WHO Country Cooperation Strategy 2008-2011 Thailand
WHO Country Cooperation Strategy 2008-2011 Thailand
, July
© World Health Organization 2007 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for SouthEast Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
ii
WHO Country Cooperation Strategy 2008-2011
Contents Preface .............................................................................................................. v Foreword ........................................................................................................ vii Executive Summary .......................................................................................... ix 1. Introduction ............................................................................................... 1 2. Country health and development challenges in Thailand ............................ 3 1. 2. 3. Economic and social development ................................................................. 3 Health policies ............................................................................................... 4 Burden of disease and the health development situation ................................ 5
3. Development assistance and partnerships: Aid flow, instruments and coordination ..................................................... 17 1. 2. 3. 4. Partnership with UN and other international development agencies ............. 17 Partnership with developing countries .......................................................... 19 Technical cooperation with other countries .................................................. 19 WHO Collaborating Network ....................................................................... 20
4. Current WHO cooperation ....................................................................... 21 1. 2. 3. 4. 5. 6. 7. 8. 9. Work of the WHO Country Office encompasses .......................................... 21 Focus of WHO’s collaboration with Thailand ............................................... 21 Funding of WHO collaborative programmes. ............................................... 22 Fellowships .................................................................................................. 22 Regional Sub-units ....................................................................................... 23 Staffing ........................................................................................................ 23 Office premises ............................................................................................ 24 Information and communication technology ................................................ 24 Use of CCS .................................................................................................. 24
Thailand
iii
5. WHO policy framework – Global and regional directions ......................... 25 1. 2. 3. Global challenges in health .......................................................................... 25 Global health agenda ................................................................................... 26 Regional policy framework ........................................................................... 27
6. Strategic agenda: Priorities jointly agreed for WHO cooperation in and with countries ................................................................................ 28 1. 2. 3. Principles ..................................................................................................... 28 Strategic agenda .......................................................................................... 28 Modalities of implementation: ..................................................................... 32
7. Implementing the strategic agenda: Implication for WHO Secretariat, follow-up and next step at each level ........................... 34 1. 2. 3. 4. 5. Introduction ................................................................................................. 34 Staffing: Current and future .......................................................................... 34 Financial allocation ...................................................................................... 35 Information and communication support ..................................................... 35 Implementation of the strategic agenda ........................................................ 35
Annexes 1. 2. 3. 4. 5. 6. 7. National health development data ............................................................... 37 Strategic objectives and their scope under MTSP 2008-2013 ....................... 38 MoPH budget in present value and real terms .............................................. 43 Health budget allocation for major types of programmes during the first half of the Ninth National Health Development Plan ....................... 44 Thailand’s scorecard on MDG Targets (Goal 1-7) .......................................... 45 Organogram – Ministry of Public Health ....................................................... 46 Morbidity rates of hospitalized cases (per 100 000 population) due to selected NCDs, injuries and mental illness Thailand (excluding Bangkok), 2001–2004 ................................................................. 47 Organogram WHO Country Office Thailand ................................................ 48 References ................................................................................................... 49
8. 9.
iv
WHO Country Cooperation Strategy 2008-2011
Preface Collaborative activities of the World Health Organization (WHO) in the South-East Asia (SEA) Region are geared to improve the health status of the population of Member States. Although WHO has been contributing as a key catalyst to Thailand’s health policies and programmes, there is a need to thoroughly analyze and discuss how the Organization can further improve its contribution to the development of health in Thailand. The South-East Asia Region was the first among WHO’s Regions to promote the Country Cooperation Strategy (CCS) as a process to identify how the Organization can best support health development in our Member States. All 11 Member States of the Region have prepared their CCSs over the past six years. In the case of Thailand, two CCSs have already been prepared and have been used continuously as guidelines for the WHO Country Office (WCO) to plan and coordinate work effectively with their national as well as international counterparts for health development in the country. Analyses of the current health situation and the likely scenario over the next four years have together formed the basis of the priorities outlined in this CCS. The inputs and suggestions from the Ministry of Public Health, whose officials have been the major collaborators in developing this document, are appreciated. In addition, the advice and recommendations of the health development partners in Thailand and the United Nations Partnership Framework (UNPAF) 2007-2011, of which the WHO Country Office is also a signatory, were invaluable in guiding the development of this CCS. The consultative process here will help ensure that WHO inputs provide the maximum support to health development efforts in the country. To help achieve the objectives of this CCS and to promote technical assistance from Thailand to other Member countries, we recognize the importance of a strong WHO Country Office working closely with key counterparts, keeping in mind local conditions. Nonetheless, the entire organization is committed to the work of the CCS. The staff of the WHO Regional Office will use this CCS to determine regional priorities and support collaborative activities in Thailand. Furthermore, we will also seek assistance, as necessary, from WHO Headquarters towards bolstering these efforts. I would like to thank the Ministry of Public Health and Faculty of Tropical Medicine, Mahidol University, Bangkok for providing office space for the regional-level units, Communicable Disease Surveillance and Response Sub-unit and the Malaria Mekong Sub-unit.
Thailand
v
I would like also to specially thank all those who have contributed to development of this Country Cooperation Strategy, which has the full commitment of the Regional Office. We will provide our maximum support towards achieving its objectives over the next four years. Our joint efforts, I am confident, will help in achieving the maximum health benefits for the people of Thailand.
Samlee Plianbangchang, M.D., Dr.P .H. Regional Director
vi
WHO Country Cooperation Strategy 2008-2011
Foreword Thailand is one of the countries in the South-East Asia Region that have an advanced health infrastructure, a robust surveillance system and public health professionals with a high degree of expertise. The country has demonstrated excellence and expertise in many areas of public health, medical specialities and nursing. Thailand has also achieved many of the Millennium Development Goals (MDGs). The WHO Country Office (WCO) is in a unique position to have national experts in both long-term and short-term positions who can contribute to the work of the Organization in Thailand. The Country Office also facilitates training programmes for Fellows from neighbouring countries and other Member countries of the Region, for capacity building. Even with such remarkable progress, communicable diseases such as HIV/AIDS, tuberculosis (TB) and avian influenza (AI) continue to have a negative impact on the country, with certain situations exacerbated by the prevalent circumstances along Thailand’s borders. Health promotion efforts and control measures for NCDs are well advanced in terms of both legislation and intervention. The WCO provides the necessary support to enhance these efforts. The purpose of this Country Cooperation Strategy (CCS) is to reflect the mediumterm vision of WHO for its cooperation with Thailand and to elucidate the strategic framework for such cooperation. The CCS represents a balance between evidencebased country priorities and organization-wide strategic priorities in order to contribute optimally to national health development. It is very timely for WCO Thailand to prepare the new CCS covering the period 2008-2011, since the current Strategy will end in 2007. The WHO Medium-Term Strategic Plan (MTSP) 2008-2013 is being prepared and a new planning approach has been introduced. The priorities and strategic framework are based on: (1) National and international partners’ recommendations; (2) The national health development situation, and (3) Strategic objectives of WHO and the Regional Office for South-East Asia under the MTSP . Overall, the priorities and strategic framework presented in this CCS are consistent with WHO’s strategic objectives in meeting Thailand’s needs. We hope that this CCS shall be disseminated and used by national and international partners in health for better cooperation and collaboration in planning and implementing relevant activities to enhance the health and well-being of the people of Thailand.
P .T. Jayawickramarajah, M.D., M.Ed., Ph.D WHO Representative to Thailand Thailand
vii
viii
WHO Country Cooperation Strategy 2008-2011
Executive Summary Since the current Country Cooperation Strategy (CCS) will end in 2007, the preparation of a new CCS is timely to cover the period of 2008-2011. In the context of a new CCS, it is relevant to list the following important related documents that are being or have been prepared for the corresponding period: (a) The 10th National Health Development Plan, 2007-2011; (b) The WHO six-year Medium Term Strategic Plan (MTSP), 20082013, which serves as an outline of WHO’s strategic objectives and (c) The United Nations Partnership Framework, Thailand (UNPAF 2007-2011), of which the WHO Country Office is also a signatory. Thailand is a developing country that has registered impressive successes in both economic and social development, though all regions of the country have not registered the same degree of advancement. The country also has a long and successful history of health development. The Ninth Five-Year National Health Development Plan, 20012006, has just been completed, and the Tenth Plan is in the final stages of completion. The basic principles of these plans are based on a people-centered approach and philosophy of “sufficiency economy.” The Thailand Human Development Index has improved, inexorably aided by major contributions from the robust health indicators. Almost all MDGs relating to maternal and child mortality have been achieved. Although considerable progress and achievement has been registered, Thailand still faces several challenges with the health situation and health development. Some of the major challenges to advancement of health development are as follows: (1) Important communicable diseases remain key public health concerns in Thailand. These include malaria, dengue haemorrhagic fever, HIV/AIDS, TB and emerging diseases, particularly avian influenza. The coordination of the disease surveillance and epidemic response, and the efficiency of DOTS at the peripheral level still leave room for improvement. (2) Morbidity and mortality of major non-communicable diseases such as injuries and mental illnesses show a rising trend. The country requires clear and well-defined national multi-sectoral coordination policies and strategies for the effective prevention and control of these diseases. (3) Environmental pollution and contamination of food by hazardous substances are still important public health issues. Occupational safety standards and the permissible levels of hazardous substances are yet to be enumerated. (4) Thailand has increasingly become prone to natural disasters. Although the government is relatively self-reliant in disaster relief, WHO and the UN Disaster Management Team have important roles to play to support the country in
Thailand
ix
assessing the health situation and needs as well as coordinating joint action for health. (5) Cross-border health risks have become important health and political issues over the past few years. These risks include the spread of communicable diseases and drug-resistant pathogens, and also national security. There are many players involved in the improvement of the living conditions and health of migrants and refugees along the border of Thailand. Better coordination among all involved is needed. (6) Thailand has accorded high priority to health promotion, as is clearly reflected in the Ninth and Tenth National Health Development Plans. The Ministry of Public Health (MoPH) has initiated many programme and project approaches. The Thailand Health Promotion Foundation plays an important role in financing and advocating health promotion. However, the country’s main challenge lies in establishing firm levels of collaboration with sectors outside of the Ministry of Public Health. (7) The most recent phase of health systems reform began in 2000. Several offices and institutes were established to strengthen health systems development and enable the reform process. For example, the National Health Systems Research Institute (HSRI) established the Health Systems Reform Office to function as the secretariat for the National Health Systems Reform Committee to guide health systems development. The International Health Policy Programme (IHPP) was established to develop and strengthen national capacity in health policy research and international health. The National Health Security Office (NHSO) was established in 2003 to expand coverage of health insurance/security for those citizens who have not as yet been covered by any government insurance scheme. The national health budget has gradually increased from 5.8% of the total government outlay in 1993 to 7.6% in 2004. About 60% of all health expenditure comes from government sources compared with 40% from private sources. In 2001 the government introduced the Universal Health Care (UC) policy (the “30-Baht scheme”). In April the next year, the government announced universal health care coverage and in 2007 universal coverage without pay was introduced. In 2004, the UC scheme represented 75.2% of the total health insurance schemes that covered a population of about 47 million. There are still issues concerning the quality of services, sustainability of the schemes, and the resignation of physicians from public service that need to be addressed. Thailand is gradually becoming a development partner, like other middle-income countries, by assisting other developing countries. Therefore, in terms of developmental assistance, Thailand has received mostly technical support, but only limited financial support, from donor agencies and countries. In relation to partnerships with developing
x
WHO Country Cooperation Strategy 2008-2011
countries, Thailand is active in a number of regional and sub-regional cooperative initiatives in many sectors including health. The work of WHO with Thailand is based on the WHO-Country Collaborative Programme, which is developed on a biennial basis. The WCO focuses overall on supporting policy development, advocacy, technical advice, and the development of norms, standards and guidelines. In addition to the WCO, there are two WHO subregional units in Thailand: a) Mekong Malaria Control Project (MMP) that was established for coordinating malaria control activities in the countries of the Mekong Basin that involves two WHO Regions and for coordinating border health activities, and b) Communicable Disease Surveillance and Response (CSR) regional sub-unit that was established to support countries to strengthen capacities in areas of epidemiology, disease surveillance and epidemic response. The WCO has National Professional Officers (NPO) who work in programme planning, monitoring and evaluation, HIV/ AIDS-Tuberculosis, communicable disease control and tobacco control. All other international technical staff are assigned to work for the above two sub-units. WHO has established a clear Global and Regional Framework, under the Tenth General Programme of Work (GPW) and the Medium Term Strategic Plan (MTSP), and all the offices will work to perform six core functions of WHO. Based on the above situation analysis and extensive consultations, the following seven strategic agendas have been identified as priorities for the next four years: (1) To enhance primary prevention, surveillance and control of communicable diseases and epidemics; (2) To integrate measures to reduce the risks of non-communicable diseases (NCDs), injuries and mental illnesses; (3) To build capacity and partnerships for health promotion and healthy public policy; (4) To strengthen capacity for monitoring and evaluating health systems development; (5) To initiate a multi-sectoral approach to address health services for the poor and at-risk population, including those in border and conflict areas; (6) To promote environmental health and surveillance of environmental hazards; (7) To strengthen the development of human resources for health through existing networks within and outside the country.
