How to Sustain Funding
on Health Promotion
Lesson Learns from ThaiHealth
Background
From limited and unreliable funding to a push for stable funding.
In the early 1990s, when Thailand opened its market to international tobacco companies, efforts to strengthen tobacco control faced challenges due to limited and unreliable funding. This led to a push for stable funding for health promotion and tobacco control. Around the same time, there was a proposal to create a health promotion fund alongside a universal health insurance fund, supported by a study on using a dedicated tax managed by an independent agency. After eight years of planning and advocacy, with strong support from anti-tobacco groups, the Thailand Health Promotion Foundation (ThaiHealth) was established in 2001 as a semi-independent organization under the Health Promotion Foundation Act.
Health Promotion Foundation Act
In the late 1990s, Thailand faced growing public health challenges from rising tobacco use, alcohol consumption, and NCDs.
In the late 1990s, Thailand faced growing public health challenges from rising tobacco use, alcohol consumption, and non-communicable diseases (NCDs). Advocates, led by Professor Dr. Prakit Vathesatogkit and Dr. Supakorn Buasai, spearheaded efforts to secure sustainable funding for health promotion. Limited and unreliable budgets for health programs highlighted the urgent need for a dedicated health promotion fund. The Ministry of Finance, in its 1997–2001 plan, proposed combining a health insurance fund with a health promotion fund to address both medical care and public health. This idea gained conditional acceptance, with the vision of aligning it with Thailand’s social development goals.
Great Collaboration
A working group was established in 1996 to explore models for setting up a health promotion institute. The group, which included representatives from the Ministries of Finance and Public Health, NGOs like ASH Thailand, academic institutions, and international organizations such as the WHO, focused on developing a sustainable funding mechanism. Early studies proposed using a specific tax, managed by a government-established independent agency, to fund health promotion activities.
Advocates used various strategies to gain support for the health promotion fund, including scientific conferences, public forums, and international meetings to engage policymakers. Study tours to Australia’s VicHealth and New Zealand’s Health Sponsorship Council provided valuable insights into using taxes on tobacco and alcohol to fund health promotion. Experts from VicHealth were also invited to share their experiences with Thai policymakers, helping to build understanding and support for a similar model in Thailand.
Research
The Health System Research Institute supported the effort by analyzing data on the economic impact of tobacco and alcohol use, health costs, and the benefits of taxation for health promotion. Research included foreign examples and cost-benefit analyses, while public polls showed strong support for using “sin taxes” to fund health programs, further strengthening the case for a dedicated health promotion fund.
Overcome resistance
Cost-effectiveness and risks
Advocates faced resistance, especially from the Ministry of Finance, over concerns about the cost-effectiveness and risks of using tobacco and alcohol taxes for health promotion. Fears of misuse and financial disruption added to the challenges. However, the Deputy Minister of Finance confirmed there were no legal barriers to earmarked taxes and supported the surcharge tax, presenting it to Parliament as a beneficial investment for the country.
Concerns about overlapping
Opposition also came from industries dependent on tobacco and alcohol revenues and concerns about overlapping responsibilities with existing health programs. Advocates clarified that the foundation would focus on prevention and broader health promotion, complementing rather than duplicating the Ministry of Public Health’s curative services. Leadership changes delayed progress but reduced resistance by highlighting the tax’s focus on industries, not government budgets, and its potential to reduce the economic loss of over 200 billion baht annually.
- Focusing on prevention and broader health promotion, complementing rather than duplicating the Ministry of Public Health’s curative services.
- Highlighting the tax’s focus on industries, not government budgets, and its potential to reduce the economic loss of over 200 billion baht annually.
Approved in 1999
After years of advocacy, the Thai Cabinet approved the draft Royal Decree to establish ThaiHealth as a semi-independent agency under the Public Organization Act BE 2542 (1999). Parliament approved the Health Promotion Foundation Act in 2001, creating the Thai Health Promotion Foundation (ThaiHealth). The Act introduced a 2% surcharge tax on tobacco and alcohol to provide sustainable funding for health promotion programs. This innovative funding mechanism ensured independence from traditional budgets and offered flexibility to address pressing public health issues.
In its first year, ThaiHealth received an allocation of 150 million baht but spent only a fraction as it focused on drafting operational regulations and establishing its structure. The foundation’s journey, from proposal to legislation, spanned nearly seven years (1995–2001), driven by collaboration among health advocates, researchers, government officials, and international partners.
