Political Instability: A Roadblock for Equity to Universal Health Coverage in Thailand

Thailand is under the world's scrutinizing eye in the next democratic election slated to be December 2007. Contrary to intuitive logic, candidate preference has little impact on access to healthcare for Thailand’s poor. Whether the government can return to political stability will determine the population's health future. If the health system remains the government's priority amidst a perceived increased need for defense spending, a decreasing Gross Domestic Product (GDP), and a lessening interest by foreign investors, the successes of its Universal Coverage (UC) health scheme may prevail in providing equitable universal coverage.

Thailand has been called one of South-east Asia’s most stable democracies. This title was tarnished after a military coup ousted Prime Minister Shinawatra in September 2006 validated by accusations of wide-spread corruption and abuses of power1. This political instability was unappealing to foreign investors and is thought to influence future economic development inThailand. Many investors are eagarly awaiting the outcome of the election for reassurance that democracy will again be restored2.



Thailand’s free-enterprise economy with pro-investment policies has been doing well2. The Thai economy grew 6.9% in 2003, 6.1% in 2004 and it is predicted that real GDP growth will slow to an annual average of 4.5% a year in 2008-12, down from 5.5% in 2003-07. This shift is mainly due to higher crude oil prices and lower anticipated foreign investment 3.
During the periods of economic growth, Thailand devoted a larger portion of the National Budget towards the Ministry of Public Health (MoPH) budget which enabled them to incrementally launch a successful UC scheme. For example, in 1990 of the 335, 000 million baht national budget, 4.8% (or 16, 225.1 million baht) was designated to the MoPH. In 2004, 8.1 % (or 77, 720.7 million baht) of the 1,028,000 million baht national budget was given to the MoPH 4. By 2004, the percentage of the budget spent on security versus health was 13.5% and 8.1% respectively 5.



However, with political instability and military spending on the rise, many worry that additional spending on national security, coupled with reduced foreign investment, will divert funds from the health sector. Thailand's military leaders recently awarded themselves pay increases totaling $9 million and increased the defense budget by over 30 percent. This is a $1.1 billion hike, reportedly at the cost of its health sector6. In a budget requested December of this year, the allocation for defense spending will increase to 115 billion baht (3,639,008,201 USD) or 33.8%, in comparison to the 86 billion in 20067. In December 2006, the Thai Board of Investment reported the value of investment applications from January to November had declined by 27% year-on-year2. This increased military spending has the potential to greatly impact the successes of UC in Thailand.






Thailand has been moving toward a tax-based UC scheme for all Thai citizens. The population covered by public health insurance schemes increased from 71% in 2001 to 95% in 20038. The UC scheme is funded by progressive direct taxes in which wealthier people contribute more to the system. Additional funds are to be raised from a sin tax on alcohol and tobacco9 . However, with less funding available to the national budget, making health accessible to Thailand’s population may be negatively impacted.

Although this scheme has proven to be innovative and unprecedented, many reports state a lack of health equity in under-served populations as well as a major stress on human and material resources within hospitals. Many regional hospitals have been accruing increasing debt 10. In fact, Siriaj Hospital, Thailand's oldest medical school, faces debts of approximately $13.5 million- due to earlier phases of the UC scheme 11. Under-served populations (i.e. those with Thai as a second language) have shown dramatic disparities. Nationally, 90 per cent of children are immunized against the six major preventable childhood diseases by the age of two. However, the rate drops to 81 per cent for children in these households 12. These examples demonstrate opportunity for further health sector spending to improve access to healthcare across the Thai population.



In order for Thailand to continue on a path of improved health for all, as is the goal for the Universal Coverage scheme, a continued emphasis must be placed on allocating sufficient national budget to public health expenditure. If the elections on December 23, 2007 are able to restore democracy and political stability, the stage is created for foreign investors to continue to be attracted to Thailand, the GDP will eventually begin to rise and the health sector can continue to receive the attention it needs. International and national forces should join together to ensure the upcoming election is fruitful in restoring political stability, if not for the economy, then for the health of those on the margins of Thai’s society.







