Healthcare providers' perspectives on integrating NCDs into primary healthcare in Thailand: a mixed method study.

BACKGROUND: In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement. METHODS: This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews. RESULTS: Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs. CONCLUSION: PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Primary health care and sustainable development goals.

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Dans le présent document, nous étudions le potentiel et les limites des soins de santé primaires en matière de réalisation des objectifs de développement durable (ODD) liés à la santé. Nous formulons également des recommandations politiques pour l'instauration d'un système de soins de santé primaires efficace. Les gouvernements ont récemment réaffirmé leur engagement envers les ODD en 2018 par le biais de la Déclaration d'Astana, qui redéfinit les trois fonctions des soins de santé primaires comme suit: fourniture de services, actions multidisciplinaires et implication des citoyens. En d'autres termes, les ODD liés à la santé ne peuvent être atteints uniquement en proposant des services médicaux. Certains problèmes de santé sont inhérents à l'environnement et requièrent les efforts conjoints des partenaires locaux, nationaux et internationaux; d'autres nécessitent de sensibiliser le public (médecine préventive) aux maladies évitables. Cependant, la fourniture de soins de santé primaires, et par conséquent la réalisation des ODD, rencontre de nombreux obstacles. Tout d'abord, les dépenses inadéquates des gouvernements en matière de santé sont aggravées par le faible pourcentage octroyé aux soins de santé primaires. Ensuite, la pénurie et les inégalités de répartition des professionnels de la santé ainsi que l'absentéisme chronique dans certains pays ont débouché sur une situation où le niveau des effectifs est inversement proportionnel au niveau de pauvreté et aux besoins. Par ailleurs, le personnel soignant n'est pas formé aux actions multidisciplinaires et subit déjà une charge de travail écrasante. Et enfin, la méconnaissance des bases sanitaires est fréquente au sein de la population, même dans les pays développés. Nous conseillons aux gouvernements d'accroître leurs dépenses en soins de santé et soins de santé primaires, d'intervenir pour encourager les soignants à rester dans les régions rurales, et de mettre à jour les programmes de formation initiale du personnel pour y inclure des compétences en collaboration multidisciplinaire et en amélioration de l'engagement communautaire.

Se analizan las posibilidades y las limitaciones de la atención primaria de salud para contribuir al logro de los objetivos de desarrollo sostenible (los ODS) relacionados con la salud, y se recomiendan políticas que permitan el funcionamiento del sistema de atención primaria de salud. Recientemente, los gobiernos reiteraron su compromiso con los ODS en la Declaración de Astaná de 2018, en la que se redefinen las tres funciones de la atención primaria de salud, a saber: la prestación de servicios, las medidas multisectoriales y una mayor participación de los ciudadanos. Es decir, los ODS relacionados con la salud no se pueden cumplir tan solo con la prestación de servicios de atención de la salud. Algunos temas de salud están relacionados con el medio ambiente, lo que requiere esfuerzos conjuntos entre los asociados locales, nacionales e internacionales; otros temas requieren la concienciación del público (conocimientos sobre la salud) acerca de las enfermedades que se pueden evitar. Sin embargo, la prestación de atención primaria de salud, y por consiguiente el logro de los ODS, presenta diversas dificultades. En primer lugar, el gasto público inadecuado en salud empeora debido a los porcentajes tan reducidos que se asignan a la atención primaria de salud. En segundo lugar, la escasez y la mala distribución del personal sanitario, así como el absentismo crónico en algunos países, han creado una situación en la que los niveles de personal están relacionados de manera inversa con la pobreza y la necesidad. En tercer lugar, el personal sanitario no está capacitado para emprender medidas multisectoriales, además de que ya tiene una carga de trabajo abrumadora. Por último, la falta de conocimientos sobre salud es común entre la población, incluso en los países desarrollados. Se recomienda a los gobiernos que aumenten el gasto en salud y en atención primaria de la salud, que implementen intervenciones para fidelizar al personal sanitario de las zonas rurales y que actualicen los programas de capacitación del personal previa a la prestación de servicios para integrar las habilidades en la colaboración multisectorial y el aumento de la participación de la comunidad.