Thailand
xi
viii
WHO Country Cooperation Strategy 2008-2011
1 Introduction Thailand is one of the countries that has already formulated two Country Cooperation Strategy (CCS)* reports. The first covered the period of 2002–2005, and it was later updated in 2004 for 2004–2007. As one of the fundamental principles of the CCS, the strategic agendas identified in these documents have been used as a basis for the WHO country collaborative programmes and for the Organization’s operations in the country. The CCSs were developed in close consultation with the national authorities from within and outside the Ministry of Public Health (MoPH). Consultations were held with most UN Agencies and other partners who are active in the health sector. As the current CCS will end in 2007, it is timely to formulate a new CCS for the following reasons: (1) The Royal Thai Government (RTG) has drafted its Tenth National Health Development Plan (2007–2011) which outlines its strategies and priorities based on the vision of “sufficiency economy”. This will allow WHO to align its medium-term strategies, including the planning cycle, with the strategies and priorities of the RTG. (2) The six-year WHO Medium-Term Strategic Plan (MTSP) based on WHO’s Eleventh General Programme of Work (GPW) 2006–2015 outlines the Organization’s global strategies covering the period 2008–2013. This exercise can take into account the latest WHO long- and medium-term strategies and priorities while identifying the Organization’s strategic agenda for its technical cooperation with the RTG for the period 2008–2011. This will also help RTG respond, in a flexible and dynamic manner, to a changing international health environment. (3) The United Nations Development Assistance Framework (UNDAF), which is referred to in Thailand as the United Nations Partnership Framework (UNPAF), covering the period 2007–2011, has just been developed and fully aligned
*The CCS reflects a medium-term vision of WHO for its work with a given country and defines a strategic agenda for working with that country. The timeframe is four to six years but may be less for countries in crisis. The CCS is the WHO instrument used to aligning with the national agenda while harmonizing with the functions of other organizations in the UN system and other agencies in the country.
Thailand
1
with the national priorities. WHO, as agreed in the Paris Declaration, follows the principles for alignment and harmonization of its strategies and programmes with that of the United Nations system and other development partners working in the area of health. Although the WHO Country Office, Thailand did not have a distinctive role to play in the poverty reduction strategy of UNDAF, the strategy was considered a core value and an overlapping element that has to be integrated into WHO’s strategic objectives. Taking advantage of the opportunities stated above and in accordance with the agreements with the national authorities, it was decided to formulate the CCS in Thailand for WHO’s cooperation with RTG over the period of 2008-2011.
2
WHO Country Cooperation Strategy 2008-2011
2 Country health and development challenges 1. Economic and social development In terms of social and economic development, Thailand has achieved outstanding progress over the last few decades to emerge a middle-income country. Per capita income in terms of Purchasing Power Parity (PPP) in 2005 was (Intl. $) 8440. Thailand has a Human Development Index (HDI) of 0.784, which increased from 0.615 in 1975. The number of people living below the poverty line was reduced by almost twothirds between 1990 and 2002. The reach of education has also increased, with almost all children attending primary school and enrolment in secondary schools rising every year. Aided by high levels of attendance in schools, the literary rate is currently 92.6%1. Despite this impressive progress, the fruits of development have not reached all regions of the country in equal measure. While the Bangkok Metropolitan Area in 2002 had less than 2% of its population living in poverty, the incidence of poverty was as high as 16% in the north, 17% in the north-east, and 8% in the south of the country. Poverty rates in Narathiwat and Pattani, two of the southern-most provinces, were 18% and 23%, respectively2. Furthermore, drawn by Thailand’s economic wealth and stability in comparison with some of its neighbours, many migrants arrived in search of employment and a living. These migrants do not always have full access to social services such as health care and those not registered are often vulnerable to exploitation. The Tenth National Health Development Plan, currently in draft form, covering the period 2007–2011 will follow the vision and philosophy of the Ninth Plan. This new plan focuses on three areas for strengthening and developing the national capital formation: (a) economic capital, (b) social capital, and (c) natural resources and the environment. Health falls under social capital, and the health sector is considered to be a new wave in Thailand’s competitive surge in the context of global trade liberalization. While the Ninth Plan has emphasized a life-cycle health approach, promoting healthy lifestyles, improving the quality of health care, disease prevention and control, and preparing for the need of an ageing population, the Tenth Plan emphasizes public and national self-reliance in health. In the past, government administration and services had been largely centralized. However, decentralization is now an accepted political objective and is gradually being implemented. Efforts are already on to decentralize public services, including health, to the 76 provinces and 876 districts, including Bangkok. This will require substantial efforts to build capacity at the local level. Thailand
3
2. Health policies Thailand has had a long history of health development going back to the 13th Century. More recently, the First (five-year) National Health Development Plan was initiated in 1961, and subsequent plans continued through the Ninth Plan, which covered the period 2001–2006. There has been continuous change in and evolution of health policies in response to the country’s social and health problems and in line with international developments in health. At the end of the Seventh Plan and throughout the Eighth Plan, WHO introduced a Health Future Studies approach to the Ministry of Public Health. Consequently, since 1999 public sector reform, including health, has been part of the government’s agenda. The Ninth Plan provided a clear vision of a people-centered approach and the philosophy of a “sufficiency economy”. Its objectives were to: (a) promote health and prevent and control diseases; (b) establish health security; (c) build capacity in health promotion and health system management; and (d) establish measures in generating knowledge through research. In 2003 “Healthy Thailand” was adopted as a national agenda to be used as guidance to reducing behavioural risks and to solve major health problems in pursuing the target Millennium Development Goals (MDGs) by 2015. While continuing with the philosophy of “sufficiency economy,” the Tenth National Health Development Plan places more emphasis on national self-reliance, quality of services, people’s values and dignity. Its objectives are as follows: • • • • • • • • • • Develop uniformity and good governance in the management of health systems. Accelerate the pro-active health promotion approach to develop basic elements for good health. Develop a health culture and ways of life with sufficiency and happiness. Develop community health systems and a strong primary care service network. Develop a health service system that will lead to both health care receivers’ and health care providers’ satisfaction. Develop health security systems with equitability, good quality, and better distribution. Develop individuals’ immune systems and readiness to minimize the impact from diseases and risks to health. Develop several alternative healthcare services, integrating the respective strengths of Thai and international approaches. Develop a foundation of health knowledge through knowledge management. Develop societies that do not neglect sufferers and that care for the poor and disadvantaged people with due respect for their values and human dignity.
4
WHO Country Cooperation Strategy 2008-2011
In September 2006, political developments led to the establishment of an interim government in Thailand. The health minister subsequently announced health policies that are in line with the Tenth National Health Development Plan. On account of the problems that were encountered in implementing the 30-Baht health-care scheme, universal coverage without fees was initiated. In general, health systems reform and health security, especially social health insurance, will continue to be an important part of the health development agenda in Thailand for the next four to five years.
3. Burden of disease and the health development situation Along with Thailand’s impressive economic development, the government has developed an effective public health system to improve the health of its population. Since 1989, Thailand’s Infant Mortality Ratio (IMR) has improved from 38 per 1000 live births in 1990 to 19.8 in 20053. According to the Millennium Development Goals Report 2004, the maternal mortality rate, a good indicator of the effectiveness of a public health system, has decreased from 36.2 per 100,000 live births in 1990 to 14 in 2002, with about 98% of births having been attended by skilled health personnel. Thailand’s progress with the MDGs (Annex 5) has been so impressive that the country has adopted targets beyond those in the MDGs, which are known as the MDG-Plus targets. However, despite the progress made with the MDGs, challenges still remain in those regions with a high number living in poverty and among migrant populations, particularly in the border areas. Thailand is witnessing a series of both demographic and epidemiologic transitions. The total fertility rate (TFR) has dropped from 2.41 in 1990 to 1.6 in 2006 with an average population growth rate of 0.7% in 2004-152. With the reduction in communicable diseases, improved nutritional status, and the provision for skilled birth care, the pattern of morbidity and mortality has gradually veered towards noncommunicable Diseases (NCDs), injuries and mental illness.
3.1 Communicable diseases While progress has been made in the reduction of communicable diseases, some significant problems remain. These will be the focus of efforts during the next four years, as enumerated below: (a) HIV/AIDS: In 1991, the number of new HIV infections reached 143,000, indicating that Thailand was on the brink of a major health crisis. The Government, working with NGOs, mobilized effective interventions to increase general awareness on HIV and thereby reduced the transmission of HIV appreciably. With the number of new infections at 19,000 per annum in 2004, Thailand is one of the few countries to make substantial progress in fighting AIDS. Currently, of the estimated 500,000 people who are living with AIDS, anti-retroviral drugs (ARVs) are being provided to about 100,000 of them who urgently need such treatment. With the government committal since October 2003 to the policy of universal access to anti-retroviral drugs Thailand
5
for AIDS patients. But with the possibility of limited funds for the same, the authorities, in March 2007 applied compulsory licensing measures to produce two low-price, generic HIV/AIDS drugs. Over the past three years there has been growing concern regarding the increasing incidence of HIV/AIDS among adolescents, almost consistent with an increasing incidence of sexually transmitted infections (STIs). (b) Tuberculosis: Thailand ranks 17th of the 22 global high-burden countries for tuberculosis4. The DOTS (Directly Observed Treatment, Strategy) still requires strengthening to ensure higher case detection and treatment success rates. In 2004, the country achieved the 70% case detection target. However, the treatment success rate achieved was 74% which is significantly lower than the target of 85%. There is a need to strengthen TB programme management and capacity to guide and oversee the implementation of TB services under the decentralized health system. The lack of coordination between various stakeholders including provincial administrations poses constraints to the programme. Inadequate treatment supervision and sub-optimal drug procurement and supply management need to be addressed. The emergence of multi-drug resistance and a high HIV prevalence among TB patients, the issue of TB among migrants both internal and in the border areas, are other major concerns. The WHO estimates for tuberculosis incidence and mortality rates in Thailand in 2005 were 142 and 19 per 100,000 population4 respectively. These rates are about three and 80-fold higher respectively than those reported under the routine surveillance system, Bureau of Epidemiology5. However, the surveillance report has been used for monitoring the disease trends rather than the actual disease burden (Figure 1). Figure 1: Morbidity and mortality of pulmonary turberculosis, Thailand, 1996-2005
Source: Bureau of Epidemiology (Surveillance Data)
6
WHO Country Cooperation Strategy 2008-2011
(c)
Vector-borne diseases: The countrywide incidence of malaria has been decreasing but problems remain in border areas, both in terms of number of cases and drug resistance. To ensure that the disease will be controlled completely, malaria is likely to remain a vertical programme before full integration into the routine health services. While the country has been successful in case management of dengue haemorrhagic fever (DHF) and in reducing its case fatality rate to less than 1%, disease morbidity is still high with an increasing incidence among adults. The main strategies of disease control have been focused on eliminating vector breeding places by schoolchildren and on improving the environment using a “healthy setting” approach. Long-term results are yet to happen. It should be noted that malaria, DHF and outbreaks of some other communicable diseases often increase after natural disasters.