WORKS CITIED

1. The Nation, "What Thaksin had done wrong", 22 November 2006


2. https://www.cia.gov/library/publications/the-world-factbook/geos/th.html


3. http://www.economist.com/countries/Thailand/profile.cfm?folder=Profile-Economic%20Data


4. Wibulpolprasert, Suwit, Thailand MDG’s and Universal Coverage of Essential Health Services. Available at http://www.wpro.who.int/NR/rdonlyres/5DB24877-DD7E-499D-A2D2-473E32AE0F10/0/15ThailandMDGsanduniversalcoverageofessentialhealthservicesSWibulpolprasert


5. Wibulpolprasert, Innovations in the Health Financing: The Thai’s Experience, presented April 20th, 2004


6. USA for Innovation website: Available at: http://www.aei.org/publications/pubID.25890/pub_detail.asp


7. Asia Defense News. Available at: http://www.asiandefense.com/news/update/12-06-2006.html


8. PRAKONGSAI, PHUSIT, et al. Assessing the Impact of the Universal Coverage Policy on Financial Risk Protection, Health Care Finance, and Benefit Incidence of Thai Households, Journal of Health Science, 2007


9. Mills, Anne, Strategies to achieve universal coverage: are there lessons from middle income countries? 30 March 2007


10. Hughes and Leethongdee. “Universal Coverage In The Land Of Smiles: Lessons From Thailand’s 30 Baht Health Reforms”. Health Affairs, 26, no. 4 (2007): 999-1008


11. Corbe, Ron. “Thailand’s Health Plan Creates Challenges for Hospitals” Available at http://www.voanews.com/english/archive/2006-05/2006-05-03-voa33.cfm


12. UNICEF-Thailand. Available at: http://www.unicef.org/thailand/reallives_3888.html
    
    
    
    
    
    
    
    
    
    

Mumbai Storm

Mumbai Storms

Thundering hearts beating on a face
Lost to the instinct to survive
In a city
Where every dweller is the endured

Roaring clouds silently gathering
To afford shade to the indulgers
Feeding a city
Gorged on cosmopolitan idealism

Striking lightning with the match of hope
Igniting more than imagined in an
Illuminated city
Darkened by evolving altercations

Flying crows spilling their song
Fueled by the refuse of plenty
Contrasting a city
Where Bollywood’s dung is burned for fuel

Dripping rain on each person’s soul
Not allowing the flaming dreams to extinguish
The spirit of a city
Symbiotically loved and hated by millions

Waning heat after la tormenta
Allows you to finally exhale and indulge
In the city’s enchantment
Home to stormy malleable ideas of life

Drug Wars; the new AK-47

OK, So I understand that it takes science, technology, research, etc to develop a medicine. Of course, for every medicine that makes past the various stages of clinical trials, there are hundreds that fail in their infancy. When these compounds are seen to have beneficial effects, whose responsibility is it to get it to the appropriate populations and at what cost?

There are many issues to consider. Who are the appropriate populations are how are they defined? What medicines fall into this category to have a great impact? Are they "essential medicines" and who defines this? What about the laws in place to protect this property and their proprietors? What are the repercussions and implications to acting within the limits and outside the limits of the law? And of course lastly, how do we as a population of public health advocates, walk the tightrope by ensuring populations obtain the medicines without disrupting the balance of current donation schemes?

Let me ask you this: if you had in your hands the cure to a disease, or even a medicine that could alleviate the suffering of a child, a mother, a worker whose bones rattle with poverty at night when he sleeps, would you let it churn through the cycles of Intellectual Property and patent rights to eventually disseminate into the population? Are you confident that the population who truly needs it, or better yet deserves it will be able to access it?

How do we decide who is deserving of a medicine? Is it because you are born in a certain country; under a certain star; to certain parents? Is it because your discomfort is more than another? Is it because your silent pain is not heard by the those who need to hear it or that those who need to hear it have their i-pods plugged in too tight to be bothered by it.
Is someone labeled as "deserving" if they have less opportunity in a land of milk and honey versus someone who has more opportunity in the barren land of hope. How relative is it?

Let's look again and the definition of essential medicines:

The term "essential medicines" is defined by WHO as the medicines "that satisfy the needs of the majority of the population and therefore should be available at all times, in adequate amounts in appropriate dosage forms and at a price the individual and community can afford". Are these medicines defined by the people who live in these countries? This is do not know.

For example, recently Thailand declared Kaletra, an AIDS medicine, a lawful compulsory license allowing it to be reproduced. According to TRIP's, Article 31 permits countries to violate the patents to "be waived by a Member in the case of a national emergency or other circumstances of extreme urgency or in cases of public non-commercial use". Thailand has declared the AIDS epidemic a national emergency with various people demonstrating resistance to the current medicines out there and it is being used non-commercially.

What implications does this have? Well, a government declaring a national emergency should be at the discretion of the government. If for example, the U.S.A. had 10 reported cases of Ebola on a New York subway, I think that would warrant an emergency given the air borne transmission of the virus.

Even though Thailand was well within the limitations and completely legal by my understanding-a storm cloud looms over them. Abbott, the pharmaceutical company who produces this drug, engaged in negotiations with the Thai government.


