First Boys Rescued From Thailand Cave as Rest of Youth Soccer Team Awaits Safety. But What About the Thai Health Care System?

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Karen Mizoguchi of People magazine reported this morning that rescue operations have begun for the 12 boys and their coach trapped at the Thailand cave for more than two weeks.

On Sunday, after at least eight hours since a team of divers started rescue efforts, at least four boys have emerged from the cave, as reported by multiple news outlets. The Thai Navy SEAL official Facebook page also confirmed four players were evacuated.

In addition, two ambulances were seen leaving the site with one boy believed to be in each. A team of 13 international cave diving experts and five Thai Navy SEALs entered the cave with the mission of accompanying each boy one by one through the flooded tunnels, that claimed the life of a former Thai Navy SEAL diver on Friday.

“Two kids are out. They are currently at the field hospital near the cave,” Tossathep Boonthong, chief of Chiang Rai’s health department and part of the rescue team, told Reuters. “We are giving them a physical examination. They have not been moved to Chiang Rai hospital yet.”

The bobbleheads then when on to taut the wonder of the Thai healthcare and how wonderful it is and that it is free universal health care.

Well, even as I have only one or two more edits on my original post for the week on Bernie Sanders and his Medicare for All policy, I thought that I would look at the Thai health care system. Is it as great as the commentators have been suggesting?

So, what is the health care system in Thailand all about?

Wikipedia states that Thailand has had “a long and successful history of health development,” according to the World Health Organization. Life expectancy is averaged at seventy years and a system providing universal health care for Thai nationals has been established since 2002.

Health and medical care are overseen by the Ministry of Public Health (MOPH), along with several other non-ministerial government agencies, with total national expenditures on health amounting to 4.3 percent of GDP in 2009.

Non-communicable diseases form the major burden of morbidity and mortality, while infectious diseases including malaria and tuberculosis, as well as traffic accidents, are also important public health issues.

Infrastructure                                                                                                                               Most services in Thailand are delivered by the public sector, which by 2010, included 1,002 hospitals and 9,765 health stations. Universal health care is provided through three programs: the civil service welfare system for civil servants and their families, Social Security for private employees, and the universal coverage scheme that is theoretically available to all other Thai nationals. Some private hospitals are participants in the programs, but most are financed by patient self-payment and private insurance. According to the World Bank, under Thailand’s health schemes, 99.5 percent of the population have health protection coverage.

The MOPH oversees national health policy and also operates most government health facilities. The National Health Security Office (NHSO) allocates funding through the universal coverage program. Other health-related government agencies include the Health System Research Institute (HSRI), Thai Health Promotion Foundation (“ThaiHealth”), National Health Commission Office (NHCO), and the Emergency Medical Institute of Thailand (EMIT). Although there have been national policies for decentralization, there has been resistance in implementing such changes and the MOPH still directly controls most aspects of health care.

Thailand introduced universal coverage reforms in 2001, one of only a handful of lower-middle income countries to do so. Means-tested health care for low-income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card, which allows them to access services in their health district and, if necessary, to be referred for specialist treatment elsewhere.

The bulk of health financing comes from public revenues, with funding allocated to contracting units for primary care annually on a population basis. According to the WHO, 65 percent of Thailand’s healthcare expenditure in 2004 came from the government, while 35 percent was from private sources. Thailand achieved universal coverage with relatively low levels of spending on health, but it faces significant challenges: rising costs, inequalities, and duplication of resources.

Although the reforms have received a good deal of criticism, they have proved popular with poorer Thais, especially in rural areas, and they survived the change of government after the 2006 military coup. Then, the Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the scheme free. It is not yet clear whether the scheme will be modified further under the military government that came to power in May 2014.

In 2009, annual spending on health care amounted to 345 international dollars per person in purchasing power parity (PPP). Total expenditures represented about 4.3 percent of gross domestic product (GDP). Of this amount, 75.8 percent came from public sources and 24.2 percent from private sources. Physician density was 2.98 per 10,000 population in 2004, with 22 hospital beds per 100,000 population in 2002

Data for utilization of health services in 2008 include 81 percent contraceptive prevalence, 80 percent antenatal care coverage with at least four visits, 99 percent of births attended by skilled health personnel, 98 percent measles immunization coverage among one-year-olds, and 82 percent success in the treatment of smear-positive tuberculosis. Improved drinking-water sources were available to 98 percent of the population, and 96 percent were using improved sanitation facilities (2008).