(d) Epidemic preparedness and response: In 2003 there were nine reported cases of Severe Acute Respiratory Syndrome (SARS) and two deaths due to it in Thailand. Following reports of human avian influenza (AI) in China and Vietnam in 2003, Thailand reported confirmed AI outbreaks and deaths in poultry in July 2004. The first confirmed human case of AI in Thailand occurred in August 2004 and by the end of November 2006 25 AI cases and 17 deaths in humans were reported. In response to this, the Government established a multi-sectoral National Committee for Avian Influenza Control, comprising representatives from the ministries of Public Health, Agriculture, Natural Resources and Environment, the Institute of Animal Health, the Bangkok Metropolitan Administration and WHO. However, it is still a challenge to extend this coordination to the sub-national level because there is no standard policy and decentralization is still in a transitional phase. (e) Surveillance: Outbreaks of communicable diseases can be prevented if cases are detected early as well as the related risk factors and effective action immediately taken. The performance and quality of disease surveillance in the provincial health offices and public health laboratory services in provincial hospitals are not adequate yet. This may adversely affect the timeliness and effectiveness of responses to epidemics. Health personnel also have to be trained in risk communication so that families and communities will know how to avoid high-risk behaviour related to the outbreaks or epidemics. Efforts to strengthen surveillance systems are also needed to support the implementation of the new and revised International Health Regulations (IHR) 2005 being implemented since June 2007. The disease surveillance system and capacity building for epidemiology are the responsibility of the Bureau of Epidemiology, which has since long been recognized globally as one of a few successful centres for FETP (Field Epidemiology Training Programme). The short-course FETP may be considered in tandem with the existing twoyear course to address the increased requirements.
Thailand
7
3.2 Maternal, child and adolescent health While Thailand has already achieved MDG targets for child and maternal mortality on U5MR and MMR (Annex 5), Maternal and Child Health (MCH) and reproductive health services still need strengthening for poor households and in underserved regions. Micronutrient deficiencies, especially of iron and iodine, remain and are often associated with increased morbidity and retarded mental growth. Special attention is required for adolescent health since this group is susceptible to sexually transmitted diseases such as HIV. There are separate programmes for MCH, reproductive health and adolescent health, while target populations are the same or overlap. School health programmes also need strengthening to support better health practices and health services need to be adjusted to provide effective services to adolescents.
3.3 Noncommunicable diseases, injuries, and mental health The burden of disease in Thailand is gradually shifting to noncommunicable diseases, injuries and mental health. The greatest public health benefits are gained through prevention of NCD (cardiovascular diseases, cancers and diabetes mellitus in particular), injuries and mental health disorders. This can be achieved if the risk factors are identified and appropriate interventions implemented to reduce or avoid these risk factors. In addition, if NCDs and mental illnesses are detected at an early stage and appropriate controls initiated, the severity of these can be reduced. It should be noted here that the burden of noncommunicable diseases usually falls disproportionately on the poor who often have excess exposure to risk factors and limited access to health services. Diseases such as diabetes, cancers and of the heart are often not detected till at an advanced level. Aware of the increasing trends of NCDs and injuries, the RTG has placed high priority on prevention and control initiatives. The Bureau of Noncommunicable Diseases is responsible for NCDs, injury prevention, and tobacco and alcohol control programmes. The Bureau has made appreciable progress in monitoring the burden of NCDs and injuries and identifying major behavioural risk factors classified by their provinces. The Bureau also plans to improve the collection and analysis of NCD and injury mortality and morbidity data in order to monitor trends and evaluate the success of interventions for risk factors. Due to the unreliability of incidence data for selected NCDs, injuries and mental illnesses among the population, cases of hospitalization with more accurate diagnosis are presented to ascertain the trends in the burden of disease depicted in Figure 2 and in Annex 7. Since the NCD and injury prevention and control programmes emphasize the public health and primary care approaches (rather than secondary and tertiary treatment), effective multi-sectoral collaboration is required. Clearly, traffic injury prevention and tobacco and alcohol control programmes cannot be implemented by the health sector alone. The RTG has demonstrated a strong commitment to the control
8
WHO Country Cooperation Strategy 2008-2011
Figure 2: Morbidity rates of selected diseases/conditions in Thailand (excluding Bangkok) 2001-2004
Source: Bureau of Policy and Strategy
of tobacco use and alcohol consumption by drafting legislations, particularly in the area of advertisement. However, the major challenge ahead remains how to effectively reduce risk behaviour (smoking and alcohol consumption) and increase regular exercise and healthy diet. The Department of Mental Health, Ministry of Public Health (MoPH), is in the process of developing National Strategies on Mental Health, based on the Tenth National Health Development Plan. To ensure the success of implementation, advocacy and multi-sectoral collaboration are required to address the root of social problems that are considered to be the major causes of mental illness.
3.4 Environmental health and food safety After several reorganizations in the government, the main responsibilities for water supply and sanitation and pollution control services have been transferred from the Ministry of Public Health to the Ministry of Natural Resources and Environment. The Bureau of Environmental Health limits its responsibilities to providing technical support and capacity building, especially to local organizations. The healthy settings approach is used to promote healthy cities with clean public toilets and healthy markets, schools and hospitals. The Bureau is currently developing a National Environmental Health Action Plan (NEHAP). The Health Impact Assessment (HIA) is an important tool to minimize the adverse environmental influences on health. More support is needed to improve national capacity for conducting HIAs. Future environmental challenges include climate change, increasing urbanization, and the danger posed by hazardous waste
Thailand
9
and chemicals, including exposure to heavy metals in the environment. These contaminants, from industrial or natural sources, include asbestos, cadmium, arsenic and lead. Standards have yet to be set for permissible levels of hazardous chemicals in food, water and the environment, and surveillance of violations should be strictly enforced. Although occupational health has been a prime concern for Thailand for more than 30 years, accidents and diseases caused by the workplace environment are on the rise. Besides accidents, the most common reports of occupational health incidents are pesticide poisoning, skin disease due to exposure to chemicals, back pain, lead poisoning and silicosis. The government response to these problems is rather passive, and largely confined to providing medical care or financial compensation to the victims. Effective prevention of occupational hazards is still limited. Systems to report all occupational health events need to be established and strengthened. Occupational safety standards should be established and inspections undertaken to ensure compliance. The promotion of food safety is one of the government’s priorities under the Healthy Thailand campaign. Food should be safe for domestic consumption as well as for export. The government currently assigns responsibility to several agencies. In the Ministry of Public Health these include the Food and Drug Agency, the Bureau of Health Promotion, and the Bureau of Environmental Health. In the Ministry of Agriculture, the agencies concerned are the National Bureau of Agriculture Commodities and Food Standards, the Department of Livestock Development, and the Department of Fisheries. Good coordination and collaboration among these concerned agencies needs to be strengthened.
3.5 Emergencies Thailand is prone to natural disasters, a fact demonstrated most tragically by the devastating tsunami in December 2004 that struck the southern provinces of the country. The country was affected again by heavy floods during August and September 2006, which hit 47 central and southern provinces and forest fire in the Northern Region in 2007. The Royal Government of Thailand is self-reliant in disaster relief operations. WHO and the UN Disaster Management Team have however, supported the country in assessing the health situation and needs as well as in coordinating joint action for health.
3.6 Cross-border health risks Thailand shares borders with the Union of Myanmar, the Lao People’s Democratic Republic, the Kingdom of Cambodia and Malaysia. However, border health concerns are mainly located along the Thailand-Myanmar border and within the Mekong Basin which spans the frontiers with Lao PDR and Cambodia. In the ten provinces of Thailand that border Myanmar there are 401 000 registered migrants, about 117,000 registered
10
WHO Country Cooperation Strategy 2008-2011
in the camps, and an estimated 300 000 to 500 000 people who are not registered citizens. Malaria is a particular concern in the provinces bordering Myanmar because they account for nearly 70% of the disease burden in Thailand. On account of the frequent and unregulated movement of migrants and their varying access to health services, drug resistance to malaria and tuberculosis are a major concern. This is more so since these migrants can potentially spread resistant strains to people in other parts of the country. Apart from six UN agencies, including WHO, about 25 international NGOs are working along the Thailand-Myanmar border. Department for International Development had provided funds to WHO Thailand for its Border Health Programme during 2001–2005. While substantial progress had been made, the same cannot be sustained without inter-agency collaboration and intersectoral support from the Ministries of Public Health, Foreign Affairs, Interior and Labour.
3.7 Health promotion Under the umbrella of “Healthy Thailand,” the Ministry of Public Health initiated nine programme/project approaches. These are: Child Development, School Children in Health Promoting Schools, Healthy Families for a Healthy Thailand, Healthy Cities, Physical Activity and Diet for Health, Reproductive Health, Food Safety, Healthy Public Toilet and Healthy elderly. Several health promotion programmes, campaigns and initiatives have been launched in different parts of the country with either targeted messages or target groups. While there is adequate infrastructure within the MoPH to implement health promotion practices and policies through 12 Regional Health Promotion Centres and 75 Provincial Health Offices, the biggest challenge is to establish effective collaboration and partnerships with other sectors outside the MoPH. These include the Ministries of Education, Interior, Social Development and Security, and Agriculture and Cooperation, and NGOs and civil society. Although the MoPH has a limited budget for developing health promotion, substantial support is being provided by the Thailand Health Promotion Foundation, established by the 2001 Health Promotion Foundation Act. Two per cent of the excise taxes on tobacco and alcohol, or about US$ 55 million annually, has been allocated as revenue for the Foundation, which serves as a catalyst for health promotion activities. The Foundation is supervised by a governing board chaired by the Deputy Prime Minister. In August 2005, the Sixth Global Conference on Health Promotion which yielded the Bangkok Charter for Health Promotion was organized in Bangkok, Thailand. Thailand is in the process of implementing the Bangkok Charter actions and commitments with WHO support.
Thailand
11
3.8 Health systems Health systems development and stewardship Thailand has a developed health infrastructure, and good financial and health resources. Access to basic health care has steadily increased over the past 30 years. The government has accorded high priority to social health security to meet the goal of universal healthcare coverage. However, efforts are needed to improve the quality of services and to ensure the sustainability of the health system. There is also the issue of inequitable access to quality health care in different parts of the country. There are large gaps, for example, between Bangkok and the northeastern region in the magnitude of health resource distribution. The Bangkok Metropolitan Area has about one-fourth and one-tenth of the population per bed and per physician respectively as compared to the corresponding figures for the Northeastern Region (Table 1). While private hospital beds account for about 25% of the total, these mostly serve a limited number of patients who can afford them. Table 1: Distribution of health resources classfied by region, 2004
Source: Report of Health Resources, Bureau of Policy and Strategy, MoPH6.
The most recent Health Systems Reform began in 2000. The National Health Systems Research Institute (HSRI) established the Health Systems Reform Office (HSRO) to serve as the secretariat to the National Health Systems Reform Committee (NHSRC), which plays a guiding role. With the involvement of society and community organizations, the Committee drafted the National Health Bill policies to address the health needs of the people, and to propose an essential health infrastructure that would sustain the new health systems. After seven years of concerted efforts, the Bill was finally approved by the Cabinet in March 2007. The International Health Policy Programme (IHPP), a semi-autonomous organization, was established in 2001, with joint collaboration by the Ministry of Public Health and the HSRI. It aims to develop and strengthen national capacity in health systems, policy research and international health. In 2003, the National Health Security Office (NHSO) was established with the main responsibility of expanding the coverage of health insurance or security to the people who have not been covered by any other government health insurance scheme. It is also responsible for developing standardized
12
WHO Country Cooperation Strategy 2008-2011
benefit packages and financing and ensuring health security rights to target population groups. Considerable progress in health systems development – particularly in expanding health services – notwithstanding, many national challenges remain. These include improvement in the equity and efficiency of services among the poor and disadvantaged groups of the population. At the same time, capacity building in the areas of financial management, health policy development, healthcare system research, medical anthropology, and health-related public laws is being enhanced. With these initiatives Thailand has demonstrated its commitment to health systems development. The National Health Act should generate healthy public policy that would then be implemented by all sectors concerned. The National Health Act blends and balances the philosophy of “sufficiency economy” and the principles of the Tenth National Development Plan. Having learned from the experience of the World Health Assembly, the National Assembly will aim to function effectively, in response to local and national health needs. In conclusion, the health system in Thailand is geered towards raising the level of happiness of the people and the quality of their life as opposed to merely confining itself to the prevention and control of disease. Health financing (a) Health expenditure The national health budget has increased from 5.8% of the total government expenditure in 1993 to 7.6% in 2004 (Annex 3). As depicted in Table 2, about 60% of total health expenditure comes from government sources, against 40% from private sources (outof-pocket and private prepaid plans). External aid in health is as low as 0.1%–0.3% of annual government health expenditure. Table 2: Sources of health expenditure (%)
Sources: World Health Report,20067.
