using innovation in tobacco taxation in promoting health - prakit vathesatogkit
2 - Why Setting up ThaiHealth? - The process of setting up ThaiHealth - How ThaiHealth operate? - Some of Thai Health’s first decade achievement
3 Thailand :1990-1995: low budget interventions on tobacco control Enacting two comprehensive Tobacco Control Law in 1992 (Product control & smoke free areas). Regular tobacco tax increases policy in 1993.
Problem faced4 1. Government provide very little budget for tobacco control. 2. Request for more budget through conventional method were unsuccessful.
5 The idea of setting up “health promotion fund” originally arise from we want to secure funding to support tobacco control
6 There are other emerging non communicable diseases Alcohol related problem Road traffic accident Cardiovascular diseases facing the same problem as with tobacco control: no funding
Thailand in 1995 - 967 Per capita alcohol consumption rank no. 7th of the world and increasing 13,000 traffic accident death per year, Half of which age 15-35 year 26% related to drunk driving Traffic accident cost 1,707 million US$ = 2.25-3.48% of GDP
Research Estimate8 If health promotion efforts succeed in reducing health care expenditure in tobacco, alcohol, traffic accident by 10 percent, Thailand would save 488 million US$ per year.
Ministry of Finance : Health financing reform policy (1996) Appoint working group to study; 1. Universal Health Insurance, - to provide health security. 2. Setting up Health Promotion Institute / Foundation, - to decrease health care cost.The 2nd policy was intended to compliment the 1st policy.
Challenges faced when Establishing Thai Health10 Winning support from cabinet member; Overcoming MOH’s query - We already are conducting HP, why set up a new agency? - If set up a new agency, why not set it up in MOH? Overcoming MOF’s reluctance. - Why a dedicated funding? - Why not from the regular budget?
11 Need to clearly explain WHAT IS“HEALTH PROMOTION ?”
Population Groups Classify According to Health Status12 Healthy Group 1 Having Risk Group 2 behavior Diseases but not seeking Group 3 care Sick and Group 4 seek care
Population Groups ClassifyAccording to Health Status Health Healthy Promotion Having Risk behavior Diseases but not seeking care Sick and Conventional seek care Health 13 Care system
“Health Promotion” Population Group 114 prevent them to progress to Group 2 Educate about how to improve their health/avoid unhealthy lifestyles Control of unhealthy environment - physical environment eg. Road/air quality - marketing of unhealthy products/food
“Health Promotion” Population Group 2/3/415 Help them to; - stop smoking/drinking - abandon risk behavior a) not exercise/unhealthy food b) unsafe driving Promote healthy behavior exercise/health food. Regulate marketing of unhealthy products.
Measures (Action) to promote health16 - Build healthy public policy - in all ministries; - Create health supportive environment. - Get community involve. - Reorient – adjust health services. “Make healthy choice easy choice”
Existing approach New approach17 Preventive & Activator for Promotive care change; : services - Lifestyle - Environment Mainly within MOH Out side MOH Involve MOH and those Involve the whole of the who are sick & family government and society
Targeting different groups of population Health Healthy Promotion Having Risk (ThaiHealth) behavior Diseases but not seeking care Conventional Sick and Health seek care Care system18 (MOH)
Ministry of Finance : Health financing reform policy (1996)MOF was the sponsor of theThailand Health PromotionFoundation Bill, steering thebill through the cabinet andthe parliament.
20 establishing Thai Health Promotion Fund under an autonomous state agency, requiring 2% of alcohol and tobacco surcharged (levy) to this fund
21 1. Health promotion needs regular and sustainable budget. 2. Because health promotion concentrate on software rather than hardware, existing funding agencies do not understand process-based funding priorities. 3. A dedicated/specific source of funding provide a predictable, more stable amount of budget. 4. Less susceptible to diversion of funding for other purposes.
Critical proposal/Politically acceptable source of budget22 - The fund to come from tobacco and alcohol importer/producer to pay an additional 2% of excise levy (whenever they pay for the excise tax) - Key word:Government does not have to pay - : The polluter pay
23 1. The nature of the work (Health Promotion) Development VS. Established services Project based not Service based 2. Success is based on innovation 3. Not achievable through bureaucratic system 4. Needs flexible management 5. An autonomous agency is less susceptible to administrative interference (of programs and projects)
24 Under the bureaucracy system Difficulty (if not impossible) in working with agencies out side MOH eg : NGOs Tendency to subject to bureaucratic/political interferences Instability of the budget
Thai Health Promotion Foundation Act 2001 • Promotion of good health of Thais according to National Public Health Policy • Encouraging healthy lifestyles through social and physical environments • Supporting community initiatives to promote better health conditions • Campaign and sponsorship of sports, the arts and popular cultures • Development and research (D&R) Health promotion is NOT only health education.
