Healthcare In Thailand: A Story To Inspire Confidence: Opinion

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Healthcare in Thailand: a story to inspire confidence

Mushtaque Chowdhury,

Natalie Phaholyothin1

Special to The Nation

Thailand can be proud to have achieved most of the eight UN Millennium Development Goals (MDGs), in particular the three health-related goals.

THAILAND: -- In 1970, Thailand had an infant mortality rate of 68 per 1,000 live births, while today it is estimated at 13 per 1,000 live births. According to a 2008 study published in the medical journal Lancet, Thailand enjoyed the highest annual rate of reduction in child mortality among 30 low- and middle-income countries between 1990 and 2006. The maternal mortality ratio has also shown a similar decreasing trend. In addition, Thailand has been successful at curbing new HIV infection rates by 83 per cent since 1991, thanks to the arduous efforts made by governments and NGOs.

Such impressive health outcomes did not occur in isolation from its socio-economic development context. From 1969 to 2009, its gross national income (GNI) grew from US$210 to $3,760 in current figures, or 17 times over 40 years. During the 1970s and 1980s, Thailand invested heavily in highways that connect the isolated and impoverished Northeast and North to Bangkok; electrification throughout the country; as well as expansion of school enrollment for both boys and girls. As a result, the positive spillover effects also benefited the public health sector. As economic growth accelerated in the mid-1980s and 1990s, the country continued to finance infrastructure projects which brought greater connectivity, wider access to electricity and safe drinking water and clean sanitation, primary and secondary schools, and primary health centres in rural areas across the country.

Four decades ago when Thailand was still a low-income country, it invested early in health care infrastructure that has reached the most remote rural communities. Instead of concentrating resources to urban tertiary hospital development, public health leaders placed more financing to rural areas from 1982 onwards, which has encouraged greater and affordable access to healthcare at the most local levels. Such investments have paid off. In a study carried out by the London School of Hygiene and Tropical Medicine and released in Bangkok last month, Thailand featured as one of the countries to achieve "good health at low cost". According to the World Health Organisation (WHO), its total health expenditures (THE) is estimated at 4.1 per cent of its GDP or $328 per capita, which is relatively low for the health outcomes achieved. The extensive network of primary healthcare facilities implemented through district health systems supplemented by some of the excellent research outfits undoubtedly played a crucial role in improving health outcomes especially for the rural population.

In addition, Thailand has been successful in training nurses and doctors for its health system, innovatively distributing human resources to rural areas by engaging new medical graduates to serve for three years in a rural hospital, and providing additional monetary incentives. In addition, health volunteers recruited from local communities also play important support, prevention and detection roles, thereby enhancing community involvement

Thailand's health achievements are not limited to impressive indicators, but extend to attaining universal health coverage (UHC). Globally, the number of countries that have attained UHC is relatively small, and comprises mostly of OECD countries. Within Asean, Brunei, Malaysia, Singapore and Thailand have achieved UHC, with the Philippines, Vietnam, and Indonesia approaching full coverage as they embark on reforms. Yet, according to the International Labour Organisation (ILO), only 5 to 10 per cent of people are covered in sub-Saharan Africa and South Asia, while in middle-income countries, coverage rates vary between 20 to 60 per cent. Annually across the world, about 150 million people suffer financial catastrophe and 100 million are pushed below the poverty line due to regressive payment systems for healthcare and absence of UHC.

In 2002 when Thailand was still a lower-middle income country with a GDP/capita of $1,900, the country achieved UHC. This did not happen overnight but gradually since the 1970s through the creation of three health insurance schemes: the Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS) and subsequently the Universal Coverage (UC) Scheme - formerly referred to as the "Bt30" Scheme. Achieving a coverage rate of 99 per cent of the population is more than just meeting a national objective; it represents a source of inspiration to other low- and middle-income countries. As a matter of fact, officials from various health ministries and NGOs from Asia and Africa often request a visit to Thailand's public health institutions such as the National Health Security Office, International Health and Policy Programme, Health Systems Research Institute and the Ministry of Public Health to "study how Thailand did it".