Thailand
13
(b) Health insurance schemes During 2002–2004 the budget allocation of the Ministry of Public Health for health security accounted for 77.8% of total health budget (Annex 4). These funds supported capitation for nationwide health services under the scheme for universal health care coverage (UC), at that time called the ‘30-baht Scheme’, including a special fund for preventive and promotive health services. In 2004, the UC Scheme was estimated to account for 75.2% of the total health insurance schemes in Thailand, and it covered a population of about 47 million. Although the study showed the appropriate capitation rate for the UC is Baht 1,510, the actual per capita payment in 2004 was Baht 1,309 (Table 3). Table 3: Coverage of health insurance schemes in Thailand in 2004
*Due to overlap in coverage the totals may not add up. Sources: Jongudomsuk, NHSO Report 20048.
The UC scheme combined and amalgamated many healthcare coverage schemes and only three public health insurance schemes remained. These were the Social Security Scheme (SSS), Civil Servants’ Medical Benefit Scheme (CSMBS) and the UC Scheme (UCS). Other important achievements of UC include the continuously increasing utilization rates of health care at district hospitals (from 14% to 22%) and at primary healthcare facilities (from 22% to 26%) in 2001 and 2003 respectively, while utilization rates at provincial hospitals were reduced by 50%9. Moreover, the catastrophic health expenditure, among the group of 10-25% of non-food expenditure on health, was reduced from 11.9% in 1996 to 7.6 in 2002, and, among > 50% non-food expenditure group, from 1.4% to 0.5% during the same period10.
14
WHO Country Cooperation Strategy 2008-2011
Health systems and infrastructure Health care in Thailand is organized and provided by both the private and public sectors. The Ministry of Public Health (MoPH) is the principal agency responsible for promoting, supporting, controlling and coordinating all health services for the people. In addition, there are several agencies playing significant roles in providing health services as well as health development. These include the Ministries of Defence, Interior, and Education, the Bangkok Metropolitan Administration, state enterprises, and the private sector. There are also a number of non-profit agencies that provide health services to the people. The main sources of their funding are from the MoPH subsidized budget or from international donors. Health services in Thailand are generally classified into five categories according to the level of care: • • • • • Self-care level (in the household). Primary healthcare Level (village level: midwifery centre). Primary care level (Tambon level: health centre). Secondary care level (District level: community hospital). Tertiary care (provincial level: provincial/regional hospital).
According to the Decentralization Act 1999, decision-making and management authority has been decentralized to the community in response to a demand for local government accountability and a role in national development. Hence, at the primary health care and primary care levels, the Tambon Administrative Organizations (TAOs) are the responsible units for disease prevention and provision of basic health services. During the past 10 years, the number of private clinics and hospitals in Bangkok and other provincial cities has rapidly increased. The total number of beds in these health facilities accounts for about 20% of the total hospital beds. The proportion of health service utilization by private and public services is 24% and 76% respectively6.
3.9 Human resource for health In 2006 there were 25,932 physicians in Thailand, which is about 12,000 less than the optimal requirement stipulated by WHO. The inequitable distribution of physicians and other health personnel between urban and rural, and central and other regions– particularly the north-eastern region is taken into account. According to a Ministry of Public Health report in 2005, about 76% of the people utilize the services at primary healthcare facilities and district hospitals, which have no specialists. However, currently about 77.7% of available physicians are specialists, in either area, who provide services mostly in major hospitals.
Thailand
15
The problem of an acute shortage of physicians was exacerbated by a considerable number of physicians and nurses having resigned from the public health system. Many of them shifted to private hospitals. There was a net loss of physicians, between 194 (22.0%) to 756 (74.6%), during 2001–200311. The principal reasons for their resignation were improved educational opportunities, unsatisfactory hospital management of government, higher pays, and better work conditions12. The biggest exodus was seen in the three southernmost provinces, due to continous unrest situation in the areas. If all requests for transfer from these provinces were granted, government hospitals and clinics would lose 70% of their staff strength13. Thailand, however, has the advantage of two important international HRH networks, namely, the South-East Asia Public Health Institution Network (SEAPHEIN), the Asia-Pacific Action Alliance on Human Resources for Health (AAAH) and SouthEast Asian Regional Association for Medical Education (SEARME) being located in the country, whose expertise it can be fully utilized.
16
WHO Country Cooperation Strategy 2008-2011
3 Development assistance and partnerships: Aid flow, instruments and coordination 1. Partnership with UN and other international development agencies Partnership in health is a key component in the strategy for the progress of health development in Thailand. The country has established viable mechanisms for effective coordination and collaboration on two fronts: • Thailand receives support from development partners in terms of technical and financial resources to strengthen national capacity in specific areas in the health sector. Thailand is also gradually becoming a development partner, like other middle income countries such as People’s Republic of China, Republic of Korea, and others, by assisting developing countries, both within and outside the region, through its foreign policy of “forward engagement”. It has established the Thai International Technical Cooperation Agency (TICA) for technical cooperation with other countries.
•
With regard to the first issue above, key partners of Thailand in health include UN agencies (ILO, IOM, UNAIDS, UNDP, UNESCO, UNFPA, UNICEF and WHO), development banks (The World Bank and Asian Development Bank), bilateral donors (DFID, USAID, EU, etc.) and a few international NGOs. The Ministry of Public Health has also established the Thailand MoPH–US CDC Collaboration Center (TUC) to strengthen national capacity in the prevention and control of epidemics and emerging communicable diseases. Thailand has ratified a range of UN conventions and treaties, those on human rights, child rights (CRC), discrimination against women (CEDAW), labour, environment and tobacco being among them. In addition to UN country offices, the country hosts a number of UN regional offices (23 UN agencies and two development banks) which are based in Bangkok and provide services to neighbouring countries. The United Nations Development Assistance Framework (UNDAF), referred to as the United Nations Partnership Framework (2007–2011) in Thailand, has been developed jointly with the Royal Thai Government (RTG). In keeping with the UN’s reform, alignment and harmonization agenda, it provides a framework to jointly plan and support, in a complementary and coordinated manner, the national plans and 17
Thailand
strategies in areas where the UN has mandated expertise and comparative advantage. As a specialized agency, WHO is one of the signatories to this framework, which outlines the following five areas of cooperation: (a) (c) (e) Access to quality social services and protection; Access to comprehensive HIV prevention, treatment, care and support; Global partnership for development – Thailand’s contribution. (b) Decentralization and provincial/local governance; (d) Environmental and natural resources management, and With regard to the second item above, with large-scale financial contributions from other development partners being reduced, these do not have permanent programmes in Thailand any more. Assistance is provided to the country through targeted areas of action and cooperation. Health-related areas that received financial and technical cooperation from the development partners in 2004–2005 including support for women and gender issues; HIV/AIDS treatment, prevention, and advocacy; and support for improvement of land and water resources to reduce vulnerability to natural disasters and enhance productivity. The UNDAF 2002–2006 for Thailand was developed with the overarching goal of promoting the reduction of disparity and ensuring sustainable human development. An indicative programme resource framework, according to individual agency mandates, was also made14. This is indicated in Table 4 below. Table 4: UNDA Indicative Programme Resources Framework, 2002–2004
18
WHO Country Cooperation Strategy 2008-2011
2. Partnership with developing countries Thailand has been active in a number of regional and sub-regional cooperation initiatives with developing countries in many areas, including health. These initiatives have been carried out through agencies, mechanism and other initiatives such as the Association of South-East Asian Nations (ASEAN), Asia-Pacific Economic Cooperation (APEC), Greater Mekong Sub-region (GMS), Mekong-Ganga Cooperation (MGC), AyeyawadyChao Phraya-Mekong Economic Cooperation Strategy (ACMECS) and the Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation (BIMST-EC). The Greater Mekong Sub-region, which comprises six countries along the Mekong basin (Cambodia, PR China, Lao PDR, Myanmar, Thailand and Viet Nam), builds strong partnerships in social and economic cooperation. In the area of health, programmes such as the Mekong Basin Disease Surveillance (MBDS), Mekong Malaria Programme and Human Resource Development Projects are included. The Asia-Pacific Action Alliance on Human Resources for Health (AAAH), its main office being located in Thailand, is a response to the international recognition of the need for global and regional action to strengthen country planning for HRH. Thailand is the only non-member of the Organization for Economic Co-operation and Development (OECD) that produced a report on Millennium Development Goals (MDG) -8: The Global Partnership for Development. This goal sets targets for increased Official Development Assistance (ODA), ensuring access for developing countries to technology and essential drugs. By engaging in the South-South development cooperation and taking a leading role in regional and sub-regional cooperation initiatives, Thailand is actively sharing with other countries its own knowledge of what it takes to reduce poverty rapidly, improve health and education, and confront the challenges of environmentally sustainable development. This cooperation policy has also led to an engagement in programme development assistance to African countries, notably in the field of HIV/ AIDS prevention, in collaboration with UNDP .
3. Technical cooperation with other countries During 2004–2006, a total of 602 Fellows from all Member countries of the South-East Asia, Western Pacific and Eastern Mediterranean Regions visited Thailand to gain experience in different medical and health fields. Their fields of study were health systems, primary health care, health promotion, nursing care, laboratory investigation and epidemiology. During 2005–2006 about 50 Thai experts were recruited as consultants by WHO and other international health-related agencies to work within and outside the Region. They contributed in varied sectors including health insurance, quality assurance of laboratory services, disaster preparedness and response, registration of medicines, HIV/STD, dengue prevention and control, and epidemiology training.
Thailand
19
4. WHO collaborating network Currently Thailand has 33 designated and functioning WHO Collaborating Centres and 35 Centres of Expertise. These centres provided training to national and international fellows, conducted studies in areas identified or stipulated by WHO, and offered reference laboratory services. A “Network for WHO Collaborating Centres and Centres of Expertise in Thailand” (NEW-CCET) was established to share experiences and strengthen institutional capacity. The “National and Regional Experts System for SouthEast Asia Region (NRES)” was developed under the NEW-CCET. This system includes Thai experts and institutional databases. This is a good initiative, but to be fully functional, it requires improvement and sustainable funding. The role of the NEW-CCET is being reviewed.
20
WHO Country Cooperation Strategy 2008-2011
4 Current WHO cooperation
1. Work of the WHO Country Office encompasses: • Advocacy, technical advice, and technical services/support to the government, UN agencies and other development partners on health and health-related matters; Partnerships and coordination with other stakeholders for effective response, especially in tackling health issues; Identifying Thai technical expertise and facilitating the sharing of that expertise with neighbouring countries, other Regions, and also globally; Providing administrative support to the Regional Office, HQ and other Country Offices in arranging fellowships, consultations, conferences and technical meetings and facilitating laboratory services to Bhutan, Myanmar and Nepal under the polio eradication programme; Disseminating WHO’s policies and positions through the media and other communication channels, and Providing administrative support and common services to WHO sub-regional health units that are based in Bangkok.
• • •
• •
2. Focus of WHO’s collaboration with Thailand WHO’s collaboration with Thailand is based on the WHO Country Collaborative Programme which is developed on a biennial basis. The current CCS 2004–2007 was used as a framework and guideline for the development of the biennial programme budget and workplans in the 2004-2005 and 2006-2007 bienniums. The Country Office focused on supporting policy development, providing technical advice, and developing norms and guidelines. In accordance with the CCS 2004-2007 and in continuation of some priorities from the 2004-2005 biennium, the WHO Country Office has in the current biennium focused on the following areas of work: • • Communicable disease prevention and control, including epidemic alert and response; Prevention and management of chronic and non-communicable diseases, and health promotion; Thailand
21
• • • • •
Health research, evidence, and health systems development; Emergency preparedness and cross-border health; Immunization and vaccine development; Technical cooperation among countries, and Health and environment.
Previous CCSs have helped to focus WHO collaboration with the RTG on a few priority areas where the Organization has an advantage and for which it receives requests from the government. Nevertheless, additional efforts are required to streamline the number of activities carried out within the ambit of these broad priority programmes. The WHO Country Office still issues a large number of contracts to implement these activities. The administration of these contracts require considerable time and effort on the part of the Country Office staff. In order to ensure that the research and studies undertaken with WHO support are applied to developing and monitoring health programmes, principal investigators were requested, at the end of 2006, to present their work at the WHO Country Office. Many of these were found to be valuable, and feasible to implement. Some have been replicated within the MoPH and other related institutions. However, it will be useful to review the studies undertaken and models developed to ensure that there is no duplication, and that they are practical and feasible.
