healthcare system in thailand: past - present and where is the future ? 1

HealthCare System in Thailand:Past - Present

and Where is the Future ?

1

Dr. Pradit SintavanarongMinister of Ministry of Public Health, Thailand

2

Thailand Population CensusPopulation of

Thailand 2011 2012 2013Total Population 63,891,000 64,413,000 64,623,000 - Male 31,445,000 31,683,000 31,438,000 - Female 32,446,000 32,730,000 33,185,000Urban area 23,078,000 28,406,000 29,662,000Rural area 40,813,000 36,007,000 34,961,000Children (under 15 years) 13,010,000 12,892,000 12,123,000Labor force (15 - 59 years) 43,091,000 43,410,000 42,983,000Elderly (60 years and over) 7,790,000 8,111,000 9,517,000School ages (6 - 21 years) 15,192,000 15,092,000 14,027,000Women of reproductive ages(15 - 49 years) 17,711,000 17,712,000 17,388,000Crude birth rate (per 1,000 population) 12.4 12 11.6Crude death rate (per 1,000 population) 6.9 7.1 7.7Natural growth rate (percent) 0.6 0.5 0.4Infant mortality rate (per 1,000 live births) 12.3 11.8 11.2Child mortality rate (per 1,000 live births) 14.3 13.7 18.4Total fertility rate 1.5 1.5 1.6

Source: Institute for Population and Social Research, Mahidol University

3

Thailand Population Census

Estimated Population of

Thailand in the Next 20 Years

(2033) 65,759,000

- Male 31,633,000

- Female 34,126,000Source: Institute for Population and Social Research, Mahidol University; Estimated Population at Midyear 2013 (1st July)

4

Health statistics

Coverage of Health Insurance 99.46 % Life Expectancy at birth (2010) 74 ( Male 71 (71.1),

Female 77 (78.1) )

Crude birth rate (per 1,000) 12.4 (11.6)

Crude death rate (per 1,000) 6.5 (7.7)

IMR (per 1,000 live births) 6.6 (11.2)

MMR (per 100,000 live births) 8.9

Source: Ministry of Public Health , Public Health Statistics 2011

( ) = Institute for Population and Social Research, Mahidol University

5

Thailand Health Status

Aged Society

Year 2553 Year 2554 Year 25550.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

19.89 19.47 19.05

68.41 68.39 68.33

11.70 12.14 12.63

Ages 0-14

Ages15-59

Ages60 and Over

Year 2553 Year 2554 Year 2555

Age Group count percentage count percentage count percentage

Ages 0-14

12,672,935 19.89

12,496,939 19.47

12,241,023 19.05

Ages15-59

43,577,838 68.41

43,892,616 68.39

43,911,198 68.33

Ages 60 and Over

7,450,930 11.70

7,791,446 12.14

8,114,144 12.63

Total

63,701,703

64,181,001

64,266,365

Elderly = 12.63% of Total Population

Aged Society

6Source: Bureau of Policy and Strategy, Ministry of public health

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision

Japan

Korea

China

Thailand

World

7

Proportion of elderly (>65 years old)

Disease Year 2011 Year 2012Infectious disease 2007.28 2044.77Non communicable diseases• Circulatory diseases• Accident• Cancer

1881.01712.36700.91467.74

1970.27724.18762.75483.34

Rate per 100,000 populations

Morbidity


Disease 2007 2008 2009 2010 2011

Infectious disease 60.6 61.2 60.7 64.9 64.6Non communicable diseases• Circulatory diseases• Accident• Cancer

208.2555.268.184.9

209.7356.066.187.6

209.6755.266.188.3

215.7961.962.791.2

227.3268.863.495.2

Rate per 100,000 populations

Mortality


•Rate per 100,000 populations

2007 2008 2009 2010 20110

50

100

150

200

250

60.6 61.2 60.7 64.9 64.6

208.25 209.73 209.67215.79

227.320000000001

Infectious diseaseNon communicable diseases• Circulatory diseases• Accident• Cancer