ThaiHealth has reduced the burden of NCDs and encouraged healthier lifestyles.
This innovative approach aligns financial policy with public health goals and has inspired other countries to adopt similar systems.
ThaiHealth is a global model for sustainable health promotion funding. By using “sin taxes” to fund prevention and health programs, it has reduced the burden of non-communicable diseases and encouraged healthier lifestyles. This innovative approach aligns financial policy with public health goals and has inspired other countries to adopt similar systems.
Funding mechanisms and management
Funding mechanisms
- Mandates a 2% surcharge on alcohol and tobacco taxes, ensuring stable funding for health promotion.
- Independent structure, protected by law.
The ThaiHealth Act mandates a 2% surcharge on alcohol and tobacco taxes, ensuring stable funding for health promotion. Collected by the Excise and Customs departments, the funds go directly to ThaiHealth, bypassing the Ministry of Finance and normal budgets. This independent structure, protected by law, makes the fund resistant to industry interference. ThaiHealth uses the revenue for health initiatives that improve public well-being, and efforts to abolish it would likely face public backlash due to its significant impact on public health.
Management
Transparency
- Independent audits
- Annual performance and financial reports
- Funds are allocated through open and proactive grants.
ThaiHealth’s Governance Board, chaired by the Prime Minister, ensures transparency and accountability in operations and fund distribution. A finance sub-committee manages finances, with independent audits conducted by the Auditor General of Thailand. Annual performance and financial reports are submitted to the Cabinet and Parliament. Advisory committees offer expert guidance, and projects undergo financial audits. Funds are allocated through open and proactive grants, with flexibility for emerging health issues.
Collection and distribution of the ThaiHealth fund
Using these funds to address major health risks like smoking, alcohol use, traffic accidents, and physical inactivity.
Its campaigns have raised public awareness, reducing resistance to tax increases despite industry opposition.
Since its inception in 2001, ThaiHealth has steadily grown its funding through a 2% surcharge tax on tobacco and alcohol, using these funds to address major health risks like smoking, alcohol use, traffic accidents, and physical inactivity. Its campaigns have raised public awareness, reducing resistance to tax increases despite industry opposition. ThaiHealth allocates its budget across 14 health promotion plans, focusing heavily on creating healthy communities, media systems, and programs to prevent health risks, promote healthy lifestyles, and fund open grants.
Complement
ThaiHealth complements the Ministry of Public Health by focusing on population-based health programs and partnering with non-health sectors and NGOs. While the ministry delivers services like counseling, vaccination, and rehabilitation through health centers, ThaiHealth funds broader initiatives such as mass media campaigns and advocacy for public health laws. This collaboration bridges gaps in health promotion, enabling community, school, and workplace health initiatives that the ministry’s limited resources cannot support.
This collaboration bridges gaps in health promotion, enabling community, school, and workplace health initiatives that the ministry’s limited resources cannot support.
Funding Implementation
Despite its small size, ThaiHealth plays a vital role in improving the nation’s health and serves as a model for sustainable public health funding.
Statistics
ThaiHealth has played a key role in reducing non-communicable diseases (NCDs) through policies, campaigns, and increased excise taxes on tobacco and alcohol. Smoking prevalence among adults dropped from 25.5% in 2001 to 17.4% in 2021, and alcohol consumption decreased from 32.7% in 2004 to 28.0% in 2021. Physical activity improved from 66.3% in 2012 to 74.6% in 2019, though it fell to 57.5% in 2021 due to COVID-19 restrictions. Road traffic fatalities also declined, from 21,996 in 2011 to 16,957 in 2021. Thailand leads the Southeast Asia region in implementing WHO’s “best-buy” interventions, fully achieving 13 and partially achieving 6 indicators, showcasing ThaiHealth’s significant impact on public health.
ThaiHealth’s investments deliver significant social returns. From 2001 to 2010, its spending on tobacco control yielded an 18-fold return, with 18 baht gained for every baht invested. Similarly, road traffic accident prevention programs achieved an even greater impact, returning 130 baht for every baht spent. These outcomes highlight the effectiveness of ThaiHealth’s initiatives in improving public health and reducing economic burdens.