Most hospitals in Thailand are operated by the Ministry of Public Health. Private hospitals are regulated by the Medical Registration Division. Other government units and public organizations also operate hospitals, including the military, universities, local governments, and the Red Cross.

Government Health Services                                                                                                            In Thailand, government-funded health care is funded by the Department of Medical Services at the Ministry of Public Health. The Ministry is in charge of public health services, government hospitals, and medical services. Public health facilities in Thailand offer good medical services, but government hospitals are often crowded, which means waiting times can be long. In addition, facilities in public hospitals may not be as good as those in private hospitals in Thailand. Treatment is completely free for Thai citizens holding a Universal Coverage Health card, except on Saturdays, when a charge is made. The National Health Security Office issues this Universal Coverage Health card. Normal charges apply for non-Thais, but these charges will be less than in a private hospital.

Private Medical Sector                                                                                                            Thailand is one of the leading medical tourism destinations in Asia. Most of the private hospitals in Thailand have excellent medical facilities and staff.

Non-Profit Health Organizations                                                                                                      A variety of agencies exist in Thailand to help disadvantaged people. These agencies include the Red Cross, World Vision, and Médecins Sans Frontières.

Doctors in Thailand                                                                                                                        Most of the doctors in Thailand are specialists. For this reason, it may be difficult for you to find a reliable general practitioner to treat you for minor medical issues. At a general hospital, a doctor who is a specialist in a certain field will most likely examine you. It may be difficult for this specialist to deal with a number of smaller medical conditions that you might have. The best idea for you might be to seek an internist as your first resort.

Please note that there are still major hospitals in Thailand that employ family doctors or medical practitioners. In addition, most doctors in Thailand do not have one specific place of work. Thai surgeons and physicians are employed at different hospitals that can be spread all over the city. Some of these doctors also have private clinics. For this reason, doctors in Thailand are likely to go from hospital to hospital to do their rounds. Some issues arise from this. For example, if you have just had surgery and a problem arises, your surgeon may have already left for another hospital and may have to deal with your situation over the phone.

Emergency Transport Facilities                                                                                       Emergency transport facilities in Thailand are unfortunately somewhat lacking. Although large hospitals in Thailand do have mobile intensive care units, you will rarely see an ambulance racing through the streets of Bangkok. Traffic accidents are attended to by volunteer organizations. The main obstacle in terms of emergency transport is the traffic in Bangkok; cars do not generally move out of the way for an ambulance.

Thailand has had a universal health-care coverage scheme since 2002. Apiradee Treerutkuarkul examines how renal-replacement therapy for the chronic end-stage renal disease is straining the scheme’s resources.

In 1998 21-year-old Thunyalak Boonsumlit fell ill so her worried parents took her to hospital. “I thought I had food poisoning,” she recalls. The doctor, however, told her she had acute kidney disease and would die without immediate treatment. There was more bad news: although her parents were insured by Thailand’s Civil Servant Medical Benefit Scheme, this scheme only covers dependents up to the age of 20. Boonsumlit was treated for a month and sent home.

In 2002 Thailand reformed its public health financing system. This extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less-comprehensive schemes.

It was the realization of a project that had been a quarter of a century in the making, starting with the creation of a social welfare scheme for the poor in 1975. The new scheme offered comprehensive health care that included not just basics, such as free prescription drugs, outpatient care, hospitalization and disease prevention, but more expensive medical services, such as radiotherapy, surgery and critical care for accidents and emergencies. But it did not cover renal-replacement therapy due to budget constraints. Boonsumlit and thousands of fellow sufferers were on their own.

“There was a concern that renal-replacement therapy could burden the system. Major health risks leading to kidney diseases, such as diabetes and hypertension, were still not well controlled,” says Dr. Prateep Dhanakijcharoen, deputy secretary general of the National Health Security Office, which oversees the Universal Coverage Scheme. And renal replacement therapy is expensive. The cost of hemodialysis is about 400,000 baht (US$ 12,100) per year. This is four times higher than the 100,000 baht (US$ 3,000) per quality-adjusted life year threshold set by the National Health Security Office’s benefits package subcommittee for drugs and treatments. This threshold was adopted as a national benchmark.

Dhanakijcharoen believes that the Universal Coverage Scheme plan should have included kidney disease from the outset, a view shared by Dr. Viroj Tangcharoensathien, director of the International Health Policy Programme at the Ministry of Public Health. It was a simple matter of fairness: “There are three health-care schemes in Thailand,” he says. “Only the Universal Coverage Scheme did not include renal-replacement therapy.”