Legislating for public accountability in universal health coverage, Thailand.

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand's universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand's position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens' rights and government accountability has been implemented. Thailand's constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens' voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens' ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens' trust.

Maintenir la couverture sanitaire universelle exige une forte participation publique à l'élaboration des politiques et à la gouvernance. En Thaïlande, le régime de couverture universelle a été mis en œuvre dans tout le pays en 2002, permettant de couvrir l'ensemble de la population grâce à trois régimes publics d'assurance maladie et d'améliorer les résultats de santé. Bien que la position de la Thaïlande concernant les Indicateurs de gouvernance mondiaux de la Banque mondiale se soit détériorée depuis 1996, des dispositions en matière d'expression et de reddition de comptes ont été intégrées à la législation et à la structure du régime de couverture universelle. Nous discutons ici de la mise en œuvre de la législation relative aux droits des citoyens et à la reddition de comptes du gouvernement. En vertu de la constitution de la Thaïlande, les citoyens ont pu soumettre un projet de loi dont les dispositions en matière d'expression et de reddition de comptes ont été intégrées aux textes législatifs et transposées dans la loi. La législation rend obligatoire l'enregistrement des bénéficiaires, une assistance téléphonique 24h/24 et 7 j/7, des auditions publiques annuelles et une aide financière systématique pour les patients qui ont été victimes d'événements indésirables. Pour garantir le droit à des services de santé, permettre aux citoyens de faire entendre leur voix et s'assurer que des mesures soient prises, les institutions doivent être en mesure d'appliquer la législation. Par exemple, la Thaïlande devait pouvoir enregistrer 47 millions de personnes et les rattacher au réseau de prestataires de soins du district où elles vivaient, et réenregistrer les personnes qui changeaient de district. Les auditions publiques annuelles doivent faire participer les citoyens, les prestataires de soins, les organisations de la société civile et les parties prenantes telles que les collectivités locales et les groupes de patients. Les réponses qui en découlent au point de vue des politiques et de la gestion sont importantes pour instaurer la confiance dans le processus et permettre aux citoyens de se l'approprier. Les rapports annuels publics sur les résultats du régime de couverture permettent d'accroître la transparence et de renforcer la confiance des citoyens.

Para mantener la cobertura sanitaria universal se requiere una sólida participación activa del público en la formulación de políticas y la gobernanza. El plan de cobertura universal de Tailandia se implementó en todo el país en 2002, lo que permitió a Tailandia lograr una cobertura completa de la población a través de tres planes de seguro médico público y demostrar mejores resultados en materia de salud. Aunque la posición de Tailandia respecto de los Indicadores mundiales de gobernanza del Banco Mundial ha disminuido desde 1996, las disposiciones relativas a la voz y la rendición de cuentas estaban incorporadas en la legislación y en el diseño del plan de cobertura universal. Se discute cómo se ha implementado la legislación relacionada con los derechos de los ciudadanos y la rendición de cuentas del gobierno. La Constitución de Tailandia permitía a los ciudadanos presentar un proyecto de ley en el que las disposiciones sobre la voz y la rendición de cuentas se incorporaban con éxito en los textos legislativos y se aprobaban como ley. La legislación exige el registro de los beneficiarios, una línea telefónica de ayuda 24 horas al día los 7 días de la semana, audiencias públicas anuales y asistencia financiera gratuita para los pacientes que han sufrido eventos adversos. Para garantizar el derecho a los servicios de salud y que se escuche la voz de los ciudadanos y se adopten medidas, es necesario contar con la capacidad institucional para aplicar la legislación. Por ejemplo, Tailandia necesitaba la capacidad de inscribir a 47 millones de personas y ponerlas en contacto con la red de proveedores de servicios de salud del distrito en el que viven, y de volver a inscribir a los miembros que se trasladan fuera de sus distritos. Las audiencias públicas anuales deben incluir a los ciudadanos, los proveedores de servicios de salud, las organizaciones de la sociedad civil y las partes interesadas, como los gobiernos locales y los grupos de pacientes. Las respuestas políticas y de gestión subsiguientes son importantes para generar confianza en el proceso y en la apropiación del plan por parte de los ciudadanos. El informe público anual sobre los resultados y el rendimiento del plan fomenta la transparencia y aumenta la confianza de los ciudadanos.

