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HEALTH SERVICE INNOVATION
Dr. Thiravat Hemachudha
Dr. Thiravat is Professor of Neurology at the Department of Medicine and Molecular Biology, Center for Neurological Diseases, Chulalongkorn University Hospital. He is Director of WHO Collaborating Center for Research and Training on Viral zoonoses and was former Director, WHO Collaborating Center for Research on Rabies Pathogenesis and Prevention. He is Member of WHO Expert Advisory Panel on Rabies, and a columnist on health issues and “Detox Thailand” in Matichon and Bangkok Business newspaper, among others.
By Pokrath Hansasuta, MD, DPhil (Oxon), FRCPath
1. In your opinion, how does the current situation stand for Southeast Asia’s health services?
“Access to health services is always a key determinant of development. Within Southeast Asia, the countries with the most efficient delivery of health services are Malaysia and Singapore. I think that one of the trends in the region is that health services in developing countries often end up a casualty of populist politics, and are used as a tool to maximize votes. Sadly, politicians neglect their responsibilities under their social contract. The result is overly complex and underfunded national health systems, longer waiting lists and inefficient service delivery.”
“Moreover, preventive healthcare campaigns in the community have not generally met with success. Patients more frequently present with more severe symptoms than previously. Moreover, severe cases (imposing high treatment costs) are frequently transferred by physicians to central or provincial hospitals, provoking a ‘knock-on’ budgetary problem and higher total costs of service delivery.”
“The result is conflict between patients and physicians, longer queues at hospitals, and heavier pressure on medical professionals in Bangkok and provincial cities. With the threat of lawsuits always at hand, many doctors have resigned from their posts at government hospitals to work in the better resourced and less bureaucratic private hospitals instead. This certainly worsens the situation and drains the system of precious human resources.”
“In addition, conflicts have grown within the profession itself over the policy of allowing doctors to choose only from an official list of cheaper drugs under the health insurance system. Often the best and most effective medicines are expensive out-of-list patented and imported drugs, e.g. medicines for Alzheimer’s disease or cancer. However, the situation may be improving as the committee of the National Drug Formulary or essential drug program, Thai FDA, started implementing policies that state that drugs to be used in Thailand under the national welfare program should fulfill criteria of efficacy, safety and accessibility. Drugs that save lives or disease-modifying drugs, even those with high cost, have also been included. However, there are rigid inclusion criteria, such as for whom to use, when to initiate, for how long, when to consider a drug is not effective, and which institutions are capable of handling such patients.”
“If we don’t do something radical, the conflicts throughout all levels of Thailand’s health system will worsen: conflicts between service providers and patients, budgetary conflicts, demoralized and declining medical professionals. The situation will be exactly what countries in South Asia, i.e. India, Nepal, and Bangladesh, are also now being faced with.”
2. How will the increasing intensity of movement of people, goods, and animals across the region affect health service delivery?
“Thailand is under close watch for human trafficking and illegal trade across borders. This is because the country was formerly a hub for trade in endangered species, and labor migration, both legal and illegal. Diseases are easily transmitted across borders in this way, and emerging diseases often have this etiology, with the close animal-human contact facilitating the jump from animal to human. Looking ahead, increasing trade liberalization surely will exacerbate these risks, so I expect to see new emerging diseases arise more frequently. Increasing treatment costs will therefore place higher burdens on health services all around the region.”
3. Which innovations might offer a high impact solution to enhance access to health services for vulnerable and marginalized groups?
“Service innovation in healthcare is needed to address these system failures. We need to facilitate universal access based on an understanding of social change, the drivers of the existing system, budgetary constraints, and the supply of medical professionals. Thailand’s universal health care scheme offers a useful case study in this regard. The main target of universal healthcare schemes is to offer free healthcare services to all. Thailand’s strategy has been to allocate budgets to local health service providers such as health centers and district hospitals. Preventive care strategies complement this effort, using campaigns to raise awareness to help individuals stay healthy and prevent sickness, in theory reducing the patient burden at hospitals. (As I mentioned earlier, approaches to preventive health have so far not met with much success and need to be rethought). Scientists and sociologists must work together to solve these complex problems, so that research can deliver meaningful answers to real-life problems rather than just for academic advancement.”
“Thailand might benefit from approaches of other countries in balancing the workload of medical professionals between research teaching and patient care. For instance, the United States categorizes medical manpower, giving clear separation to these roles, and minimizing the need for trade-offs, between medical research and the work of physicians. System design is the key to sustaining a relevant research agenda; specialization creates the risk of a silo mentality; players need to have a broad understanding of the needs and challenges of other actors in the healthcare system.”
“In countries like Malaysia and Singapore and China, a “semi-dictated” policy might not be that bad. A unified well-structured system and policy, topped down from the government with stringent control and monitoring to keep things in place proves effective. Scientists and physicians can be teachers. They can simplify things considered as complicated to the students. Good science starts even at the primary school level. Each then knows how to “learn” and to acquire knowledge by his or her own and not by spoon-feeding.”
“In Thailand, the problems are that policymakers do not know what has been going on and each and every sector (knows this), and they tend to freely operate like an unguided missile with collateral damage, with time and national budget loss. Decentralization as in Thailand is not a problem. It is that all levels do not know what to do and which direction to go. Thailand is just like the jigsaw pieces not knowing when to complete the image.”
“We also need to take a more rational look at the cost-effectiveness of drugs. Locally-manufactured generic drugs of proven quality must be considered first. There is no need to spend more (it can be up to 10-30 times higher) for original imported drugs whose patents have already expired. Dramatic budget savings can be achieved in this way. Also, we should not be blinded by technology in seeking solutions: the public has to be continuously educated on how to stay healthy. Eating vegetables 3-5 times a day helps prevent stroke and cancer, whilst dietary supplements are a fraud. Eating right and daily exercise can yield massive reductions in total need for prescription drugs, and so healthcare systems should start right there. Finally, we may have to think whether co-payments by the patients who can afford it can be possible to make this national welfare system sustainable.”