Programs and Campaigns
- Smoking
- Expanding smoke-free areas
- Increasing cigarette pack health warnings
- Combating tobacco advertising
- Funding smoking cessation and alcohol reduction programs
- Collaborating on road safety measures
- Backing regulations like the Unsafe Product Act and toy control laws
- Mobile phone use restrictions while driving
- and many more.
ThaiHealth supports policies and programs that enhance the well-being of Thais, including expanding smoke-free areas, increasing cigarette pack health warnings, and combating tobacco advertising. It funds smoking cessation and alcohol reduction programs, collaborates on road safety measures, and backs regulations like the Unsafe Product Act and toy control laws. Other efforts include safe Internet cafes, mobile phone use restrictions while driving, and funding public broadcasting from tobacco and alcohol taxes. Institutions like the Tobacco Control Research and Knowledge Management Centre and the Social Enterprise Promotion Office further advance health promotion.
ThaiHealth plays a vital role in improving the nation’s health and serves as a model for sustainable public health funding.
ThaiHealth’s budget, funded by earmarked taxes, complements but does not replace the Ministry of Public Health’s curative treatment focus. Its annual budget, representing less than 2% of the Ministry of Public Health and National Health Security Fund budgets, has a disproportionate impact by supporting innovative health promotion programs. Despite its small size, ThaiHealth plays a vital role in improving the nation’s health and serves as a model for sustainable public health funding.
Program priorities and granting mechanisms
ThaiHealth aligns its strategies with national health priorities, focusing on promoting health and preventing diseases for a sustainable society. It acts as a catalyst to accelerate health promotion programs outlined in national policies, working across various sectors through policy advocacy and social mobilization.
ThaiHealth aligns its strategies with national health priorities, focusing on promoting health and preventing diseases for a sustainable society.
With reliable funding, ThaiHealth supports a wide range of programs and innovative projects across 14 master plans. These address issues like tobacco and alcohol control, traffic safety, physical activity, healthy eating, and disaster management. Most funds (36%) target reducing major health risks, including tobacco and alcohol use, unsafe driving, and improving food safety and physical activity. ThaiHealth’s programs have a broad impact, reaching diverse groups and communities to address key health challenges nationwide.
ThaiHealth’s programs have a broad impact, reaching diverse groups and communities to address key health challenges nationwide.
Types of grants
ThaiHealth supports health promotion through two types of grants: proactive and open.
Proactive
Aligns with master plans
Proactive grants fund major projects aligned with ThaiHealth’s master plans, implemented by external partners with clear goals and strategies.
Open
Public involvement
Open grants are available to any organization, fostering public involvement and innovation in health promotion.
ThaiHealth emphasizes capacity-building, helping communities, organizations, and government agencies plan and implement health programs through research, education, policy development, and social mobilization.
Advantage
Collaborating with diverse partners like ministries, private entities, communities, and educational institutions, ThaiHealth complements rather than replaces existing efforts. Open grants provide stable funding for long-term projects that promote healthy lifestyles and social change. ThaiHealth shares expertise through mentorship, workshops, and study visits, supporting countries like Mongolia, Vietnam, and Laos. As a global leader, ThaiHealth has been the secretariat for the International Network for Health Promotion Foundation since 2011, offering guidance and support to international health promotion efforts.
Monitoring and reporting system
ThaiHealth relies on strategic partnerships to finance and implement its short- and long-term programs. To ensure effective progress and achievement of objectives, the foundation employs a project monitoring and reporting system. Fourteen master plans, each containing various programs, are funded, and each plan is administered by a committee comprising external experts representing government, NGOs, academia, and other interest groups. These committees manage the plans, monitor project progress, and appoint program managers. ThaiHealth also funds internal and external plan managers to oversee and monitor the implementation of each plan.
ThaiHealth facilitates programs through a series of projects, utilizing external organizations as the operational units. The foundation does not directly implement projects but serves as a facilitator. Grantees assess progress through self-assessment and are required to submit financial and progress reports at each phase’s conclusion. Upon approval of the report, financial support for the next phase is released.
Key success factors
The success of ThaiHealth can be attributed to four key factors:
- Key advocates
- Knowledge
- Organization
- Favorable opportunities and policy context
The success of ThaiHealth can be attributed to four key factors: key advocates, knowledge, organization, and favorable opportunities and policy context.
Key advocates
Their skills, integrity, honesty, and dedication to public health built trust among stakeholders, including the Ministry of Finance, securing support for ThaiHealth’s success.