Political economy of Thailand's tax-financed universal coverage scheme.

PROBLEM: The challenge of implementing contributory health insurance among populations in the informal sector was a barrier to achieving universal health coverage (UHC) in Thailand. APPROACH: UHC was a political manifesto of the 2001 election campaign. A contributory system was not a feasible option to honour the political commitment. Given Thailand's fiscal capacity and the moderate amount of additional resources required, the government legislated to use general taxation as the sole source of financing for the universal coverage scheme. LOCAL SETTING: Before 2001, four public health insurance schemes covered only 70% (44.5 million) of the 63.5 million population. The health ministry received the budget and provided medical welfare services for low-income households and publicly subsidized voluntary insurance for the informal sector. The budgets for supply-side financing of these schemes were based on historical figures which were inadequate to respond to health needs. The finance ministry used its discretionary power in budget allocation decisions. RELEVANT CHANGES: Tax became the sole source of financing the universal coverage scheme. Transparency, multistakeholder engagement and use of evidence informed budgetary negotiations. Adequate funding for UHC was achieved, providing access to services and financial protection for vulnerable populations. Out-of-pocket expenditure, medical impoverishment and catastrophic health spending among households decreased between 2000 and 2015. LESSONS LEARNT: Domestic government health expenditure, strong political commitment and historical precedence of the tax-financed medical welfare scheme were key to achieving UHC in Thailand. Using evidence secures adequate resources, promotes transparency and limits discretionary decision-making in budget allocation.

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings.

BACKGROUND: Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS). OBJECTIVE: This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement. METHOD: In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings. RESULTS: The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency. CONCLUSIONS: Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner.

Health systems development in Thailand: a solid platform for successful implementation of universal health coverage.

Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

Lessons from the Thai Health Promotion Foundation.

To facilitate the policy response to noncommunicable diseases in Thailand, parliament adopted the Health Promotion Foundation Act in 2001. This Act led to the establishment of an autonomous government body, the Thai Health Promotion Foundation, called ThaiHealth. The foundation receives its revenue from a 2% surcharge of excise taxes on tobacco and alcohol. The fund supports evidence generation, campaigns and social mobilization to address noncommunicable disease risk factors, such as tobacco-use, harmful use of alcohol and sedentary behaviour. On average, its annual revenue is 120 million United States dollars (US$). Some notable ThaiHealth-supported public campaigns are for schools free of sweetened carbonated beverages; alcohol abstinence during three-month Buddhist lent; and nationwide physical activity. The percentage of people using tobacco decreased from 22.5% in 2001 to 18.2% in 2014. The annual per capita alcohol consumption decreased from 8.1 litres pure alcohol in 2005 to 6.9 litres in 2014. The percentage of the adult population doing at least 150 minutes of moderate-intensity or 75 minutes high-intensity aerobic exercise per week, increased from 66.3% in 2012 to 72.9% in 2017. A dedicated funding mechanism, a transparent and accountable organization, and the engagement of civil society organizations and other government agencies have enabled ThaiHealth to run these campaigns.