Mortality


Source: Thailand Health Profile 2008 - 2010 11

Major Causes of Death in Thailand, 1967-2009

Source: IHPP, Burden of disease, Thailand, 1999, 2004, and 2009 12

DALYs attributable to risk factors in Thailand 1999, 2004, and 2009

13

Evolution of health system in Thailand

18881828

King Rama 3started the Western medicine

Siriraj Hospitalestablished

MoPH

Mandatory rural services

HFA/ PHC

policy

UCSNHSO

Department of Public Health, MoI

1918 19681942 2007/08/091978 20011975

Scaling up District Health System

(DH + HC)

Low Income Scheme

1980s

CSMBS 1980Health Card 1983SSS 1990

1990s

1992 A decade of

health center development

1997 ConstitutionEconomic crisis

NHCO

1992HSRI

ThaiHealth

LGs

HAI

EMIT

1946

First MoPH nursing college

MoPH = Ministry of Public Health, HSRI = Health System Research Institute, LGs = local governmentsThaiHealth = Thai Health Promotion Foundation, NHSO = National Health Security Office, NHCO = National Health Commission Office, EMIT = Emergency Medical Institute of Thailand, HAI = Hospital Accreditation Institute

1999Local

Health Funds

2006

14

Evolution of the Thai Health System

Principles of organizing healthcare system in Thailand

The 1997 Constitution was adopted as principle legal framework for moving toward welfare state by providing Universal Health Coverage,

• ‘access to needed health services is a basic right of the Thai population’

The UHC policy in Thailand aims to enable access to needed services to all Thai people and protecting them from catastrophic health expenditure

• Put emphasis on ensuring access for all at an affordable cost rather than providing the best to some

Health service delivery system has been organized as multi-level system to ensure geographical equity while maintain efficiency of the system.

15

Area

GovernorMOPH

Local Authorities

Tumbon health fund

Output/ Outcome/ Impact

PPP

NHCO

NHSO

ThaiHealth

EMIT

HAI

Ministry of Public Health

Emergency Medical Institute of Thailand

National Health Security Office

Health Accreditation Institute

Public Private Partnership

National Health Commission

Health System Research Institute HSRI

Thai Health Promotion Foundation

16

Multiple Actors in Health

17

Governance of the health system

MoPH had been sole actor in the health system for six decades; however, following various reforms, there are various actors involving in governing the health system.• Decentralization: various public health functions have been transferred to

local governments• Establishment of NHSO separation of purchasing and providing functions • ThaiHealth dealing with social determinants of health• NHCO -> citizen empowerment in health • EMIT pre-hospital care system• HAI hospital accreditation

Following various reforms, there has been brain drain from MoPH to those new autonomous agencies and resulted in weakening MoPH’s role in directive the health system.

18

Healthcare financing

Source: Thailand Data; http://data.worldbank.org/country/thailand

Note: Revenue excluding grants, GGCE = general government consumption expenditure, GGE = General government expenditure

19

General government Revenue and Expenditure 2003-2011

UHC achieved

Source: NHA 1994-2010

Economic crisis

20

Total Health Expenditure 1994 - 2010: ↑ government spending, ↓ out-of-pocket payment, but

maintain the level of spending to GDP

Source: Comptroller’s General Department, MOFNote: direct disbursement of OP services started in 2004 for chronic conditions, 2006 extended to pensioners, and 2009 extended to cover all CSMBS members

Per capita expense ≈ 12,000/ year

22

CSMBS expenditure, 1994 – 2012rapid cost escalation in opposite to declining of beneficiaries

Source: expenses from NHA 1994-2010 excluding expense on administration Number of beneficiaries at the end of each year from SSO

700 80

0

900 11

00

1250

1284

1404

xxx capitation

23

SSS expenditure 1994 – 2010 Per capita expense 2010 = 2,750 Baht

ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ� 24

งบกองที่�นัหลักประกนัสำ�ขภาพแห�งชาติ�ปี�งบปีระมาณ เปี�าหมายปีระชากรสิ�ทธิ�

UC (ล้�านคน)

อั�ตราค�าเหมาจ่�ายรายห�ว

(บาท/คน/ปี�)

งบเหมาจ่�ายรายห�วรวมเง�นเดื อัน (ล้�าน

บาท)