Central to its establishment were advocates like Dr. Prakit and Dr. Supakorn, whose complementary skills in policy presentation and public health economics were pivotal. Their respected positions in government and academia minimized resistance and helped align ministry goals with the health promotion vision. Support from a network of political allies, government officials, and advocates further facilitated change, leveraging an “inside-out” approach to drive reforms. Their integrity, honesty, and dedication to public health built trust among stakeholders, including the Ministry of Finance, securing support for ThaiHealth’s success.
Knowledge
Resonant
Knowledge creation and use played a crucial role in ThaiHealth’s success. Advocates built a strong knowledge base through collaboration with researchers and institutions like the Health System Research Institute (HSRI). They strategically used insights from other countries, particularly VicHealth in Australia, to guide their efforts. Tailored knowledge packages focusing on fiscal and health impacts helped convince policymakers, while effective oral presentations by knowledgeable advocates like Dr. Supakorn and Dr. Prakit ensured the message resonated with decision-makers.
Organization
The HSRI also served as a coordination hub, supporting ThaiHealth’s advocacy efforts. It provided research, resources, and operational models that showcased the potential of a semi-autonomous health promotion foundation. Operating outside the bureaucratic system, HSRI demonstrated flexibility and continuity, bridging gaps between stakeholders and influencing policy through evidence-based strategies. This helped to secure widespread support for ThaiHealth’s establishment and operation.
Favorable opportunities and policy context
Political stability across multiple governments, the emergence of reform-minded politicians, and economic challenges like the 1997 financial crisis created opportunities to advance the health promotion agenda.
A favorable policy context and strategic timing further propelled ThaiHealth’s success. Political stability across multiple governments, the emergence of reform-minded politicians, and economic challenges like the 1997 financial crisis created opportunities to advance the health promotion agenda. Advocates capitalized on these moments, framing the foundation as a cost-effective solution to public health challenges and a way to reduce long-term economic burdens. By navigating shifting contexts and leveraging alliances, ThaiHealth was successfully established as a model for health promotion funding.
Key successes in the past 10 years
Sustainable funding enabling planning long-term initiatives + Flexiblity
ThaiHealth has achieved remarkable milestones in the past decade, driving significant health improvements in Thailand. Its sustainable funding from sin taxes on tobacco and alcohol has not only reduced harmful behaviors but also ensured continuous support for health promotion campaigns. Legislative backing through the State Fiscal and Financial Discipline Act has provided a stable funding framework, enabling ThaiHealth to plan long-term initiatives. Operating as an autonomous agency, ThaiHealth has the flexibility to manage over 3,000 projects annually, addressing diverse health issues efficiently.
Key achievements
include success in
Tobacco and alcohol control
Tobacco and alcohol control through measures such as smoke-free zones, public awareness campaigns, stricter regulations, and alcohol-free events.
Safer roads
ThaiHealth has also made roads safer by reducing traffic accidents and fatalities through initiatives like the Road Safety Operation Centre and campaigns such as ‘Drink Don’t Drive.’
Healthier eating habits
It has promoted healthier eating habits via green markets and school nutrition policies, reduced obesity rates, and increased physical activity with urban designs and wellness campaigns.
Sexual health programs
Sexual health programs like the “Let’s Talk About Sex” campaign and hotline services have improved education and reduced teenage pregnancies.
Strengthen community health systems
- Empowering local health workers and supporting initiatives for vulnerable groups
- Programs for the elderly and disabled
- Consumer protection efforts
ThaiHealth has strengthened community health systems by empowering local health workers and supporting initiatives for vulnerable groups, including ethnic minorities and the economically disadvantaged. Programs for the elderly and disabled have improved their quality of life through skill development, economic support, and community-based care. ThaiHealth has also led consumer protection efforts by establishing regulatory frameworks and public education campaigns to ensure product safety and consumer rights.
Expanding its impact
Intellectual well-being
Expanding its impact, ThaiHealth has enhanced intellectual well-being through mindfulness initiatives, supported media literacy to promote responsible digital consumption, and improved child and adolescent health through school nutrition programs and grants.
Crisis response
Its crisis response during events like COVID-19 showcased adaptability, promoting preventive measures and telemedicine.
International partnerships
ThaiHealth’s international partnerships, particularly with WHO, have strengthened global health policies and amplified the impact of its initiatives, positioning ThaiHealth as a leader in health promotion worldwide.