Afin de soutenir l'action politique concernant les maladies non transmissibles en Thaïlande, le Parlement a adopté une loi sur la Fondation pour la promotion de la santé en 2001. Cette loi a conduit à l'établissement d'un organisme gouvernemental autonome, la Fondation thaïlandaise pour la promotion de la santé, appelé « ThaiHealth ¼. Cette fondation tire ses revenus d'une majoration de 2% des taxes d'accise sur le tabac et l'alcool. Ces fonds soutiennent la production de données, l'organisation de campagnes et la mobilisation sociale pour agir sur les facteurs de risque de maladie non transmissible, tels que la consommation de tabac, la consommation nocive d'alcool et le comportement sédentaire. Le revenu annuel moyen de ThaiHealth s'élève à 120 millions de dollars des États-Unis. Certaines campagnes publiques importantes financées par ThaiHealth prônent l'élimination des boissons gazeuses sucrées dans les écoles, la privation d'alcool pendant les trois mois de la retraite de la saison des pluies, et l'activité physique dans tout le pays. Le pourcentage des fumeurs de tabac est passé de 22,5% en 2001 à 18,2% en 2014. La consommation annuelle d'alcool par habitant est passée de 8,1 litres d'alcool pur en 2005 à 6,9 litres en 2014. Le pourcentage de la population adulte faisant au moins 150 minutes d'exercices aérobiques modérément intenses ou 75 minutes d'exercices aérobiques très intenses par semaine est passé de 66,3% en 2012 à 72,9% en 2017. Un mécanisme de financement spécial, une organisation transparente et responsable, et l'engagement d'organisations de la société civile et d'autres agences gouvernementales ont permis à ThaiHealth de mener ces campagnes.

Para facilitar la respuesta política a las enfermedades no contagiosas en Tailandia, el Parlamento aprobó en 2001 la Ley de la Fundación para la promoción de la salud. Esta ley dio lugar a la creación del organismo gubernamental autónomo, la Fundación tailandesa para la promoción de la salud, denominada ThaiHealth. La fundación recibe ingresos de un recargo del 2 % de los impuestos especiales sobre el tabaco y el alcohol. El fondo apoya la generación de pruebas, las campañas y la movilización social para hacer frente a los factores de riesgo de las enfermedades no contagiosas, como el consumo de tabaco, el consumo nocivo de alcohol y los hábitos sedentarios. De media, sus ingresos anuales ascienden a 120 millones de dólares estadounidenses. Algunas de las campañas públicas que apoya ThaiHealth van dirigidas a sacar de las escuelas las bebidas con gas azucaradas, a la abstinencia del alcohol durante la cuaresma budista de tres meses y a fomentar la actividad física en todo el país. El porcentaje de personas que consumen tabaco disminuyó del 22,5 % en 2001 al 18,2 % en 2014. El consumo anual de alcohol per cápita disminuyó de 8,1 litros de alcohol puro en 2005 a 6,9 litros en 2014. El porcentaje de población adulta que hace al menos 150 minutos de ejercicio aeróbico de intensidad moderada o 75 minutos de ejercicio aeróbico de alta intensidad por semana aumentó del 66,3 % en 2012 al 72,9 % en 2017. Un mecanismo de financiación específico, una organización transparente y responsable, así como la participación de organizaciones de la sociedad civil y otros organismos gubernamentales han permitido a ThaiHealth llevar a cabo estas campañas.

Implementation of national action plans on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam.

By 2016, Member States of the World Health Organization (WHO) had developed and implemented national action plans on noncommunicable diseases in line with the Global action plan for the prevention and control of noncommunicable diseases (2013-2020). In 2018, we assessed the implementation status of the recommended best-buy noncommunicable diseases interventions in seven Asian countries: Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. We gathered data from a range of published reports and directly from health ministries. We included interventions that addressed the use of tobacco and alcohol, inadequate physical activity and high salt intake, as well as health-systems responses, and we identified gaps and proposed solutions. In 2018, progress was uneven across countries. Implementation gaps were largely due to inadequate funding; limited institutional capacity (despite designated noncommunicable diseases units); inadequate action across different sectors within and outside the health system; and a lack of standardized monitoring and evaluation mechanisms to inform policies. To address implementation gaps, governments need to invest more in effective interventions such as the WHO-recommended best-buy interventions, improve action across different sectors, and enhance capacity in monitoring and evaluation and in research. Learning from the Framework Convention on Tobacco Control, the WHO and international partners should develop a standardized, comprehensive monitoring tool on alcohol, salt and unhealthy food consumption, physical activity and health-systems response.