% เปีล้!"ยนแปีล้ง

ปี� 2545 45.000 1,202.40 51,407.71

ปี� 2546 46.000 1,202.40 56,091.23 9.1%

ปี� 2547 46.820 1,308.50 61,212.39 9.1%

ปี� 2548 47.000 1,396.30 67,582.60 10.4%

ปี� 2549 47.750 1,659.20 82,023.00 21.4%

ปี� 2550 46.066 1,899.69 91,369.05 11.4%

ปี� 2551 46.477 2,100.00 101,984.10 11.6%

ปี� 2552 47.026 2,202.00 108,065.09 6.0%

ปี� 2553 47.240 2,401.33 117,969.00 9.2%

ปี� 2554 47.997 2,546.48 129,280.89 9.6%

ปี� 2555 48.333 2,755.60 140,609.40 8.8%

ปี� 2556 48.445 2,755.60 141,539.75 0.7%

ปี� 2557 48.852 2,895.09 154,257.98 8.9%

Data from NHSO: 78% of UCS members used benefits, OP visits increased from 2.45 to 3.37 visits/person/year, IP admissions increased from 0.94 to 1.15 admissions/person/year 26

Number of use persons, OP visits, and IP admissions of UCS, 2003-2012

27

รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2553 – 2555 สำ�ที่ธิ� UC

ปี� จ่$านวนคน จ่$านวน Visit

2553 27,098,157 144,809,385

2554 29,671,976 166,184,132

2555 32,352,507 167,790,950

ที่��มา : สำ�านักงานัหลักประกนัสำ�ขภาพแห�งชาติ�

28

รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2555 UCVisit count group Visit count Patient count Accumulative

patient count

1 - 3 1 10,123,016 10,123,016

1 - 3 2 5,618,033 15,741,049

1 - 3 3 3,615,457 19,356,506

4 - 6 4 2,634,825 21,991,331

4 - 6 5 2,037,527 24,028,858

4 - 6 6 1,620,063 25,648,921

7 - 9 7 1,293,477 26,942,398

7 - 9 8 1,047,112 27,989,510

7 - 9 9 846,614 28,836,124

10 - 12 10 688,628 29,524,752

10 - 12 11 561,665 30,086,417

10 - 12 12 455,115 30,541,532

13 ขึ้&'นไปี 13 ขึ้&'นไปี 2,140,938 32,682,470


29

รายงานัสำร�ปจำ�านัวนัการใช!บร�การ OP ป" 2555 UCVisit count group Visit count Patient count Accumulative

patient count

13 – 15 13 369,525 30,911,057

13 – 15 14 297,834 31,208,891

13 – 15 15 241,517 31,450,408

16 – 18 16 196,252 31,646660

16 – 18 17 160,178 31,806,838

16 – 18 18 131,145 31,937,983

19 – 21 19 108,554 32,046,537

19 – 21 20 89,594 32,136,131

19 – 21 21 73,962 32,210,093

22 – 24 22 61,340 32,271,433

22 – 24 23 51,668 32,323,101

22 – 24 24 43,466 32,366,567

25 ขึ้&'นไปี 25 ขึ้&'นไปี 315,903 32,682,470


• On average, salary of hospital staffs increased by 6-10% per annum

• Non-salary labor cost of district hospitals increased sharply by 50% in 2009, and it increased by 30-40% for general and regional hospitals in 2009 and 2010

• All type of hospitals had a declined rate of expense on drugs

Source: Health Insurance System Research Office; analysis of financial report of MoPH hospitals 30

Increase in cost of MoPH hospitals, 2009-2011

31Source: Office of Insurance Commission http://www.oic.or.th/en/home/index.php

Losses incurred varied from 40-50% of collected revenues

Traffic Accident Insurance

http://www.oic.or.th/en/home/index.php

Ministry of Public Health

Permanent Secretary

Technical DepartmentsDirector-General

Ministry of Interior

Permanent Secretary

Office of the Permanent Secretary

Province

Governor

Provincial Public Health Offices (76)

Provincial Chief Medical Officers

Regional & General Hospital

Community Hospitals Districts

Governors

District Health OfficesPrimary Care Unit

Tambol Health Promoting Hospitals Tambol Administration Offices

Municipalities

Provincial Administration

Offices

32

Provincial Health Administration

33

Health service delivery system in Thailand

Health centers9,768

Municipality Medical

Centers 365

District hospitals776

Provincial hospitals 68

Pharmacy 11,154

Private clinics 17,671

Other public

hospitals 120

Private hospitals

323

Regional hospitals 28

University hospitals 17

Other MoPH hospitals 55

MOPH facilities

Sub-district

District

Province

Source: 1. Thailand Health Profile 2008-20102. Bureau of Policy and Strategy, MoPH, http://hrm.moph.go.th/res53/res-rep2553.html

http://hrm.moph.go.th/res53/res-rep2553.html

Private Hospital Clinics (2013)Private Hospitals• Bangkok 98, Other provinces 224• Total 322