3. Funding of WHO collaborative programmes. Budgetary support to carry out these programmes comes from WHO’s assessed and voluntary contributions, and from other international agencies outside WHO. The assessed contribution for the WHO Country Programme in 2004–2005 was US$ 5.18 million. In addition, about US$ 1.69 million in voluntary contribution was mobilized for Thailand from across WHO, including US$ 281,000 for the tsunami relief operation. There has been an increase by 11% in assessed contributions for 2006–2007 to US$ 5.78 million, following the decision of the 2005 World Health Assembly to increase the assessed contributions by Member States. In addition to this assessed contribution, the Country Office has till date received about US$ 2–3 million through voluntary contributions.
4. Fellowships From the 1998–1999 bienniums till the current biennium, the WHO Country Office has provided 36 long-term fellowships to staff of the Ministry of Public Health and university. Fellows have completed courses leading to five certificates, 17 Masters degrees and 14 PhDs in the field of public health, HRH, health economics, health services management, international health, health policy, health planning and financing, epidemiology, policy analysis, health promotion, medical anthropology, health service research, public health nutrition and Genetic Epidemiology.
22
WHO Country Cooperation Strategy 2008-2011
5. Regional Sub-units In addition to the Country Office, WHO has two Regional Sub-units in Thailand: • • Mekong Malaria Programme: This is a bi-regional project based in Thailand to coordinate WHO activities in countries of Mekong Basin. WHO Regional Sub-unit for Communicable Disease Control (CSR Subunit): The Regional Director decided in 2005 that a CSR Regional Sub-unit was to be established in Bangkok. The rationale behind this unit being located outside the Regional Office was its locational advantage, its infrastructure in terms of transport and communications, and the technical expertise that Thailand possessed. The decision to establish a sub-unit was in keeping with the decentralization policy initiated by the Regional Office and the felt need to establish a regional presence in Bangkok to better interact with agencies in that part of the Region. The Sub-unit will operate within the broader context of supporting countries to develop the required core capacities for: a) implementing the International Health Regulations (IHR); b) strengthening the Field Epidemiological Training Programme (FETP); c) the Asia-Pacific Strategy for Emerging Diseases (APSED); d) developing early warning systems and risk assessment of potential public health emergencies of international concern (PHEICs) and response, and e) promoting research, particularly evaluative research. At the same time, Thailand will desire maximum benefit of technical support from the CSR, and the Sub-unit will engage with the MoPH to support other Member States as well. Although this sub-unit is established under the Regional Office’s technical and administration settings, its operations may go beyond the Region to assist countries in the Greater Mekong Sub-region, whenever there is a cross-border outbreak of an important disease.
6. Staffing Thailand has a relatively small office in terms of number of technical staff. Moreover, it is able to provide and share technical expertise, particularly with its neighbouring countries. WHO has played an important role in identifying and facilitating this sharing. Currently there are only two international professional staff (WR and the Administrative Officer), six national professional officers and 13 national support staff in the Thailand Country Office. Additionally, the Regional Sub-units have three international Professional staff and one General Service staff. The support for the Subunit is covered by funds from outside the country budget. The organogram is provided in Annex 8.
Thailand
23
7. Office premises The Ministry of Public Health has provided office space gratis for the WHO Country Office as well as for the CSR Regional Sub-unit. The Mekong Regional Sub-unit is located in the Faculty of Tropical Medicine, Mahidol University, Bangkok.
8. Information and communication technology Although Thailand has very good communication facilities, the Country Office as well as the CSR Sub-unit have been connected with the Global Private Network (GPN) enabling faster connections with the Regional Office and Headquarters. It is equipped with tele and video conference facilities. In view of Thailand’s strength in IT expertise, the Regional Office may consider decentralizing the maintenance and updating of the ITC system to the Country Office for reasons of expediency.
9. Use of CCS Overall, the current CCS has been well utilized by the WHO Country Office to develop workplans that align with the National Health Plan and other national health and development frameworks. Whether the priorities identified in the previous CCSs have informed the regional or global strategies and priorities still remains an issue. Table 5: Performance in priority areas, in relation to WHO core functions (2004–2007)
The extent to which the priorities identified in the CCS were implemented in line with the six core functions of WHO is presented in Table 5. The relative weight assigned, in terms of the number of pluses (+) in the table, is based on the scope of work undertaken in the biennium 2004–05 and calendar 2006. 24 WHO Country Cooperation Strategy 2008-2011
5 WHO policy framework – Global and regional directions 1. Global challenges in health The General Programme of Work (GPW) is the highest-level policy document of WHO. The Eleventh GPW (2006-2015) sets out the direction for international public health for the period of 2006 through 2015. The document notes that though there have been substantial improvements in health over the last 50 years, significant challenges remain, as elucidated in the following four gaps: (a) Gaps in social justice: Clearly, poverty is a key factor that impedes access to quality health services. In some countries, life expectancy of the poor is 20 years lower than other, more privileged members of society. Poor health and poverty form a vicious cycle. Other factors that reduce access to services are discrimination by ethnicity or gender and women’s health, which are often not adequately addressed.
(b) Gaps in responsibility: Health problems are no longer merely the responsibility of those working in health, but also require positive action by those outside the health sector. International conflicts and national crises often lead to the disruption of social services, including healthcare. Globalization and decisions on international trade have a direct impact on health, especially in pharmaceuticals and the movement of health professionals. In many countries, ministries of health often do not have the capacity to influence adequately important causes of ill health that are outside the purview of the health sector. (c) Gaps in implementation: Very often the technology to implement costeffective interventions to improve health may be available, but is not implemented because of paucity of funds and human resources, or the absence of an effective health system. Available resources may often be allocated to high-cost curative services that tend to favour urban areas, leaving inexpensive and effective interventions in rural and remote areas neglected.
(d) Gaps in knowledge: Global advances in science and technology have improved the effectiveness and efficiency of medical services and the prevention and treatment of diseases. However, information about these advances is often not available in many countries. In addition, the lack of information about health conditions and existing rigidities in many countries Thailand
25
have in turn made it difficult to formulate and manage effective health policies and interventions. Even operational research for those most in need of health services is generally not conducted, thereby reducing the efficiency of key programmes.
2. Global health agenda In order to reduce these gaps over the coming ten years, the Eleventh GPW outlines a global health agenda consisting of seven priority areas: • • • • • • • Investing in health to reduce poverty; Building individual and global health security; Promoting universal coverage, gender equality, and health-related human rights; Tackling the determinants of health; Strengthening health systems and equitable access; Harnessing knowledge, science, and technology, and Strengthening governance, leadership, and accountability.
The global health agenda is intended for everyone engaged in the field of health development. WHO will contribute to this agenda by concentrating on its core functions, which have been built on the comparative advantages of the Organization. In accordance with the global health agenda and WHO’s core functions, the Organization has set the following priorities: (1) Providing support to countries in moving to universal coverage with effective public health interventions; (2) Strengthening global health security; (3) Generating and sustaining action across sectors to modify the behavioural, social, economic, and environmental determinants of health; (4) Increasing institutional capacities to deliver core public health functions under the strengthened governance of the ministries of health, and (5) Strengthening WHO’s leadership at global and regional levels and supporting the work of governments at the country level. WHO will pursue these priorities through its Medium Term Strategic Plan (MTSP) (2008-2013) and the biennium budget of the Organization. The Director-General has clearly placed emphasis on the work of the Organization at the country level. The Regional Offices and Headquarters have been directed to emphasize support for country work and implement these priorities in Member States, especially where the health needs are greatest. 26 WHO Country Cooperation Strategy 2008-2011
WHO’s core functions • • • • • • Providing leadership on matters critical to health and engaging in partnerships where joint action is needed; Shaping the research agenda and stimulating the generation, translation, and dissemination of valuable knowledge; Setting norms and standards , and promoting and monitoring their implementation; Articulating ethical and evidence-based policy options; Providing technical support, catalyzing change, and building sustainable institutional capacity; Monitoring the health situation and assessing health trends.
3. Regional policy framework The South-East Asia (SEA) Region has the second highest population among the six WHO Regions and has the greatest burden of disease. While there has been considerable economic development in this Region in recent years, poverty and poor health remain significant issues of concern. Many Member countries have faced health emergencies of varied magnitude in the past decade and the threat of disease outbreaks always exists. Noncommunicable diseases have also become an increasingly important cause of morbidity and mortality in the SEA Region. Therefore, the global policy framework of WHO is appropriate for countries of the Region with special attention towards strengthening the capacity of Member States to support cost-effective public health interventions. The Regional Office has always placed strong emphasis on its work in Member States. Of the total budget provided to the Region, 75% is allocated for countries which is the highest ratio among the six Regions. The Regional Director for South-East Asia has recently enhanced the delegation of authority to country offices to enable them to plan and implement programmes with a higher degree of independence and to be more accountable for their work. At the same time, he has emphasized that the Regional Office staff should give the highest priority to support the work in these countries.
Thailand
27
6 Strategic agenda: Priorities jointly agreed for WHO cooperation in and with countries 1. Principles The key principles for the WHO Strategic Agenda are to: • • • Enhance advocacy in supporting government matters critical to health, based on WHO mandates and governing body resolutions; Be more selective and focused in determining which health sector programmes are to be supported; Maintain flexibility to respond to requests as they arrive, while defining the boundaries within which WHO will respond and focus on what the organization can do best; Emphasize the role of WHO as a policy adviser and broker, and differentiate WHO’s work and performance from that of the government, while continuing to work as government’s key partner in health, and Seek out opportunities to enhance and strengthen partnerships with UN agencies and actors, and explicitly take into account the harmonization of programmes among development partners.
•
•
This approach will increase the effectiveness of WHO country programmes. Welldefined priorities will help to ensure a better match between the needs of the country and the globally agreed strategic objectives, in which WHO has a clear advantage compared to other partners.
2. Strategic agenda Based on the health issues and challenges identified in the situation analysis, WHO’s GPW and Medium Term Strategic Plan, and recognizing WHO’s comparative advantage identified through the consultations with national and international partners, seven components of the strategic agenda have been jointly agreed for WHO’s cooperation with the Government of Thailand.
Strategic Agenda 1: Enhancing primary prevention, surveillance and control of communicable diseases and epidemics Important communicable diseases that are still major public health concerns in Thailand include malaria and dengue haemorrhagic fever, HIV/AIDS, STI, TB and emerging
28
WHO Country Cooperation Strategy 2008-2011
diseases, avian influenza in particular. In addition to disease prevention and control interventions by the government and stakeholders, it is very important to empower people to know how to avoid risks of contracting diseases. For national self-reliance, the government has also announced an ambitious plan to strengthen its capacity in vaccine production. Important strategies include: • • • • • • Strengthen risk communication skills for health personnel. Improve managerial skills and coordination in epidemic surveillance and response, particularly at the peripheral level. Facilitate quality assurance of laboratory investigations. Support for monitoring directly observed treatment, short-course (DOTS), antiretroviral therapy (ART) and malaria treatment at all levels. Support for timely implementation of IHR. Support for vaccine production.
Strategic Agenda 2: Integrating measures to reduce risks of noncommunicable diseases (NCDs), injuries and mental illness NCDs are groups of chronic diseases that have common risk factors. Prevention and control require multi-sectoral collaboration to address them collectively. The same principles can be applied for injury prevention. National personnel require managerial skills, especially in collaboration with multi-stakeholders and for effective implementation of the programme. Prevention of mental illness will focus on community mental health by promoting mental health through young children and adolescents. Important strategies include: • • • • • • Develop a policy of integrated control measures for non-communicable diseases, injuries and mental health. Strengthen capacity on programme management at the central and regional levels. Support scaling up of primary prevention and care for NCDs, injuries and mental illness. Standardize and systematize NCD risk factor surveillance, as well as morbidity and mortality surveillance. Strengthen implementation and monitoring of Global Strategy on Diet, Physical Activity and Health and Framework Convention for Tobacco Control (FCTC). Enhance advocacy in implementing the National Mental Health Policy.