En 2016, les États membres de l'Organisation mondiale de la Santé (OMS) avaient élaboré et mis en œuvre des plans d'action nationaux sur les maladies non transmissibles conformément au Plan d'action mondial pour la lutte contre les maladies non transmissibles (2013­2020). En 2018, nous avons évalué l'état de l'application des interventions les plus avantageuses recommandées en matière de maladies non transmissibles dans sept pays asiatiques: le Bhoutan, le Cambodge, l'Indonésie, les Philippines, le Sri Lanka, la Thaïlande et le Viet Nam. Nous avons recueilli des données à partir de toute une série de rapports publiés et directement auprès des ministères de la Santé. Nous avons inclus les interventions qui concernaient la consommation de tabac et d'alcool, une activité physique inadéquate et une consommation de sel élevée, ainsi que les réponses des systèmes de santé, et nous avons identifié les lacunes et proposé des solutions. En 2018, les progrès étaient variables selon les pays. Les lacunes étaient largement dues à un financement inadéquat; des capacités institutionnelles limitées (malgré des unités dédiées aux maladies non transmissibles); une action inadéquate dans les différents secteurs au sein et en dehors du système de santé; et l'absence de mécanismes de suivi et d'évaluation standardisés pour orienter les politiques. Afin de combler ces lacunes, les gouvernements doivent investir davantage dans des interventions efficaces telles que les interventions les plus avantageuses recommandées par l'OMS, améliorer l'action dans les différents secteurs, et renforcer les capacités en matière de suivi et d'évaluation, mais aussi de recherche. En s'inspirant de la Convention-cadre pour la lutte antitabac, l'OMS et ses partenaires internationaux devraient élaborer un outil de suivi complet et standardisé sur la consommation d'alcool, de sel et d'aliments malsains, l'activité physique et la réponse des systèmes de santé.

Para 2016, los Estados miembros de la Organización Mundial de la Salud (OMS) habían elaborado y aplicado planes de acción nacionales sobre las enfermedades no contagiosas de acuerdo con el Plan de acción mundial para la prevención y el control de las enfermedades no transmisibles (2013-2020). En 2018, se evaluó el estado de implementación de las intervenciones recomendadas en siete países asiáticos en materia de enfermedades no contagiosas: Bhután, Camboya, Filipinas, Indonesia, Sri Lanka, Tailandia y Vietnam. Se recopilaron datos de una serie de informes publicados y directamente de los ministerios de salud. Se incluyeron intervenciones que abordaron el uso del tabaco y el alcohol, la actividad física inadecuada y la ingesta elevada de sal, así como las respuestas de los sistemas de salud, se identificaron las deficiencias y se propusieron soluciones. En 2018, el progreso fue desigual entre los países. Las deficiencias en la aplicación se debieron en gran medida a la falta de financiación, a la limitada capacidad institucional (a pesar de las dependencias designadas para las enfermedades no contagiosas), a la inadecuación de las medidas adoptadas en los diferentes sectores dentro y fuera del sistema de salud y a la falta de mecanismos normalizados de supervisión y evaluación que sirvieran de base a las políticas. Para subsanar las deficiencias en materia de aplicación, los gobiernos deben invertir más en intervenciones eficaces, como las recomendadas por la OMS, mejorar las medidas adoptadas en los distintos sectores y aumentar la capacidad de seguimiento y evaluación y de investigación. A partir de las enseñanzas del Convenio Marco para el Control del Tabaco, la OMS y los asociados internacionales deberían elaborar un instrumento de seguimiento normalizado y completo para el consumo de alcohol, sal y alimentos no saludables, la actividad física y la respuesta de los sistemas de salud.

Antibiotic distribution channels in Thailand: results of key-informant interviews, reviews of drug regulations and database searches.