As of now, 99 per cent of the Thai population is covered through a comprehensive healthcare package that ranges from health prevention and primary care, to hospitalisation due to traffic accidents to renal replacement therapy and access to ART treatment for HIV.

It has been shown that the UC Scheme has contributed significantly to reducing instances of catastrophic healthcare expenditures, especially in impoverished areas of the country. Based on the recent evaluation of the ten years of the Scheme, the number of impoverished households dropped from 3.4 per cent in 1996 to 0.8-1.3 per cent between 2006 and 2009, thus contributing to poverty reduction, building greater financial stability to vulnerable households and improved long-term livelihood security. In addition, it helps Thailand to attain the principle of the right to health for all. In a country with high income inequality as measured by the Gini Coefficient, access to affordable healthcare is a bridge that helps mitigate many of the socio-economic inequities that still plague this nation.

Thailand has demonstrated that UHC may not be an unattainable dream to be experienced by only the rich countries. Low-income countries such as Ghana and Rwanda have already made much progress towards UHC, and countries such as India and Bangladesh are working towards developing effective UHC systems. The biggest single determinant in this is political commitment. In a round-table conference in Bangkok in November, 2011, UN Secretary-General Ban Ki-moon declared that no countries rich or small would have "enough" resources to carry out UHC reform but the challenge for every country is how soon they can move into it. This was echoed at the recent Prince Mahidol Award Conference with the theme of UHC. Attended by participants from 68 countries, none said that UHC is impossible to achieve in their contexts. With the right policies - social, economic and political, it is possible for a low- or middle-income country to embark on the road towards UHC.

Although Thailand has achieved universal coverage, big challenges remain. These include: how to include foreign migrant workers into the healthcare system; how to merge the three schemes to reduce inequities in benefit packages; how to ensure sufficient and highly-trained human resources in health to meet current shortages; and how to manage Thailand's transition into a "grey" society in the next decades, and what are the evolving financial mechanism that can be used to better serve the population?

UHC after all is not an endpoint in itself, but a journey that moves us closer to better health for all.

Mushtaque Chowdhury and Natalie Phaholyothin are based at the Rockefeller Foundation's Asia Regional Office in Bangkok. The article reflects the views of the authors, which do not necessarily represent those of the Rockefeller Foundation.

-- The Nation 2012-04-28

[apetley]

I recently managed to injure myself by somehow putting a 6 inch nail through my ankle and the pain was excruciating.

Any health related matters and I usually go to a private hospital which is 35 kms away.

This time however wifey and I were worried enough to hurry to the local Govt hospital.

I have a Thai health card so admittance was rapid and I saw a doctor within 5 minutes and was xrayed and cleaned up and administered with a pain killing injection within 15 minutes.

No complaints whatsoever and because I'm in the system everything was free.

I had at least expected to pay for the medication I was given but no, all covered.

Compares very favourably to the 5 hour wait I last had in casualty in a UK hospital with my daughter when she had a dislocated elbow.

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[zakk9]

I also have the best experiences with Thai government hospitals. The staff is mostly competent, and although there are limited resources, they mostly manage very well.

[geriatrickid]

Just don't get cancer or need complicated surgery in a rural area.

[OzMick]

Just don't get cancer or need complicated surgery in a rural area.

I'll dd that to my book of "Rules for a Happy Life". it should rank somewhere around "Don't read the magazines at the dermatitis clinic" but a long way behind "don't cook bacon in the nude."

[Ave]

Rockefeller..

[HerbalEd]

Just don't get cancer or need complicated surgery in a rural area.

That's true of rural areas in any country.

[al007]

"I recently managed to injure myself by somehow putting a 6 inch nail through my ankle and the pain was excruciating.

Any health related matters and I usually go to a private hospital which is 35 kms away.

This time however wifey and I were worried enough to hurry to the local Govt hospital.

I have a Thai health card so admittance was rapid and I saw a doctor within 5 minutes and was xrayed and cleaned up and administered with a pain killing injection within 15 minutes."