In 2005 Boonsumlit became ill again and was diagnosed with end-stage renal disease. For a year her parents had to pay 400,000 baht (US$ 12,100) to cover her dialysis. This time she was told that if a suitable donor could be found, a kidney transplant was the best option. The procedure cost 300,000 baht (US$ 9,000). Boonsumlit’s mother donated a kidney, and once again she and her husband paid all the bills, including the cost of post-transplant medication required to prevent the rejection of a new kidney.

But there was increasing community pressure for change. People like Subil Noksakul, who had spent his life savings on medical treatment over a period of 19 years, were tired of being treated like pariahs. “I once managed to save 7 million baht. But all my savings are now all gone,” he says. Like everyone else, he found it unacceptable that the Civil Servant Medical Benefit Scheme and the Social Security Scheme, which rely on public funds, both offered treatment for kidney disease while the Universal Coverage Scheme did not.

In 2006 Noksakul founded the Thai Kidney Club, which raised kidney patients’ awareness of their rights and put pressure on the National Health Security Office to provide treatment. Finally, in January 2008, the then public health minister, Mongkol Na Songkhla, bowed to public pressure and included renal-replacement therapy in the scheme. For Boonsumlit, Noksakul and thousands of other kidney patients, it was a watershed moment.

Unsurprisingly, since 2008, demand for treatment has spiraled. According to Dhanakijcharoen, 2.5 billion baht (US$ 76 million) of the total annual National Health Security Office budget of 120 billion baht (US$ 3.62 billion) has been allocated to renal-replacement therapy with 8,000 patients receiving haemodialysis and 4000 receiving peritoneal dialysis: to meet the full need, this treatment would require a huge increase in funding.

“The cost of renal replacement therapy is still less than 2% of the total budget,” he says, but warns the cost could blow out should Thailand fail to focus on prevention and reduce new cases.

The Ministry of Public Health’s Tangcharoensathien paints an even starker picture: “Without alternatives, renal-replacement therapy, when fully scaled up to target end-stage kidney patients, could consume more than 12% of the Universal Coverage Scheme annual budget, and push it to the verge of financial crisis,” he says.

The National Health Security Office is trying to reduce some costs by encouraging patients to perform their own peritoneal dialysis at home. This is dialysis in which patients filter their own blood by periodically injecting fluid into the abdominal cavity, which is later drained. Tangcharoensathien believes nurses can play a crucial role in training patients and family members to use equipment that is provided free of charge under universal coverage. Meanwhile, those patients who continue with the more expensive hemodialysis must now pay one-third of the total cost of treatment.

It is debatable whether home-treatment would have a big impact on costs, given the increased risk of infection and subsequent expenses associated with peritoneal dialysis, which costs up to 240,000 baht (US$ 7,300) annually. However, it would save rural patients the twice-weekly fares to visit a hemodialysis center in a provincial city, which poor patients cannot afford. The National Health Security Office aims to reduce the cost of peritoneal dialysis to about 200,000 baht (US$ 6000) per year.

More promising perhaps is the government’s broader campaign to improve the nation’s renal health. Screening for diabetes and hypertension, as part of a 2.5 billion baht (US$ 76 million project) is due to start this year. According to the National Health Security Office’s Dhanakijcharoen, the project will cover 5500 communities and municipalities nationwide. “Although the current health-promotion fund is still insufficient, it is a good start for prevention and early detection of diabetes and hypertension among local residents,” Dhanakijcharoen says, adding that encouraging healthier lifestyles will also help to reduce the cost of chronic disease and the burden it places on the health budget.

Tangcharoensathien concurs: “If the government allocated more budget to run the scheme, the National Health Security Office would be able to invest more in reducing health risks, and people would not end up with kidney disease in the first place.”

Both men are eager to see the latest universal coverage initiative succeed. They are proud of what has been achieved on total health expenditure equivalent to 4% of gross domestic product (GDP) – compared to the world median of 6.2% of GDP and 4.5% for lower-middle income countries. Dhanakijcharoen says, “We would like to let the world know that it’s not necessary to launch a universal health-care system only when the money is there; what is important is to work steadily on it. But dedication is a must.”

The Question is what Thailand can teach the world about universal healthcare

The Asian nation proves that a well-researched system with dedicated leadership can improve health, affordably. In 10 years, its plan reduced infant mortality, decreased worker sick days and lightened families’ financial burdens

While countries all over the world are moving toward universal healthcare, for many it remains just a goal. But a handful of them have rolled out universal health coverage schemes, and there’s plenty to learn from these nations. Consider Thailand, where leaders successfully implemented sweeping healthcare reform without breaking the bank.