The results: Abbott has unilaterally offered to sell Thailand Kaletra at its fixed middle-income tiered company price,$2200/patient/year, a price that is 440% higher than the cost price Abbott offers to African countries and more than five times as much as what will be charged by generic producers once there are sufficient economies of
scale and competitive generic markets-(Brook K. Baker, A New Low in the Pharma Drug Wars - Abbott Withdraws Seven Medicines in Thailand)


The whiplash is alarming. Abbott retracted applications for registration of 7 drugs including Kaletra (The six other drugs are the painkiller Brufen; an antibiotic, Abbotic; a blood clot drug, Clivarine;the arthritis drug Humira; the high-blood pressure drug Tarka; and the Kidney disease drug, Zemplar.) The power of pharmaceutical companies in this day and age is as powerful as a medieval sword in the hands of a skilled swordsman.

As public health advocates, a great challenge lies ahead. Certain pharmaceutical companies have well established pharmaceutical donation programs that extend to corner of the earth that the average population deems extreme. However, these are few and far between.

We must first look at the disease and the population. From a Public Health point of view-will this population continue to spread the disease? However, with doing this, we create artificial subjective boundaries. Do we want to save the most people as possible, or everyone? What about the 1 in a million patient with a rare auto-immune disease? Is this patient left out due to sheer prevalence and transmission of the disease?

Ask the family what they think; if your mom/dad, daughter/son had one of these diseases, would you step back and say, forget about it-its too rare to care and cure. At what length is going "too far"? This ties back to societal altruism.

Altruism is not biologically favorable. The deer who comes out and sacrifices himself in front of the herd will never pass on these altruistic genes. Have we evolved past the biological contexts of our ancestors? Does this society we live in create an artificial "survival of the fittest" measuring fitness by convoluted political and economic mean. Ooops, sorry for the digression.......

This leads me to believe we should try to help as many people as possible. The case in Thailand serves as a brilliant case study to demonstrate the power of the Pharmaceutical world and how quickly it can go from a sheep to a wolf. I know feel with this power, the wars that are now waged with pharmas and people is more dangerous than the AK-47. In a global society where many developing countries, like Mozambique, have more AK-47s than people, I ask how is it that they do not have medicines or the right to access them.

Coca Cola dreams

Today my intellectual fantasies of seeing some of the best most interesting people in my field was fulfilled. Although I was excited to see Helene D. Gayle, MD, MPH, (President and CEO of CARE USA), I have to say I wasn't all that impressed. Not the best public speaker and she didn't say anything new.

However, Jim Yong Kim, MD, PhD (Harvard, WHO, Partners in Health) was a charismatic, innovative and inspiring lecturer. I am not surprised that in 2003, he received a MacArthur Foundation "genius" grant, and in 2005, he was recognized as one of America's Best Leaders and in 2006, he was listed as one of the top 100 most influential people by Time Magazine http://www.time.com/time/magazine/article/0,9171,1187277,00.html.

He started his lecture by discussing HIV and MDR-Tb and the newer XDR-Tb which is even more drug resistant. This XDR-Tb is very dangerous. In a sample of people near Lesotho 41% had MDR-Tb and 10% of those people had the XDR. 100% of the X'ers were HIV positive and the average time from diagnosis to death for this study was 16 days. Almost all the people had the exact same strain meaning it is passing from individual to individual He gave the normal stats and photos and talked about some of the successes of DOTS-Plus. He showed the famous photo of recovering HIV/TB patients.

He reinforced that a focus on Basic science research (4-5 new drugs are needed for TB), Clinical Research (we need to know what works), and Technology (what is the best way to get this out and coordinate it) needs to be strong. However, will it help to add these new innovations on top of a heap of old, ineffective/semi-effective programs already in place?

The innovative part of his lecture was a proposal of a new discipline that will seal the gap in Public Health. This is DELIVERY SCIENCE. It looks specifically and how things are implemented and imposes a business modelling system into health.

He suggests compiling information using the case study approach to look at successes and failures. He recommends lessening the focus on outcomes and refocusing on how we get the outcomes to learn from practice. He made a very good case for this and after a few years with WHO's failed 3 by 5 goal (3 Million people by 2005-Universal access to anti-retroviral therapy for all living with HIV/AIDS), he knows his fair share of bureaucracy and the dangers and complacency it imposes in the eyes of many visionaries.

My only hesitation on his plan however, is when we are at critical epidemic rate of increasing co-morbidity from HIV/Tb, for example, where are we going to get the TIME and Funding for us to compile this information and then test and test and try and try? I understand a need to identify an effective way to have people globally access primary health care, but do we have time for trial and error? Error in some countries is genius in others.