27 The Executive Board Prime Minister as Chairman Health Minister as First Vice Chairman An Expert as Second Vice Chairman Member: Representative from 9 ministries Health / Education / Transportation / Sport / Interior / labor /University / Prime minister’ s office / Socio cultural economic board
28 • Eight Independent Experts in fields of health promotion, community development, mass communication, education, sports, arts and culture, law, as we all as administration
29 1. Tobacco Control 2. Alcohol Control 3. Traffic Injuries and Disasters Prevention 4. Health Risk Factors Control Nutrition 5. Health of Specific Group of Population 6. Health Promotion in Community 7. Children Youth and Family Health 8. Health Promotion in Organizations 9. Physical Activities and Sports for Health10. Social Marketing and Communication11. Open Grants and Innovative Projects12. Health Promotion through Health Service Systems13. Supportive Systems for Health Promotion
ThaiHealth Funding Strategy31 Open grant = 10% of budget Proactive program = 90% of budget Priority health issue (By Board) - Situation analysis - Program development - Strategic partners - Program review process - Contracting - Implementation
Key players in tobacco control32 Ministry of Health - policy development Tobacco control Research center. Mahidol U. NGO - ASH , THPI - advocacy ,lobbying - public awareness campaign Health Professional Network - smoke free health facility - smoking cessation - Quitline 1600 Teacher network - smoke free school - smoking ed program Thai Health Promotion Foundation - funding
Achievements on tobacco33 control (2001-2010) National surveillance system Ban on banning cigarette display Pictorial warnings Smoke Free environment Regulation Regular increase of tobacco tax National quitline Health professional/Teacher network against tobacco Mass media campaign Community based programs
Key players in alcohol control43 1. Alcohol Control Office : MOH 2. Center for Alcohol Study : IHPP 3. Stop-Drink Network : Community/NGOs 4. Drink Don’t Drive Foundation 5. Integrated Management for Alcohol Problem : cessation 6. ThaiHealth : funding
Alcohol policy outcomesBefore the establishment of After the establishment of ThaiHealth and triangleThaiHealth and triangle network network There are 9 national alcohol control There were 6 national policies in 4 years alcohol control policies in national alcohol policies (2003- 2007) 50 years 1. Prohibit sale for under 18 (2003) national alcohol policies (1950- 2002) 2. Partial ad ban (2003) 1. Alcohol act 1950 3. Establishing the national alcohol control 2. Limited sale time (1961) committee (2003) 3. Prohibit sale to intoxicated 4. Prohibit sale in school (2004) person (1966) 5. Warning message in outdoor billboard and 4. Drunk driving (1979) movies (2004) 5. Warning message(19p97) 6. Prohibit sale in fuel station (2005) 6. Free trade (1999) 7. Increase warning messages (2005) 8. Increase excise tax (2005) 9. Alcohol control act (2006 – 2007) 44 8 yrs per 1 policy 2 policies per 1 year
45 Children, Dental health and Obesity Before 2002, no national policies or networks to reduce sugar consumption among children 2002, NSN (govt, professional orgs, academic institutes) 2004, the Sugar Consumption Reduction Plan 2007 FDA regulation: 5 highest consumed snacks must have nutritional labeling & warning slogan “eat less & exercise regularly” 2008, Regulations on sugar in infant formulae milk powder 2009, 3,250 schools free of soda soft drinks
46 To have waist circumference of male<36 inch, female<32 inch • Media strategies. • Health care provider’s roles. • Community base program. • Policy advocacy and lobbying by the Royal College of Physician of Thailand.
What has ThaiHealth done that the government could not or did not do?49 1. Targeting different groups of population. 2. Work horizontally rather than vertically. 3. Multispectral collaboration across ministries / NGO / public / private. 4. Pilot / innovative projects. 5. Fund social marketing / mass media campaign . 6. Flexible financing mechanism.
The relation between ThaiHealth50 and government 1. Support health promotion in accordance with national health policy. 2. Prime Minister as chairman of the board Work hand in hand with MOH. Ministerof Health as deputy chair of the board. Do things that MOH can not or difficult to do. Funding for MOH projects that can not secure support from regular budget. ( not service base)
Over all Health Promotion51 and Prevention Budget (Million USD) Source 2009 MOH 400 NHSO 309 Civil Service insurance 45 Preventive Local gov 198 Promotive Other gov agencies 7.6 services International aid 13 Total 972 ThaiHealth 114 Health promotion =% of total 11.7%
ThaiHealth Budget as % of52 total health (million USD) 2006 2007 2008 Total Gov. Health Budget 6,365 7,421 8,780 Thai Health 74 74 94 = 1.16% 0.99% 1.07%
Population Groups ClassifyAccording to Health Status Health Promotion Healthy (1 % of health Having Risk budget) behavior Diseases but not seeking care Conventional Sick and seek care Health Care system(9953 % of health budget)
55 Obstacles: Securing continuity of political support Threats from the health opposition industries and commercial companies Challenges: Convincing all stakeholders of the proven benefit of the Health Promotion Foundation Capacity building of health promotion manager, advocators and experts need continuous improvement
Yearly funds Health Year Legislation 2006-7 Promotion set up in USD Foundations in:56 (per person) 1. Austria Health Promotion 1998 9,700,000 (1.18) Act 2. Switzerland Health Insurance 1994 14,000,000 (1.90) Act 3. Thailand Health Promotion 2001 63,000,000 (0.96) Act 4. Victoria Tobacco Act 1987 26,000,000 (5.10) (Australia) 5. Western Tobacco Control 1990 14,400,000 (7.00) Australia Act 6. Malaysia Malaysian Health 2006 10,000,000 (0.45) Promotion Board Act
Associate members57 1. Mongolian Health Promotion Foundation 2. Health 21 Foundation Hungarian 3. Management Centre for Health Promotion, Korea 4. Oman Health Promotion Initiative 5. Polish Health Promotion Foundation 6. Tonga Health Promotion Foundation (TongaHealth) 7. BC Coalition for Health Promotion, 8. British Columbia, Canada 9. Ministry of Health & Family Welfare, India 10. Health Promotion Initiative, Iran