In 2000, about one-quarter of people in Thailand were uninsured, and many other people had policies that granted incomplete protection. As a result, the country was in a healthcare crisis. More than 17,000 children younger than five died that year, about two-thirds of them from easily preventable infectious diseases. And about 20% of the poorest Thai homes fell into poverty from out-of-pocket healthcare spending.

In 2001, Thailand introduced the Universal Coverage Scheme (UCS). It’s described as “one of the most ambitious healthcare reforms ever undertaken in a developing country” in the book Millions Saved: New The Center for Global Development reviewed the Thai healthcare system and found Cases of Proven Success in Global Health. The UCS, which spread to all provinces the following year, provides outpatient, inpatient and emergency care, available to all according to need. By 2011, the program covered 48 million Thais or 98% of the population.

Several things worked in favor of Thailand’s UCS, including a sustained support system and a broad reach. Reformers from the 2001 general election’s winning political party, Thai Rak Thai, held leadership positions, and they were able to help back the program. As described by Dr. Suwit Wibulpolprasert, the program’s policy director and Thailand’s deputy secretary of the ministry of health at the time, the UCS had to go wide quickly. “The challenge was to implement it fast,” he says. “It couldn’t be done over 10 years because there was huge political pressure.”

Thailand’s UCS was implemented in every province by January 2002, but this level of comprehensive care had taken decades to develop. Since the 1970s, free medical care had been available to some people in poverty, but the country had a range of health insurance schemes that left many without coverage. Developing infrastructure – hospitals, clinics, and trained staff – to support universal coverage took years.

According to Dr. Sara Bennett, associate professor at Johns Hopkins Bloomberg School of Public Health, quality is the most challenging aspect of universal healthcare in developing countries. Government-funded healthcare is often free, but it can be geographically inaccessible, limited to a few facilities and administered by poorly trained staff. In addition, what works in urban areas might not be suited to rural contexts and vice versa.

When Thailand established solid health infrastructure, universal healthcare “totally changed the relationship between patients and doctors”, Wibulpolprasert says. Before, patients paid a fee to their doctors when they visited the hospital. After 2001, the government paid hospitals, including salaries for staff, and financially incentivized medical professionals to serve unpopular rural areas.

The lessons in Thailand: a well-researched system with a dedicated leadership can improve health, and in an affordable way. As of 2011, the country’s health scheme cost just $80 per person annually, primarily funded by general income tax; it effectively reduced infant mortality, decreased worker sick days and lightened families’ financial burden for healthcare.

Meanwhile, in the US, securing agreement from political leadership is one of the most contentious issues over universal healthcare. The Patient Protection and Affordable Health Care Act, also known as Obamacare, was signed into law in 2010, yet is still embroiled in political controversy. However, the plan is paying off: more people than ever are insured and out-of-pocket spending has dramatically declined among those insured.

Around the world, many low- and middle-income countries are also moving toward universal care. “They are covering more people, who are paying less out of pocket and have access to a broader array of services,” Bennett says. “Many countries are making significant strides towards this, including the poorest.”

Paying for universal health care remains a challenge. In South Korea, for instance, care is funded by compulsory health insurance from all citizens and covers about 97% of the population. However, the country’s health system is in growing deficit.

Listen carefully, in Thailand, affordability is not currently an issue, though the cost of the program as a proportion of general income tax is rising yearly. The cost and payment for the system have to be considered in our country of the U.S.A. if we want a universal health care system of any type! Still, the UCS continues to have wide support from the country’s government, health workers, and the wider population.

“The challenge is to make it more efficient, to get more for less money, particularly with the introduction of new technology and new drugs,” Wibulpolprasert says.

According to Carolyn Hart, Washington office director at health consultancy John Snow Inc, a multisectoral approach is a key to global healthcare. “We are looking at the need to develop channels at all price points including free, subsidized and pay as you go, which could be insurance,” she says.

“How can [countries] afford not to invest in the health of their people?” she adds. “Poor health holds you back so badly.”

We just have to decide to make the right decisions and what the correct design of our health care system and how we are going to pay for it. There are many differences here as there are in many of the countries that have a universal health care system and we have to examine which we can adapt to create a successful, caring and sustainable system.

Onward to discuss Bernie’s proposal and luck and prayers to the divers and Thai children and their coach.

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