OBJECTIVE: To analyse how antibiotics are imported, manufactured, distributed and regulated in Thailand. METHODS: We gathered information, on antibiotic distribution in Thailand, in in-depth interviews - with 43 key informants from farms, health facilities, pharmaceutical and animal feed industries, private pharmacies and regulators- and in database and literature searches. FINDINGS: In 2016-2017, licensed antibiotic distribution in Thailand involves over 700 importers and about 24 000 distributors - e.g. retail pharmacies and wholesalers. Thailand imports antibiotics and active pharmaceutical ingredients. There is no system for monitoring the distribution of active ingredients, some of which are used directly on farms, without being processed. Most antibiotics can be bought from pharmacies, for home or farm use, without a prescription. Although the 1987 Drug Act classified most antibiotics as "dangerous drugs", it only classified a few of them as prescription-only medicines and placed no restrictions on the quantities of antibiotics that could be sold to any individual. Pharmacists working in pharmacies are covered by some of the Act's regulations, but the quality of their dispensing and prescribing appears to be largely reliant on their competences. CONCLUSION: In Thailand, most antibiotics are easily and widely available from retail pharmacies, without a prescription. If the inappropriate use of active pharmaceutical ingredients and antibiotics is to be reduced, we need to reclassify and restrict access to certain antibiotics and to develop systems to audit the dispensing of antibiotics in the retail sector and track the movements of active ingredients.

An evaluation of health systems equity in Indonesia: study protocol.

BACKGROUND: Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia's national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. METHODS: Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. DISCUSSION: As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach - are not excluded. The results of this study will not only help track Indonesia's progress to universalism but also reveal what the UHC-reforms mean to the poor.

Implementing health insurance for migrants, Thailand.

PROBLEM: Undocumented migrant workers are generally ineligible for state social security schemes, and either forego needed health services or pay out of pocket. APPROACH: In 2001, the Thai Ministry of Public Health introduced a policy on migrant health. Migrant health insurance is a voluntary scheme, funded by an annual premium paid by workers. It enables access to health care at public facilities and reduces catastrophic health expenditures for undocumented migrants and their dependants. A range of migrant-friendly services, including trained community health volunteers, was introduced in the community and workplace. In 2014, the government introduced a multisectoral policy on migrants, coordinated across the interior, labour, public health and immigration ministries. LOCAL SETTING: In 2011, around 0.3 million workers, less than 9% of the estimated migrant labour force of 3.5 million, were covered by Thailand's social security scheme. RELEVANT CHANGES: A review of the latest data showed that from April to July 2016, 1 146 979 people (33.7% of the total estimated migrant labourers of 3 400 787) applied, were screened and were enrolled in the migrant health insurance scheme. Health volunteers, recruited from migrant communities and workplaces are appreciated by local communities and are effective in promoting health and increasing uptake of health services by migrants. LESSONS LEARNT: The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. Continued policy support will be needed to increase recruitment to the insurance scheme and to scale-up migrant-friendly services.

Auxiliary midwives in hard to reach rural areas of Myanmar: filling MCH gaps.

BACKGROUND: Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community. METHOD: The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years. RESULTS: All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident. CONCLUSIONS: Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Health workforce contributions to health system development: a platform for universal health coverage.

PROBLEM: In the 1970s, Thailand was a low-income country with poor health indicators and low health service coverage. The local health infrastructure was especially weak. APPROACH: In the 1980s, measures were initiated to reduce geographical barriers to health service access, improve the health infrastructure at the district level, make essential medicines more widely available and develop a competent, committed health workforce willing to service rural areas. To ensure service accessibility, financial risk protection schemes were expanded. LOCAL SETTING: In Thailand, district hospitals were practically non-existent in the 1960s. Expansion of primary health care (PHC), especially in poor rural areas, was considered essential for attaining universal health coverage (UHC). Nationwide reforms led to important changes in a few decades. RELEVANT CHANGES: Over the past 30 years, the availability and distribution of health workers, as well as their skills and competencies, have greatly improved, along with national health indicators. Between 1980 and 2000 coverage with maternal and child health services increased substantially. By 2002, Thailand had attained UHC. Overall health system development, particularly an expanded health workforce, resulted in a functioning PHC system. LESSONS LEARNT: A competent, committed health workforce helped strengthen the PHC system at the district level. Keeping the policy focus on the development of human resources for health (HRH) for an extended period was essential, together with a holistic approach to the development of HRH, characterized by the integration of different kinds of HRH interventions and the linking of these interventions with broader efforts to strengthen other health system domains.