Medical clinics• Bangkok 3,970 , Other provinces 14,533 • Total 18,503

Drugstores• Bangkok 4,912 , Other provinces 11,780 • Total 16,692

Traditional medicine Drugstores• Bangkok 443 , Other provinces 1,615 • Total 2,058

Private Hospital Clinics (2013)

34Source: Bureau of Policy and Strategy, Bureau of Sanatorium and Art of Healing, Food And Drug Administration; Ministry of public health

Health Facilities in the Public Sector (2010)

Source : Bureau of Health Administration; Ministry of public health

Administrative Level Health facility

Bangkok • 5 medical school hospitals• 26 general hospitals• 13 specialized hospitals/institutions• 68 community health care centers

Regional level • 6 medical school hospitals• 33 regional hospitals• 48 specialized hospitals

Provincial level • 83 general hospitals

District level • 774 community hospitals• 284 municipal health centers

Sub-district level • 9,768 health promoting hospitals

Village level • 198 community health posts• 48,049 rural community primary health care centers• 3,108 urban community primary health care centers• 1,055,000 Village Health Volunteers

Health Facilities in the Public Sector (2010)

35

36

Human resources

37Source: Thailand Health Profile 2008 - 2010

Population to provider ratios, 1979 - 2009

• There was mark reduction in the disparities of population to health care provider ratios for Bangkok and the Northeast during 2001-2009

• Population to doctor ratio of the Northeast remained 5 time of Bangkok while the ratios of other professions were 1.5 – 2 times of Bangkok

38Source: Thailand Health Profile 2008 - 2010

Disparities of population/healthcare provider ratios for Bangkok and the Northeast, 2001 - 2009

39Source: Kanchanachitr et al (2011)

Thailand has relatively low numbers of doctor and nurse to 1,000 populations compared with countries at the same level of economy

Doctor and nurse to 1,000 population among ASEAN countries

40 40

Limited production capacityCurrently, annual production increases to 2,500 for doctor and 9,000 for nurse; however, the production capacity remains lower than other countries.

Source: Kanchanachitr et al (2011)

41

Pharmaceutical industry

• During the period 1992 - 2006, with a high economic growth and new drug marketing monopolies under the Drug Act, the value and proportion of imported drugs was rising rapidly.

• The proportion of imported drugs was rising steadily to 56.3% in 2005, 64.5% in 2009, and 68% in 2010

42Source: Drug Control Bureau, Food and Drug Administration, MoPH

Pharmaceutical industry in Thailand

Percentage of prescribed items

Perc

enta

ge o

f rei

mbu

rsem

ents

Use of drugs outside national ED list in 31

hospitals

University hosp

MoPH hosp

Other public hosp

Data error

Bubble size represents amount of reimbursement

Type of hospital

43

• In Thailand, important antibiotic resistant bacteria are – Enterobacteriaceae (Quinolone resistance, <20% in community, 30-70% in hospital), – Staphylococcus aureus (Penicillin resistant 1% in community, 30-70% in hospital) – Pseudomonas aeruginosa (Carbapenam resistance 10-30%)– Acinetobacter baumanni. (Carbapenem resistance 60-85% for hospital infection)

Antibiotic use, low / middle income countries OP penicillin use and resistance 1990-2000

Source: Werner C. (2004)

Source: report of workshop on antimicrobial drug resistance, Bangkok, 6-10 August 2012

Antimicrobial drug resistance (1)

44

Aim to ensure security of drug supply and to maintain price level of necessary pharmaceutical supplies to ensure accessibility for all Thais

• Production• Stocking• distribution

Trade of between national security and promoting local pharmaceutical industry (push and pull)

• Competing with local pharmaceutical firms in producing generic drugs

• Production of vaccines

Role of Government Pharmaceutical organization (GPO)

