

Tobacco Control (FCTC):– The regular tax increase policy is on course,– Total bans on smoking in public places with strong enforcement,– Total bans on advertising and cigarette displays and strong enforcement,– Pictorial health warnings on cigarette packages.

Public policies in reducing regular smoking and morbidity in Thailand

30.525.4

22.5 19.5 18.9

55

79

0

10

20

30

40

50

60

70

80

90

year

pe

rce

nt

0

500

1,000

1,500

2,000

2,500

3,000N

um

be

r o

f c

iga

rre

tte

c

on

su

me

d (

mill

ion

p

ac

ks

)

prevalence of cigarette smoking

percent of excised tax on tobacco

Number of cigarette consumption in million packs

Smoker Die From Emphysema

Cigarette Smoke Kill

Cigarette SmokeCause

Lung Cancer

Examples of health warning on cigarette

packages in 2005

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Key successes of tobacco control in Thailand

• There is a need to have a champion (either GO or NGOs) who work patiently and continuously with legislators and regulators as well as policy makers,

• Being direct, clear, and ready with realistic proposals to offer politicians,

• Policy-relevant research is very important in mobilizing public opinion and lobbying for government actions, especially for Minister of Finance and Minister of Health,

• Nationalism and cultural values can be successfully used to encounter tobacco promotion from international tobacco companies.

Enormous current benefits of prior Enormous current benefits of prior prevention efforts towards HIV/AIDS prevention efforts towards HIV/AIDS

control in Thailandcontrol in Thailand

0.7

7.1

0

2

4

6

8

10

1985 1990 1995 2000 2005 2010

Cu

rren

t HIV

Infe

ctio

ns

in m

illio

ns

Baseline No Intervention

Red line represents what might have been if behaviors had not changed

Infectionsprevented

907

680

277

292174

136

461

803915

1208

10611145

1250

0

200

400

600

800

1000

1200

1400

1984-1990

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Outcome of introducing prevention oOutcome of introducing prevention off mother-to- mother-to-child transmission of HIV (PMTCT) in 2000child transmission of HIV (PMTCT) in 2000

Pediatric AIDS cases in Thailand 1984 – 2003Pediatric AIDS cases in Thailand 1984 – 2003

MOPH Thailand, Epidemiology Division

Inadequate health expenditure for health promotion and disease prevention in Thailand

Health administration and health insurance

8.5%

Medical goods4.3%

Ancillary services 0.4%

Prevention and public health services

4.8%

Services of curative & rehabilitative care

78.1%

Gross capital formation

3.9%

• From 2001 to 2005, health expenditure for health promotion and disease prevention in Thailand decreased from 8% to 4.8%.

• The majority of health expenditure was for curative services and rehabilitation, 79% in 2001 and 78% in 2004.

Innovative financing for health promotion: Thai Health Promotion Foundation (THPF)

• THPF is a statutory public organization established by the Health Promotion Foundation Act in 2001

• The Fund is an innovative financing mechanism generating revenue from 2% surcharge of alcohol and cigarette sales

• Its mission is to empower civic society and promotes

well-being of the citizens by acting as a catalyst and provide financial support for health promotion projects,

• Three main factors for early achievements of THPF– Financial sustainability,– Accountable agency with efficient management structure,– Effective strategies in promoting public health and

policies

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Conclusions and policy recommendations

• Sustaining positive public policies in controlling tobacco consumption and reducing other major disease burden e.g. alcohol consumption, road traffic accident, diabetes, and hypertension, hyper-lipidemia, etc.

• Increasing level of financing health promotion and disease prevention (primary, secondary, and tertiary prevention),

• Increasing value of money through applying cost-effective clinical prevention and health promotion suggested by the Disease Control Priority for Developing Countries (2nd edition),

• Improving program effectiveness (technical efficiency) in health promotion and disease prevention,

• Sustain and accelerate the work of Thai Health Promotion Foundation through:– Increase the level of sin tax from 2% to 5%,– Diversify the portfolio of the THPF to cover more cost-

effective interventions, esp. effective coverage of interventions focusing on chronic NCD.