Thailand's HIV/AIDS program after weaning-off the global fund's support.

BACKGROUND: Though 85% of financing HIV/AIDS program was domestic resources, Global Fund (GF) programs played a significant role in prevention interventions and treatment for non-Thai Key Affected Populations (KAP) and migrants. As upper-middle income country, Thailand is not eligible for GF support. This study identified the remaining challenges and funding for prevention interventions for Thai and non-Thai KAP and migrants if GF supports were to curtail. METHODS: Qualitative method was applied including document review and in-depth interviews of 21 key informants who were Principal Recipients, Sub-recipients, provincial level program implementers and policy makers in health financing agencies. A multi-stakeholder consultation workshop was convened to discuss recommendations. RESULTS: The "public financed public services model" where Principal and Agents were the same entities resulted in less accountability than the "contractual agreement" in GF programs where the Principal Recipients, as the Agents were more accountable to the GF as Principal through results based financing. If GF supports were to curtail, impacts on the current programs would be varied from low to high degree of negative consequences. Scale down the scope and targets, while keeping the most critical components were common coping mechanisms. All three, except one, Principal Recipients had difficulties in fund mobilization. Prevention among non-Thai KAP and migrants were identified as the remaining challenge. CONCLUSIONS: A pooled funding mechanism from multiple domestic sources was proposed. Replacing the conventional public-financed-public-service by a contractual model was preferable. The GF should continue funding the non-Thai KAP and migrant as transition mechanism. Multi-countries or regional programs especially at the border areas were priorities.

Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity.

BACKGROUND: Empirical evidence demonstrates that the Thai Universal Coverage Scheme (UCS) has improved equity of health financing and provided a relatively high level of financial risk protection. Several UCS design features contribute to these outcomes: a tax-financed scheme, a comprehensive benefit package and gradual extension of coverage to illnesses that can lead to catastrophic household costs, and capacity of the National Health Security Office (NHSO) to mobilise adequate resources. This study assesses the policy processes related to making decisions on these features. METHODS: The study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources. RESULTS: Continued political and financial commitments to the UCS, despite political rivalry, played a key role. The Thai Rak Thai (TRT)-led coalition government introduced UCS; staying in power 8 of the 11 years between 2001 and 2011 was long enough to nurture and strengthen the UCS and overcome resistance from various opponents. Prime Minister Surayud's government, replacing the ousted TRT government, introduced universal renal replacement therapy, which deepened financial risk protection.Commitment to their manifesto and fiscal capacity pushed the TRT to adopt a general tax-financed universal scheme; collecting premiums from people engaged in the informal sector was neither politically palatable nor technically feasible. The relatively stable tenure of NHSO Secretary Generals and the chairs of the Financing and the Benefit Package subcommittees provided a platform for continued deepening of financial risk protection. NHSO exerted monopsonistic purchasing power to control prices, resulting in greater patient access and better systems efficiency than might have been the case with a different design.The approach of proposing an annual per capita budget changed the conventional line-item programme budgeting system by basing negotiations between the Bureau of Budget, the NHSO and other stakeholders on evidence of service utilization and unit costs. CONCLUSIONS: Future success of Thai UCS requires coverage of effective interventions that address primary and secondary prevention of non-communicable diseases and long-term care policies in view of epidemiologic and demographic transitions. Lessons for other countries include the importance of continued political support, evidence informed decisions, and a capable purchaser organization.