Strategic Agenda 3: Building capacity and partnerships for health promotion and healthy public policy Thailand has accorded very high priority to health promotion as a most important approach for public health implementation, as reflected in the Tenth National Health Development
Thailand
29
Plans and the National Health Act. The Ministry of Public Health is one among many key players, and it is important that health promotion be sold to the non-health sector to ensure the success of public health interventions. Attracting investment to health promotion requires strong evidence of health promotion effectiveness, in terms of raising peoples’ health status as well as economical gain. Important strategies include: • • • • • • Advocate for healthy public policy in different sectors. Strengthen the National Health Commission and facilitate the roadmap for the Public Health Initiative under the National Health Act. Strengthen implementation, evaluation and dissemination of outcomes of Healthy Setting Approach to all sectors. Support implementation of the recommendations of the Sixth Global Conference on Health Promotion. Integrate concepts and principles of health promotion into the undergraduate medical and health training school curriculum. Supporting demonstration and dissemination of evidence-based health promotion effectiveness for advocacy and policy development.
Strategic Agenda 4: Strengthening capacity for monitoring and evaluating, and for health systems development Thailand is undergoing a transition in its health systems development. Many measures have been initiated, especially in areas of health care financing and decentralization. To ensure effective implementation, systematic monitoring and evaluation is required. The Tenth National Health Development Plan and the National Health Act are now effective. Indicators for monitoring and evaluation of the programme have to be developed, and the programme has to be assessed as a baseline from the beginning. Important strategies include: • Build capacity in the area of health policy development, financial management, health care systems research, medical anthropology, and healthrelated laws. Support monitoring and evaluation of health systems performance, including decentralization. Support development of appropriate mechanism for national healthcare financing. Advocate for the national policy on trade and health, and for networking with other countries. Facilitate technical cooperation among countries (TCC) for global and regional public health action. Support the development of appropriate health infrastructure to respond to health emergencies.
• • • • •
30
WHO Country Cooperation Strategy 2008-2011
•
Streamline essential medicines and prevent the manufacture and circulation of counterfeit and sub-standard medicines.
Strategic Agenda 5: Multi-sectoral approach to address health services for the poor and at-risk population, including those in border and conflict areas Although Thailand shares borders with Myanmar, Lao PDR, Cambodia, and Malaysia, the health of the people on the border with Myanmar and in the conflict zones of the three southern provinces pose the greatest concern. There are many national and international NGOs that deal with issues concerning migrants, labour and health in provinces along the border of Thailand and Myanmar. Understanding and collaboration among the key players is of primary importance. This requires training and orientation on health-related issues, particularly for all field staff. Important strategies include: • • • • • • Ensure incorporation of border health issues into the National Security Policy. Enhance coordination and collaboration among different partners, particularly those related to border health. Facilitate collection and dissemination of health-related information. Build capacity in border health for all related staff Network for improvement of health services delivery. Strengthen disease surveillance in key areas.
Strategic Agenda 6: Promoting environmental health and surveillance of environmental hazards Thailand has increasingly shifted from an agricultural economy to an industrialized one, keeping pace with the trends and competitiveness in industry among the nations of the world. Such a surge towards industrialization brings with it problems of migration, urbanization and environmental degradation, which sometimes assume colossal proportions. The environment can be protected most effectively through action by communities and local organizations. Their participation can be ensured, through building awareness and capacity. Important strategies include: • • • • Multi-sectoral collaboration for a healthy public policy on environmental health. Empower local organizations/communities for environmental protection and detection of environmental hazards. Support the development and implementation of environmental health legislation. Support the development, implementation and evaluation of the National Environment Health Action Plan (NEHAP).
Thailand
31
• •
Build national capacity on health impact assessment (HIA) and promote the use of the findings for policy development. Improve collaboration and coordination in the implementation of food safety programmes among all sectors concerned across the board.
Strategic Agenda 7: Strengthening the development of human resources for health through existing networks within and outside the country During the past five years, the country has been coping with the problem of health personnel migrating from rural to urban areas and from the public to the private sector. This leads to inequitable access to quality health services. Although there is less migration of public health personnel compared to those in the medical services, the public health workforce is not in any better situation. There are inadequate numbers of qualified public health personnel in the health systems, largely due to economic and career reasons. It is important that the country should identify appropriate mechanisms to address issues of human resources for health. There is a clear strategy for health manpower development that serves the new health reform under the Ninth National Health Development Plan. This strategy should be continued under the Tenth Plan. Important strategies include: • • • • Support networks for the development of the National Public Health Workforce Profile and training institutions. Promote studies addressing HRH development issues and generate evidencebased information for policy development. Support capacity building of the public health workforce in specific areas according to the country’s needs, within and outside the country. Advocate for the establishment of a producer-user forum to generate practical recommendations for development of national HRH.
3. Modalities of implementation: • For technical and administrative effectiveness and efficiency in programme implementation during the coming biennium, the modality of support will be shifted from total project support to more direct programme implementation support, for example, for training, workshops, consultancy and fellowships. The WHO Country Office will play a coordinating role in identifying and recruiting experts required by the country, as well as a facilitating role in recruiting Thai experts as WHO consultants to work within or outside the country. Rosters of Thai experts will be made available on the WHO Country Office website as well as the websites of the WHO Collaborating Centres and the Regional Directory of Training Institutions (RDTI) in SEARO. The Country Office will act as a coordinating centre for coordination to recruit consultants after being initiated by the Regional Office and Headquarters.
•
32
WHO Country Cooperation Strategy 2008-2011
•
WHO has a policy of long-term (of at least six months) Fellowship support, with degree, certificate, or diploma programmes, rather than short-term Fellowship support. Fellowship support should be completed within the same biennium. Considering sustainability, support will not be provided to the same programme for more than one biennium. Exchange visits of experts among Member countries are also encouraged. WHO Collaborating Centres shall be more fully utilized for the placement of Fellowships to conduct training and research. . Since Thailand has been considered to be an ideal centre for hosting meetings, seminars and conferences, the WHO Country Office will continue to provide support to the Regional Office and Headquarters in coordinating the arrangements for the same. WHO will continue to be actively engaged with organizations of the United Nations, and will participate in the implementation of United Nations Partnership Framework (UNPAF) and the health cluster of Inter-Agency Standing Committee (IASC) on UN humanitarian response and monitoring of the progress towards the MDGs. Emphasis will be placed on each priority area of the CCS in relation to WHO’s Core Functions as shown in Table 6 below: Table 6: Emphasis on priority areas of the CCS 2008-2011 in relation to WHO’s core functions
• •
•
•
Thailand
33
7 Implementing the strategic agenda: Implication for WHO Secretariat, follow-up and next step at each level
1. Introduction Compared to the period of the current CCS (2004-2007), there are three major issues that may have implications for the WHO Secretariat, namely (a) Establishment of the Regional Sub-unit for Communicable Disease Control and Surveillance (CSR) attached to the WHO Country Office, (b) Change of staff composition, (c) Change of the programme planning and implementation process, from setting general objectives to outlining strategic objectives. These implications include staffing, allocation of financial resources, information support and follow-up of programme implementation.
2. Staffing: Current and future Unlike the other countries of the SEA Regions, Thailand is nearly self-sufficient in the availability of experts in several health fields. The roles of the WHO Country Office in supporting health development include both technical coordination and direct technical support. Most of the WHO technical staff in the Country Office are National Professional Officers (NPOs) instead of internationally-recruited staff. There are six NPOs who are responsible for (a) programme planning and management, (b) programme monitoring and evaluation, (c) endemic communicable diseases, (d) HIV/AIDS and tuberculosis (e) surveillance of tobacco control and, (f) tobacco control. One international staff has been assigned for the Border Health Programme and for coordinating the Malaria Mekong Project. While CSR regional sub-unit and Mekong Malaria Programme (MMP) are administered and use common services with the Country Office, all Professional staff are under the technical supervision of the Director, CDS, SEARO. The Coordinator MMP is also responsible, as team leader, for the Border Health Programme. To build the technical and managerial capacities of WHO county staff, the Regional Office encourages horizontal collaboration among Member countries, with technical supervision or support from the Regional Office, when required. Periodic training and development of country staff, particularly on programme planning, monitoring and evaluation, is needed.
34
WHO Country Cooperation Strategy 2008-2011
While staff of the Thailand Country Office have to provide support to their national counterparts in implementing WHO Country Collaborative Programmes, they also have to provide administrative support to HQ, the Regional Office as well as other Country Offices during various consultations, meetings and conferences. Whenever a programme requires an authority in a particular health area, a suitable national expert would be the preference of the WHO Country Office and a few government staff may be recruited for brief periods to collaborate on programme implementation.
3. Financial allocation It is anticipated that there will be zero growth in the regular budget for the 2008-2009 and 2010-2011 bienniums compared to the current biennium, and additional voluntary contribution (VC) resources are therefore required. In addition to VC received from HQ, it is important that the Country Office should build staff capacity to be able to support the country to mobilize resources to implement important programmes and activities. With the advantage of the CSR Sub-unit being physically located in the Ministry of Public Health, it is expected that Thailand may obtain a substantial amount of VC to support the prevention and control of epidemic communicable diseases, particularly avian influenza. Thailand has an open policy for multi-country activities and is ready to provide country budget support to some countries according to their needs. This, however, requires better advanced planning to avoid uncertainty and delayed implementation.
4. Information and communication support Being the hub of coordination and collaboration activities for many WHO collaborative programmes, the Thailand Country Office requires support to improve the information and communication systems. The Country Office must regularly update and improve the WHO Thailand website, including its technical contents. It is expected that development of the Global Management System (GSM) will be completed and shall be used as a central tool for all WHO information systems during this CCS period. Past experiences with AMS and problems in reconciling routine technical and financial implementation should be considered as ‘lessons learned’. To avoid interruption of routine work, timely support for updating hardware and software and adequate training of country staff during the transitional period is crucial.
5. Implementation of the strategic agenda (a) Role of the Country Office: The WHO Thailand Country Office will provide advocacy support to government policy within the organization’s mandate, offer technical support, and coordinate
Thailand
35
programme implementation, primarily to inform about capacity building; encourage an evidence-based approach; promote research, monitoring, and evaluation; and facilitate inter-country collaboration. Another important role of the WHO Country Office would be to support the country in mobilizing resources.
(b) Role of the Regional Office: In spite of the decentralization of authority from the Regional Office to the Country Office, technical support from the Regional Office, particularly in areas where national and Country Office expertise is not available, will still be required. This includes tuberculosis programme management, NCD programme management, preparation for the implementation of GSM, and the development of a National Environmental Health Action Plan (NEHAP) and National Health Impact Assessment (HIA) and vaccine production endeavours. The Regional Office should also provide support and coordination for some MCAs and some activities that involve countries outside the South-East Asian Region.
(c) Role of Headquarters: In consultation with the Regional Office, Headquarters may be requested to provide support to the Country Office in the following areas: • • • • Demonstration and documentation of effectiveness of health promotion; Evaluation of health systems reform; Studies on the implications of trade on health and health systems, and Acquisition of new technology, production of medicines and vaccines.
Headquarters should also play a key role in mobilizing resources for important strategic areas where the regular budget is limited, for example, health promotion, injury, environmental health, and health systems development.