45

Time line of Health Sector Reform

46

47

Time line of Health Sector Reform

• Scaling up district health system• Health

volunteer• Community-

based health insurance (health card)

PHC era

• Introduction of Universal Health Coverage • Expansion to

cover high cost services i.e. ARV, RRT

Universal Coverage

• Population aging• Increase

demand for health care• Increase

burden of chronic care• Use of original

& NED drugs• Demand drive

by Advance medical technology

Increasing health

expenditure

• Sustainability doubted• Control of

health care expenditure• Harmonization

of health insurance schemes• Regional health

service plan

Health sector reform 1

• Sustainability

• Healthcare expenditure

• Quality and safety

• Management

Health sector reform 2

48

Current issues of concern

Downsizing public sector policy of various governments put pressure on public health sector

• Increased workload according to universal coverage policy• Limited public hospital capacity in recruitment and retain health

professions, especially professional nurse• Major incentive for working in public hospital with greater

workload and lower salary is being a civil servant

Disparities in financial compensation level for different health professions in the public sector

49

Health Sector Reform: issues for debate

Whether Thailand will move towards full welfare state, particularly for health care

• Wealth & Health• Balancing of revenue and expenditure; how to

generate additional revenue for health care• Equal basic benefits to all or comprehensive benefits• Explicit cost sharing policy to prevent unnecessary

use , especially high cost medicines• Long-term financial sustainability

• Burden Of Disease and old aged dependency challenges • Governance of the health system

– Role of MoPH and other partners and their relationship

• Government fiscal space and long term financial sustainability

• Harmonization of the three main schemes

• Health systems capacity to cope with – Increased demand within very strained health workforces – Decentralization context –threats and opportunities– Public private dialogues, better trust and collaboration

50

Challenges for further reforms

1

2

3

4

5

ช�วงอาย� 0 – 5 ป"

• เดื)กเก�ดืจ่ากมารดืาซึ่&"งม! ANC ครบถ้�วนในช�วงระยะเวล้าท!"เหมาะสิมแล้ะคล้อัดืในห�อังคล้อัดื

• เดื)กไดื�ร�บน$'านมมารดืาแล้ะอัาหารเสิร�มในระยะเวล้าท!"เหมาะสิม• เดื)กไดื�ร�บว�คซึ่!นท!"จ่$าเปี-นต�างๆครบถ้�วน• การไดื�ร�บการร�กษาทางการแพทย1ท!"พอัเพ!ยง• เดื)กไดื�ร�บการเตร!ยมต�วสิ$าหร�บการพ�ฒนาในช�วงว�ยต�อัไปีอัย�าง

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การดื5แล้แล้ะพ�ฒนาค7ณภาพช!ว�ตขึ้อังปีระชาชนท!"แบ�งตามช�วงว�ย

51

ช�วงอาย� 6 – 19 ป"


52

• การบร�การทางการแพทย1ท!"พอัเพ!ยง• เดื)กแล้ะเยาวชนไดื�ร�บว�คซึ่!นท!"จ่$าเปี-น แล้ะว�คซึ่!นกระต7�นครบถ้�วน• เดื)กแล้ะเยาวชนไดื�ร�บการพ�ฒนาท�กษะเพ "อัการเขึ้�าสิ5�ช�วงว�ยท$างาน

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ช�วงอาย� 20 – 59 ป"


53

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ช�วงอาย� > 60 ป"

• ไดื�ร�บการซึ่�อัมแซึ่มสิ7ขึ้ภาพในกรณ!ท!"จ่$าเปี-น• ไดื�ร�บการสิ�งเสิร�มให�ม!สิ7ขึ้ภาพท!"แขึ้)งแรงจ่นถ้&งช�วงสิ7ดืท�ายขึ้อังว�ย• ไดื�ร�บการดื5แล้จ่ากล้5กหล้านแล้ะช7มชนอัย�างอับอั7�น

54

Reform direction

1. Restructuring health sector

55

Reform direction

Separation regulatory role and service provision role in the MoPH• Policy, direction, and guidelines on financing • Policy on human resources• Regulation and supervision• Monitoring and evaluation• Implementing cost accounting system in hospitals