Interesting what does one have to do to get thee Thai health card

thanks Al007

[thaiden1]

What are the requirements to qualify for a Thai Health Card?

[apetley]

I didn't even ask for one! It was issued after I received my yellow house book. I was told at the time that any person, Thai or foreigner who appears in a tabian baan automatically qualifies as they are considered resident.

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[jamesbrock]

I had a motorcycle accident five weeks ago today, and was rushed to a Govt hospital in an ambulance. I waited in the not-busy emergency room, bloodied and broken, for about 40 minutes before anyone came to look at me, and then a nurse came and began cleaning and dressing my wounds. About 20 minutes later, while the nurse was dressing my knees, a doctor came up and asked how I felt. This was around 90 minutes after the accident, and by this stage I was a in pretty decent amount of pain.

After pointing to my left big toe, left ankle, left upper-shin, right lower-calf, and left arm saying I thought they were all broken, she says to me, "No, you've just got a lot of grazing." I pointed to my (already dressed) big toe and said, "No, I know that's broken for sure, as it's pointing in the wrong direction!" to which she reiterated that it was "only grazing". At no time did she touch any part of me. We 'discussed' my injuries some more before she acquiesced and sent me around to have some X-rays; except, the radiologist X-rayed both my knees (which I never complained about) and both my wrists...

After being wheeled back around the the emergency department, and waiting 20 minutes, during which time I was administered my first and only painkillers, the doctor came to say they'd found no breaks. It was as I again pointed to my toe, ankle, legs, and arm, telling her that they didn't X-ray them, I decided that I just wanted to be discharged so I could go to a real hospital. They wheeled me back around and X-rayed my foot (but not my toe) and my arm, and again found no breaks. After another ten minutes or so, less than two hours after arriving, they told me I was right to go... I looked at my friend, who had turned up, and we both looked back at the nurse and said, "What?!?" She, repeated that I was ok to leave, and walked away. My friend was about to complain, but I called him back and told him I just wanted to go to another hospital. With no hospital assistance offered, I tried to get up, but couldn't put any weight on either leg; my girlfriend (who had been injured herself) went outside and grabbed a wheelchair - after which an argument ensued as to what we were doing!

The whole experience was a complete farce and a nightmare, and I will never voluntarily set foot in that hospital again. If it was a normal country, where even guests have rights, I would consider complaining about the maltreatment, but as it is here, there is absolutely no point whatsoever.

It turned out, that while I was being maltreated, my gf received several calls from the local police (who had gotten her details at the accident scene) demanding that we present ourselves at the station the moment we got out of hospital, as they and the other parties were waiting to extort me. It has been suggested that this was the reason the hospital basically pushed me out into the street unable to stand... (Five weeks later and I'm only now beginning to hobble around.)

Anyway, after being extorted, I went to a private hospital where the treatment was better than anything I'd received back in Australia! The doctor actually cared and listened, visually and physically inspecting every part of me (he even diagnosed a 24 year old dislocated knee by how loose the ligaments were!); he X-rayed every part I wanted, and found my big toe was shattered, my right fibula had snapped cleanly, and my left elbow was broken. I saw the X-rays, these weren't some hard to define breaks - they were pretty obvious breaks! Even the re-cleaning and dressing of my wounds was substantially better than at the Govt hospital!

In the end I paid 2400 baht for either utter incompetence or police requested maltreatment, and 10,300 baht to be treated by professional caring staff at a well equipped hospital (not including aftercare and treatment of complications) - I know which I'd choose again if I had to.

[JeffreyMcCollum]

A month ago when my heart stopped, 1669 and the Government hospital saved my life,

All very well done. And here today because of it

Thanks Thailand !

[Puwa]

Public or private; free, cheap, or pricey; going to the hospital in Thailand is a crapshoot.

[jamesbrock]

Public or private; free, cheap, or pricey; going to the hospital in Thailand is a crapshoot.

Too true, as are most things.