Using financial resources and business models for health care product dissemination is frankly amazing. As he said, if every person in the developing countries can get a coke in their hand, then why can't we use that same marketing model to apply to health. Getting this information from the coke PR firm and blending and molding it to many of the challenges faced by global health workers may present itself to be a bigger challenge than some of the global health challenges we face today

At any rate, it was an amazingly thought provoking lecture and I will post a link as soon as its available.

If the efficiency of marketing and globalization could be used to better the health of the world, hell, even i will drink a coke and cheer to that.

Feliz Dia del Amor y Amnistad

Today is the commercialized day of love.

In my mind, everyday should be a day of love. But some people need a reminder from Hallmark. That's ok. We all have our flaws :)

After my mini-rant yesterday, how's a girl to complain when this beautiful bouquet is on my doorstep when I come home for lunch.

Love cannot endure indifference. It needs to be wanted. Like a lamp, it needs to be fed out of the oil of another's heart, or its flame burns low. ~ Henry Ward Beecher

I prefer the Latin American version of Valentine's day; its a day of love and friendship. So, to all my loves and friends out there, I wish you a soul tickling valentines day. I love you all (today and everyday :) and all of you have contributed deeply to who I am.

Valentine's day flowers-Blooming some thoughts

What is the cost on the environment for sending a bouquet of flowers to your sweetie to say you love them. Who are you impacting and how? You know, I'm a firm believer in your dollar being your biggest vote in this world.

A May 2002 cover story in Environmental Health Perspectives, published bythe U.S. Department of Health, pulled together current research on workerand environmental health in the cut flower industry. Holland remains theworld's largest producer of cut flowers, but Colombia is now a close second.One of every two flowers sold in the U.S. is grown in the Colombian savannahsurrounding Bogota. Colombia flower workers number 80,000, with another50,000 in packaging and transportation. China, Costa Rica, Ecuador, India,Malaysia, Mexico, Kenya, Tanzania and Zimbabwe all now export cut flowers.According to a report by the International Union of Food, Agricultural,Hotel, Restaurant, Catering, Tobacco and Allied Workers and Food FirstInformation and Action Network (FIAN), 190,000 people in developingcountries work in the flower business.

Well, here in the U.S. many of our roses come from either Ecuador or Colombia depending. Also, we get flowers from Holland and I'm sure other countries.

These issues exist here, but for the sake of argument, I want to look a little at the U.k. Thirty percent of their flowers come from Kenya, specifically around Lake Naivasha. Which is worse, using a large amount of fuel to fly over flowers from Kenya or importing flowers from Holland.

Preliminary results on a study done by a University in U.K. says it is actually a less negative (5 times less) impact on the environment if you get them from Africa. There they are grown in the natural, hot sun opposed to the artificial environment created in Holland in Hot houses that happens this time of the year.

I suppose you must also look and the use of pesticides, treatment of workers, sustainability (Lake Naivasha is drying up quickly and once it's gone, this will no longer be an option), and overall how much of this land could be used to produce nutritious foods instead of cash crops.

All in the name of those of us more fortunate-needing a little symbol of love. I would prefer a hand drawn photo of a flower, but how's a girl not to smile, when he thinks of you and sends you flowers.

After all, the Earth laughs in flowers. (Ralph Waldo Emerson) and who doesn't want to share a laugh with the one they love.

http://shopping.guardian.co.uk/valentinesday/story/0,,1708468,00.html

Wanderlust and drugs

As my wander lust grows, I find myself bogged down by more and more things. I keep telling myself these things are an anchor that will eventually sprout wings and carry me away with them. Till then, I do what I can sitting behind an electronic box making letters dance into words and sending them across many oceans.

Recently, I have been following the pivotal lawsuit in India involving TRiPS (WTO's International Agreement on Patent rights which generic drug production falls under via intellectual property rights). Generics and access to generics in the developing world is a big, crazy mess.

People are dying from not having access to drugs. Pharmaceutical companies are companies after all and can not do anything but what brings them good PR and helps them sell drugs. They have a bottom line to keep stock holders happy and investing and keep research flourishing. Unfortunately, healthiness, especially in the developing world, is the bastard love child at the mercy of the tryrannical abusive pharmaceutical company-father and his guilty late night indulgences with an insecurely confident ministry of health mother. Ahhh when will health become a human right. Am I only dreaming that this will ever happen.

As I research this more, I am sure I will start to sort out some of the fine ethical points of the discussion.

Till then, back to making letters dance...........