Strengthening MoPH functions as National Health Authority

Reorganize relationships between MoPH and various main actors

2. Regional health service commissioning

56

Reform direction

Decentralize administration of service provision to 12 regional MoPH areas (service plan)

• Improve efficiency of resources use by sharing resources• Improve capacity of service provision within the regions• Better referral system• Greater accountability by setting KPIs

Greater cooperation between purchaser and providers in planning, purchasing, and service provision

3. Financing reform

57

Reform direction

Expansion of health protection coverage by compulsory contributory insurance• Migrant workers and dependents• Foreign visitors• Foreign residents

Reform Traffic Accident Insurance to improve effectiveness and efficiency of the system

Pharmaceutical cost control of CSMBS and reform payment system for better cost control

Reform payment system to support MoPH service plan

57

4. Harmonization of current health insurance schemes

58

Reform direction

National Clearing House

• Accident and Emergency services • Anti-Retro Viral Therapy• Cancer

National Information center

Harmonization of benefit package and payment system

Provider

National Health

Authority

Purchase

r

Regulator

Supplement /

Agent- สำปสำช.- สำวรสำ.- สำช.- สำพฉ.

โครงสิร�างการท$างานระบบสิาธิารณสิ7ขึ้ปีระเทศูไทย

59

Walk in across border for medical visit

• MOPH hospitals at border areas provide unpaid care around 250 million Baht a year

Immigrant workers

• Illegal migrants & dependents, both registered and non-registered ≈ 3 mil.• Legal skilled migrants & dependents ≈ 1 mil. (attracted by 2 mm public

project on infrastructure)

Medical Hub

• ≈ 800,000/year, not much affected by AEC

Increase demand for health care

60

• Illegal migrant workers & dependents ≈ 3 m, share 15-20% of OP visits and 20-35% of IP admissions in provinces with high density of migrant workers.

• Non-Thais patients shared ≈ 30% of OP services and 35-50% of IP services in hospitals at west-border of Thailand

• There are ≈ 1 million foreign patients under the medical hub2008 2009 2010 2011

-

400,000

800,000

1,200,000

1,600,000

1,363,29

5

695,779 935,035 942,107

Number of Medical hub services

Health services use by non-Thais

61

Policies response to increase demand for healthcare of Non-Thais

At the border;

• Supporting capacity building of health facilities in nearby countries at border areas

• Supporting governments of neighborhood countries in moving towards UHC

Providing health protection to Non-Thais and generate additional source of finance by compulsory contributory insurance

• Migrant workers and dependents• Foreign visitors

62

Policies response to increase demand for healthcare of Non-Thais (2)

Medical hub (academic training and conference, medical care, dental care, spa and Thai traditional medicine)

• Promoting Thailand as center of medical education, academic training, and conferences)

• Loosening professional barrier in importing foreign professions

• Reduce income gap between public and private sector in order to prevent brain drain

65

Inspiration

66

ชายคนแรกตอับ “ผ่มก$าล้�งท$างานหาเง�นเพ "อัเล้!'ยงช!พอัย5�”

คนท!"สิอังตอับว�า “ผ่มก$าล้�งฝึ>กห�ดืเพ "อัเปี-นน�กแกะสิล้�กห�นช�'นยอัดื”

ชายคนท!"สิามตอับ “ผ่มก$าล้�งสิร�างว�หารอัย5�คร�บ เปี-นว�หารท!"จ่ะอัย5�เปี-นร�อัยๆ ปี�แล้ะเปี-นแรงบ�นดืาล้ดืล้ใจ่ให�คนร7 �นหล้�งอั!กหล้ายช�"วอัาย7คนหล้�งจ่ากผ่มตายไปีแล้�ว”

67

Bamboo seeding ( water for 4 yrs )

After off from land : grow 60 fts in 9 m 68

Bamboo seeding ( water for 4 yrs )

After off from land

grow 60 fts in 9 m

69

A journey of a thousand miles begins with

a single step.

Chinese proverb

70

ระยะที่างจำากโลักถึ'งดวงจำนัที่ร)1/4 ลั!านัไมลั)

ระยะที่าง 3 กม. แรก ใช!พลังงานัไป 50 % ของที่+งหมด 71

Attitude is a little thing that

makes a big difference

Winston Churchill

72

73

THANK YOU

healthcare system in thailand: past - present and where is the future ? 1

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