36
WHO Country Cooperation Strategy 2008-2011
Annex 1
National health development data Indicator Finance General government expenditure on health as a percentage of total expenditure on health General government expenditure on health as a percentage of total government expenditure Per capita total expenditure on health at average exchange rate (US$) Per capita total expenditure on health in dollars Per capita GDP at average exchange rate (US$) Per capita GDP in international dollars Per capita government expenditure on health at average exchange rate (US$) Per capita government expenditure on health in international dollars Prepaid plans as a percentage of private expenditure on health Private expenditure on health as a percentage of total expenditure on health Out-of-pocket expenditure as a percentage of private expenditure on health Social security on health as a percentage of general government expenditure on health Total expenditure on health as a percentage of GDP Total expenditure on health as a percentage of GDP Human resources Health workers (rate per 1000 population) Physicians Nurses Midwives Public & environmental health workers Service delivery In-patient beds per 1000 population Physician: Hospital beds 2.13 1:7 Report on Health Resource and Survey Data 20046 22,435 (0.37) 171,605 (2.82) 872 (0.01) 2,151 (0.04) WHR 2006 7 61.6 13.6 76 260 2,490 7,930 47 160 14.6 38.4 74.8 32 3.3 6.12 Thailand Health Profile (2001-2004)16 WHR 2006 7 World Development Indicators Database, World Bank, 18 April 200615
Unit
Source
WHR 2006 7
Thailand
37
Annex 2
Strategic objectives and their scope under MTSP 2008-2013 Strategic objective 1. To reduce the health, social and economic burden of communicable diseases Scope of strategic objective The work under this Strategic Objective focuses on prevention, early detection, diagnosis, treatment, control, elimination and eradication measures to combat communicable diseases that disproportionately affect poor and marginalized populations. The diseases to be addressed include, but are not limited to vaccine-preventable, tropical, zoonotic and epidemic-prone diseases, excluding HIV/AIDS, tuberculosis and malaria. The work under this Strategic Objective will focus on scaling-up and improving HIV/AIDS, TB and malaria prevention, treatment, care and support interventions so as to achieve universal access, including among high-burden populations, women, infants, children, adolescents, poor and vulnerable groups; advancing related research; addressing key bottlenecks that are currently impeding intervention access, use and quality; and contributing to the broader strengthening of health systems. The work under this Strategic Objective focuses on policy development, programme implementation, monitoring and evaluation, strengthening of health and rehabilitation systems and services, implementation of prevention programmes and capacity building in the area of chronic noncommunicable conditions, including cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, hearing and visual impairment and genetic disorders, as well as mental, behavioural, neurological and psychoactive substance use disorders, and injuries due to road traffic accidents, drowning, burns, poisoning, falls, violence in the family, community or between organized groups, and disabilities from all causes. The work undertaken under this Strategic Objective will focus on action towards ensuring universal access to and coverage of effective public health interventions for maternal, newborn, child, adolescent, and sexual and reproductive health, with emphasis on addressing gender inequality and health equity gaps; development of evidence-based, gender-sensitive, coordinated and coherent approaches to addressing the needs at key stages of life and improving sexual and reproductive health, using a life-course approach; fostering synergies between maternal, newborn, child, adolescent, sexual and reproductive health along with other public health programmes, and supporting action to strengthen health systems; and formulation and implementation of policies and programmes that promote healthy and active ageing for all individuals.
2. To combat HIV/AIDS, malaria and tuberculosis
3. Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, mental disorders, violence and injuries
4. To reduce morbidity and mortality and improve health during the key stages of life, including pregnancy, childbirth, neonatal period, childhood and adolescence, while improving sexual and reproductive health and promoting active and healthy ageing for all individuals using a lifecourse approach and addressing equity gaps
38
WHO Country Cooperation Strategy 2008-2011
Strategic objective 5. To reduce the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact
Scope of strategic objective Joint efforts of the Member States and the Secretariat regarding this Strategic Objective encompass the following aspects: Health sector emergency preparedness, intersectoral action for risk and vulnerability reduction within the framework of the International Strategy on Disaster Reduction, response to the health needs (including nutrition as well as water and sanitation) of emergencies and crises, needs assessment of affected populations, transition and recovery health actions in postconflict and post-disaster situations, fulfilling the mandate of WHO within the framework of Humanitarian Reform, global alert and response system for environmental and food safetyrelated public health emergencies, threat-specific risk reduction along with preparedness and response programmes for such emergencies. The work under this Strategic Objective focuses on integrated, comprehensive, multi-sectoral and multidisciplinary health promotion processes and approaches across all relevant WHO and country programmes, and the prevention and reduction of six major risk factors: Use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diet and physical inactivity and unsafe sex. The main activities involve capacity building for health promotion across all relevant programmes, risk factor surveillance, the development of ethical and evidence-based policies, strategies, interventions, recommendations, standards and guidelines for health promotion, and the prevention and reduction of the major risk factors. The work under this Strategic Objective focuses on leadership in intersectoral action on the broad social and economic determinants of health; improvement of population health and health equity by better meeting the health needs of the poor, vulnerable and excluded social groups; connections between health and various social and economic factors (labour, housing and educational circumstances; trade and macroeconomic factors; and the social status of various groups such as women, children, the elderly, and ethnic minorities); development of policies and programmes that are ethically sound, responsive to gender inequalities, effective in meeting the needs of the poor and other vulnerable groups, and consistent with human rights norms. This Strategic Objective is aimed at addressing and reducing a broad range of traditional, modern and emerging health and environmental risks. Its purpose is to encourage strong health sector leadership for primary prevention of disease through environmental management as well as support strategic direction and guidance to mobilize non-health sector actors about how their policies and investments can lead to win-win development strategies that also benefit health.
6. To promote health and development, prevent and reduce risk factors for health conditions associated with tobacco, alcohol, drugs and psychoactive substance use, unhealthy diets, physical inactivity and unsafe sex
7. To address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, genderresponsive and human rights-based approaches
8. To promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health
Thailand
39
Strategic objective
Scope of strategic objective The work undertaken in this Strategic Objective will focus on the assessment and management of environmental and occupational health risks, including such risks as unsafe water and inadequate sanitation; indoor air pollution and solid fuel use; and disease vector transmission. The scope of this Strategic Objective also includes: health risks related to change in the global environment (e.g. climate change and biodiversity loss); development of new products and technologies (e.g. nanotechnology); consumption and production of new energy sources and the increasing number and use of chemicals; and also health risks related to changes in lifestyles, urbanization and working conditions (e.g. deregulation of labour, an expanding informal sector and the export of hazardous working practices to poor countries).
9. To improve nutrition, food safety and food security throughout the lifecourse and in support of public health and sustainable development
The work under this Strategic Objective focuses on nutritional quality and safety of foods; promotion of healthy dietary practices throughout the life-course, starting with pregnant women and including breastfeeding and adequate complementary feeding, and considering diet-related chronic diseases; prevention and control of nutritional disorders, including micronutrient deficiencies, especially among the biologically and socially vulnerable, with emphasis on emergencies, and in the context of HIV/AIDS epidemics; prevention and control of zoonotic and non-zoonotic foodborne diseases; stimulation of intersectoral actions promoting the production and consumption of, and access to, food of adequate quality and safety; and promotion of higher levels of investment in nutrition, food safety and food security at the global, regional and national levels. The work to be undertaken as part of this Strategic Objective will enhance the way health systems perform in response to the needs and demands of the population. It is underpinned by the principles of Primary Health Care and Health for All, and a concern to reduce inequity in access to, and eliminate exclusion from the benefits of, health care. It seeks to equitably expand access across the range of services needed to improve health outcomes and respond to legitimate demand for care, by matching service response to needs and demand, by increasing organizational and managerial capacities of institutions and provider networks, and by strengthening informed demand; and covers the organization and management of all population-based and personal health services – individual providers, facilities and provider networks; public, private and voluntary; at all levels, from those within the community to tertiary hospitals and specialized services.
10. To improve health services through better governance, financing, staffing and a management informed by reliable and accessible evidence and research
40
WHO Country Cooperation Strategy 2008-2011
Strategic objective
Scope of strategic objective It is concerned with the promotion of all aspects of quality in relation to service delivery: patient- and communitycenteredness, responsiveness, continuity of care, as well as safety, effectiveness and efficiency; with overcoming the fragmentation that results from the multiplication of disease specific programmes and initiatives, in ways that are tailored to local and national circumstances and priorities; and anticipating how technological innovation, changing needs and evolving demand will influence service delivery.
11. To ensure improved access, quality and use of medical products and technologies
Medical products include medicines, vaccines, blood and blood products, cells and tissues of mostly human origin, biotechnology products, traditional medicines and medical devices. Technologies include diagnostic tests, imaging and laboratory tests. The work undertaken under this Strategic Objective will focus on improving equitable access (as measured by availability, price and affordability) to essential medical products and technologies of assured quality (including safety, efficacy and cost-effectiveness), as well as their sound and costeffective use. The sound use of products and technologies focuses on evidence-based selection; prescriber and patient information; appropriate diagnostic, clinical and surgical procedures; vaccination policies; supply systems, dispensing and injection safety and blood transfusions. Information includes clinical guidelines, independent product information and ethical promotion. This Strategic Objective facilitates the work of WHO vis-a-vis all other Strategic Objectives. Responding to priorities in the Eleventh General Programme of Work, it recognizes that the context for international health has changed significantly. The scope of this objective covers three broad, complementary areas: leadership and governance of the Organization; WHO's support for, presence in, and engagement with individual Member States; and the Organization's role in bringing the collective energy and experience of Member States and other actors to bear on health issues of global and regional importance. The main innovation implicit in this objective is that it seeks to harness the depth and breadth of WHO's country experience in order to influence global and regional debates – thereby to influence positively the environment in which national policymakers work, and contribute to the attainment of the healthrelated Millennium Development Goals and other internationally agreed upon health-related goals.
12. To provide leadership, strengthen governance and foster partnership and collaboration in engagement with countries, to fulfil the mandate of WHO in advancing the Global Health Agenda as set out in the Eleventh General Programme of Work
Thailand
41
Strategic objective 13. To develop and sustain WHO as a flexible and learning Organization, enabling it to carry out its mandate more efficiently and effectively
Scope of strategic objective The scope of this Strategic Objective covers the functions that support and enable the work of the Secretariat in countries, regional offices and Headquarters. The work under this objective is organized according to the following: entire resultsbased management framework and processes, from strategic and operational planning and budgeting to performance monitoring and evaluation; management of financial resources through monitoring, mobilization and coordination at an Organizationwide level, ensuring an efficient flow of available resources throughout the Organization; management of human resources, including human resource planning; recruitment; staff development and learning; performance management; and conditions of service and entitlements; provision of operational support, ranging from the management of infrastructure and logistics; language services; staff and premises security; staff medical services; to the management of information technology; ensuring that there is proper accountability and governance mechanisms in place across all areas. In addition, the Strategic Objective covers a broad institutional reform agenda that will ensure that the above functions are continuously strengthened and able to provide better, more efficient and cost-effective support to the rest of the Organization. This agenda is closely linked to broader reforms within the United Nations system at both the country and global level.
42
WHO Country Cooperation Strategy 2008-2011
Annex 3
MoPH budget in present value and real terms (in million baht) (Extracted from Thailand Health Profile 2001–2004) Total MoPH budget (present value) 24 640 32 898 39 319 45 833 55 861 67 574 (68 934) 63 705 (65 065) 59 277 (62 787) 60 641 (63 001) 61 097 (61 563) 70 923 74 134 77 720 Consumer price index (1994 = 100) 92.1 95.1 100 105.8 112.0 118.2 127.8 128.2 130.2 132.3 133.2 135.7 136.7 a
Year
MoPH budget
Health insurance revolving funds – – – 730 625 1 030 1 080 2 056 2 215 2 400 27 612 32 138 32 578
Budget of 2004 value 36 572 47 289 53 749 59 219 68 180 78 150 (79 723) 68 141 (69 596) 63 154 (66 950) 63 668 (66 146) 63 129 (63 610) 72 787 74 680 77 720
Increase/ decrease from previous year – +29.3 +13.7 +10.2 +15.1 +14.6 (+16.9) -12.8 (-12.7) -7.3 (-3.8) +0.8 (-1.2) +0.8 (-3.8) +15.3 +2.6 +4.1
Percentage of National Budget – 5.8 6.3 6.4 6.7 7.3 (7.4) 7.7 (7.8) 7.2 (7.6) 7.1 (7.3) 6.7 (6.8) 6.9 7.4 7.6
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
24 640 32 898 39 319 45 103 55 236 66 544 62 625 57 171 58 426 58 697 43 311 41 996 45 147
Source: Bureau of Policy and Strategy, Ministry of Public Health, Thailand. Notes: (1) MoPH budget figures have include the budget of other agencies under MoPH supervision, i.e. Health Systems Research Institute and National Health Security Office. (2) The number in ( ) includes foreign loans for health programmes in 1997-2001. (3) Since FYs 1995-2001, MoPH has received a supplementary budget for health insurance cards, called “health insurance revolving fund subsidies” which were previously included in the MoPH’s budget. (4) Since the FY 2002, the MoPH has received a budget as “Health Insurance Revolving Fund” instead of “Health Card Revolving Fund”. The MoPH continues to administer the revolving fund of the National Health Security Office for the first three years, after the National Health Security Act came into force. (5) a
Consumer price index as of January 2004.
(6) The Health Insurance Revolving Fund does not include personnel and operating costs.
Thailand
43
Annex 4
Health budget allocation for major types of programmes during the first half of the Ninth National Health Development Plan (in million baht) (Extracted from Thailand Health Profile 2001–2004) 2002 Type of programmes 2003 Increase/ decrease from 2002 +8.8 2004 Increase/ decrease from 2003 +4.7 Proportion (%)
Amount
Amount
Amount
1) Universal health security 2) Disease prevention/control and health promotion 3) Health systems development 4) Support for training and development of personnel 5) Standard and quality of health services and products 6) AIDS prevention and control 7) Drug abuse prevention and resolution 8) Thai traditional and alternative medicines 9) Medical rehabilitation services for patients and the disabled
53 022.9
57 697.2
60 431.2
77.8
7 619.9
6 292.0a
NA
4 951.2b
NA
6.4
1 519.6 1 501.5
1 674.0 1 464.6
+10.2 -2.4
2 474.5 1 459.9
NA +2.1
3.2 1.9
812.9 698.7 524.7
819.6 885.1 538.2
+0.8 +26.7 +2.6
1 085.0 1 355.1 1 100.1
+32.4 +53.1 +104.4
1.4 1.7 1.4
39.1
73.7
+88.5
120.1
+63.0
0.2
65.7
79.5
+21.0
82.1
+3.3
0.1
Source: Bureau of Policy and Strategy, Ministry of Public Health, Thailand. Note: For FY 2003, the budget for the disease prevention/ control and health promotion decreased as the Department of Health had transferred its programme on environmental surveillance and analysis, and water supply provision to the Ministry of Natural Resource and Environment, according to bureaucratic policy. a
For FY 2004, budget for the disease prevention/ control and health promotion also decreased as the Department of Health has revised its role and thus the budget for disease prevention/ control and health promotion under the health service programme has been shifted to the health systems component of the Health System Development Support Programme. b
44
WHO Country Cooperation Strategy 2008-2011
Annex 5
Thailand’s scorecard on MDG Targets (Goal 1-7) Target 1. Halve, between 1990 and 2015, the proportion of people living in extreme poverty 2. Halve, between 1990 and 2015, the proportion of people who suffer from hunger Scorecard Already achieved Remarks Poverty incidence reduced from 27.2% in 1990 to 9.8% 2002. Proportion of population under food poverty line dropped from 6.9% to 2.2% between 1990-2002, and the prevalence of underweight children under five dropped from 18.6% to 8.5% between 1990-2000. Gross enrolment ratio and the retention rate indicate that it is likely that Thailand will achieve universal primary education well ahead of 2015. Thai girls and boys have had equal education opportunity. There is a small gender gap at the primary level. Girls are outnumbering boys in higher education. Given the low starting point 1990, this target is considered not feasible and therefore not applicable. The new feasible target is adopted under the “MDG Plus”. Given the low starting point 1990, this target is considered not feasible and therefore not applicable. The new feasible target is adopted under the “MDG Plus”. Yearly new infections have dropped by over 80% since 1991. HIV, however continues to spread among some groups. Young people continue to be vulnerable. Achieved for malaria. The disease is an area-specific problem, and has been effectively managed. Principles of sustainable development, partnership and public participation have been integrated into country policies and programmes. But reversing the loss of environmental resources is still Thailand’s greatest challenge. Very close to universal access.
Already achieved
3. Ensure that by 2015, boys and girls alike will be able to complete a full course of primary schooling 4. Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015 5. Reduce by two thirds, between 1990 and 2015, the under-five mortality ratio
Highly likely
Already achieved
Not applicable
6. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
Not applicable
7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases 9. Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources
Already achieved
Already achieved for malaria
Potentially
10. Halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation 11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum-dwellers (globally)
Already achieved
Likely
Most Thai people, including slumdwellers, have secure tenure. Various measures have been implemented and more are underway to improve the slum livelihood.
Source: Thailand Millennium Developemtn Goals Report 200417. Thailand
45
46 Ministry of Public Health Office of the Minister
Annex 6
Professional Councils
National Health Board
WHO Country Cooperation Strategy 2008-2011 Cluster of Medical Services Development Deputy Permanent Secretary Deputy Permanent Secretary Cluster of Public Health Development Cluster of Public Health Services Support Deputy Permanent Secretary Department of Disease Control – Office of the Secretary – Personnel Division – Finance Division – Planning Division – Bamrasnaradura Institute – Rajprachasamasai Institute – Office of Disease Prevention and Control 1-12 – Bureau of Epidemiology – Bureau of Occupational and Environment Diseases – Bureau of General Communicable Diseases – Bureau of Vector-Borne Diseases – Bureau of Non-communicable Diseases – Bureau of AIDS, TB and STIs Department of Health – Personnel Division – Finance Division – Dental Health Division – Planning Division – Nutrition Division – Sanitation and Health Impact Assessment Division – Food and Water Sanitation Division – Reproductive Health Division – Division of Physical Activities and Health – Regional Health Promotion Centres 1-12 – Bureau of Health Promotion – Bureau of Environmental Health Department of Health Service Support – Bureau of Administration – Medical Registration Division – Division of Design and Construction – Medical Engineering Division – Primary Health Care Division – Health Education Division – Bureau of Health Services System Development Department of Medical Services – Office of the Secretary – Division of Cosmetics and Hazardous Substances – Division of Biological Products – Division of Planning and Technical Coordination – Division of Radiation and Medical Devices – Regional Medical Sciences Centres 1-12 – National Institute of Health – Medicinal Plant Research Institute – Bureau of Quality and Food Safety – Bureau of Laboratory Quality Standards – Bureau of Drugs and Narcotics Food and Drug Administration – Office of the Secretary – Medical Device Control Division – Drug Control Division – Narcotics Control Division – Food Control Division – Import and Export Inspection Division – Technical and Planning Division – Public and Consumer Affairs Division – Rural and Local Consumer Health Products Protection Promotion Division – Bureau of Cosmetic and Hazardous Substance Control Public Organizations (Royal Decrees reuired) – Health facilities (Royal decree enacted for Ban Phaeo Hospital) – Institute of Speciality Medicine – Bureau of Emergency Medical Services System – Institute of Hospital Quality Improvement and Accreditation (HA-Thailand)
Permanent Secretary
Office of the Permanent Secretary – Bureau of Central Administration – Information and Communication Technology Centre – Praboromarjchanok Institute of Health Manpower – Development – Burea of Inspection and Evaluation – Burea of Policy and Strategy
Organogram – Ministry of Public Health
Provincial Administration – Provincial Public Health Offices – District Health Offices
Department of Medical Services – Office of the Secretary – Personnel Division – Finance Division – Planning Division – Nopparat Rajathanee Hospital – Mettapracharak Hospital (Wat Rai Khing) – Rajavithi Hospital – Lerdsin Hospital – Priest Hospital – Sirindhorn National Medical Rehabilitation Centre – Institute of Dentistry – Institute of Pathology – Prasat Neurological Institute – National Cancer Institute – Thanyarak Institute – Chest Disease Institute – Institute of Dermotology – Institute of Geriatric Medicine – Queen Sirikit National Institute of Child Health – Bureau of Nursing – Bureau of Medical Technical Development Department for Development of Thai Traditional and Alternative Medicine – Office of the Secretary – Division of Alternative Medicine – Institute of Thai Traditional Medicine Department of Mental Health – Office of the Secretary – Personnel Division – Finance Division – Planning Division – Social Mental Health Division – Srithunya Psychiatric Hospital – Mental Health Regional Centres 1-12 – Galyarajanagarindra Institute – Somdet Chaoprya Institute of Psychiatry – Rajanukul Mental Health Retardation Institute – Mental Health Technical Development Bureau
Agencies under the Supervision of MOPH: – Health Systems Research Institute – National Health Security Office – Praboromarajchanok Institute of Health Workforce Development (Act required) – National Institute of Health (Act required)
State Enterprise: – Government Pharmaceutical Organization
Source: Ministerial Regulations of the Ministry of Public Health, 2002 Note: Public organizations and agencies under the supervision of the MOPH are not under any of the clusters.
Annex 7
Morbidity rates of hospitalized cases (per 100 000 population) due to selected NCDs, injuries and mental illness Thailand (excluding Bangkok), 2001–2004
Source: Bureau of Policy and Strategy
Thailand
47
48
Annex 8
WHO Country Cooperation Strategy 2008-2011
Organogram WHO Country Office Thailand
a
CSR = Communicable Disease Surveillance and Response Sub-unit is under technical supervision of SEARO, using WCO common services MMP = Malaria Mekong Project is under joint technical supervision of SEARO and WPRO, using WCO common services c Under process of recruitment; d Supported by CSR and other VC budget and pooled for common services in WCO; common sevices * SSA or short-term contract.
b
Annex 9
References (1) United Nations Development Programme. Human development report 2006: beyond scarcity: power, poverty and the global water crisis. New York, 2006. (http://hdr.undp.org/hdr2006/ pdfs/report/HDR06-complete.pdf – accessed 23 July 2007). United Nations Development Programme. Thailand human development report 2007: sufficiency economy and human development . Bangkok, 2007. (http://www.undp.or.th/NHDR2007/ index.html – accessed 23 July 2007). United Nations Population Fund. Country profiles for population and reproductive health: policy and development indicators 2005., New York: UNFPA and Population Reference Bureau, 2005. (http://www.unfpa.org/publications/detail.cfm?ID=260&filterListType= – accessed 23 July 2007). World Health Organization. Global tuberculosis control: surveillance, planning, financing: WHO report 2007. Geveva, 2007. (http://whqlibdoc.who.int/publications/2007/9789241563141_ eng.pdf (File size : 3.4Mb) – accessed 23 July 2007) Ministry of Public Health, Department of Disease Control, Bureau of Epidemiology. Morbidity and mortality rate of pulmonary TB cases from report 506 (1979-2005). (http://epid.moph.go.th/ dssur/respir/pulmtb.htm – accessed 26 July 2007). Ministry of Public Health, Bureau of Policy and Strategy. Report on health resources 2004, Bangkok, 2004. (http://203.157.19.191 – accessed 26 July 2007). World Health Organization. The world health report: 2006: working together for health. Geneva, 2006. (http://whqlibdoc.who.int/publications/2006/9241563176_eng.pdf (File size : 6.6 Mb) – accessed 23 July 2007). Ministry of Public Health. National Health Security Office Annual Report 2004. Nonthaburi, 2004. Thai National Statistical Office. The 2003 health and welfare survey. Bangkok, 2003. (http:// service.nso.go.th/agrc/health46/eng.htm – accessed 26 July 2007).
(2)
(3)
(4)
(5)
(6) (7)
(8) (9)
(10) Tangcharoensathien V, Teokul W, ChanwongpaisarnL. Social Welfare System in Thailand: Challenges of implementing universal coverage . Bangkok: UNRISD, 2004. (11) Ministry of Public Health, Bureau of Policy and Strategy. Thailand health profile 2001-2004. In: Unpublished paper, (extracted from Thailand National Health Profile 2004, page 253, Table 6.7). (12) Vasavid, Chitpranee. IHPP Research on Health Care Financing 2003. Presentation at the IHPP Annual Conference on 14 May 2004. (http://www.ihpp.thaigov.net/research_annual04/ Agenda%203%20Chitpranee.pdf – accessed 23 July 2007) (13) Ministry of Public Health. Minister fears for hospitals. Clipping from the Nation newspaper, Friday 27 April 2007. (http://eng.moph.go.th/ContentDetails.php?intContentID=16042 &strOrgID=001002002 – accessed 26 July 2007).
Thailand
49
(14) United Nation Country Team in Thailand, UN Resident Coordinator’s Office. Thailand Common Country Assessment 2005. Bangkok, 2005. (http://www.undp.org/rbap/Country_Office/CCA/ Cca-Thailand2005.pdf – accessed 24 July 2007). (15) World Bank. World development indicators database . 18 April 2006. (http:// devdata.worldbank.org/data-query/ – accessed 23 July 2007). (16) Wibulpolprasert, S. Thailand health profile 2001-2004. Bangkok: Ministry of Public Health, 2004. (http://www.moph.go.th/ops/health_48/index_eng.htm – accessed 23 July 2007). (17) National Economic and Social Development Board. Thailand millennium development goals report 2004. Bangkok, 2004.
50
WHO Country Cooperation Strategy 2008-2011
Permanent Secretary Building No.3 4th floor, Ministry of Public Health Tiwanon Road, Muang Nonthaburi 11000 Thailand www.whothai.org