Pulmonary Tuberculosis in Thailand: Problems and Management

Tuberculosis is still a major public health problem in Thailand. It ranks fourth among the ten leading causes of death in Thais and is the number one cause of death among infectious diseases. The mortality rate decreased gradually during the past decade (Fig. 1). The Division of Tuberculosis estimated a mortality rate of 10.1 per 100,000 population in 1987. This represents over 5000 deaths for Thailand's total population of 54 millions. The estimated incidence of new infectious cases is 95 per 100,000 population, which amounts to over 50,000 cases annually. The estimated prevalence of sputum-positive cases is 0.22%, for a total of 118,800 cases nationwide (Table 1). As in many other developing countries, several factors contributed to the slow progress of the tuberculosis control program. These included an inadequate health budget, poor health infrastructure, and inadequate health manpower. Of the total 1989 national budget of $11.4 billion (US $), only 4.0% or $0.46 billion was allocated for total health care. This is compared to 17.7% for defense and 17.2% for education. The total tuberculosis budget for 1989 was $3 million. This represents only $0.55 per capita for tuberculosis control. This is compared to $1.54 in Japan and $0.90 in Malaysia. Of the total $3 million tuberculosis budget, 25%, or $750,000, is for drugs. The budget for drugs per case of tuberculosis is thus only $6.5 if calculated from the total sputum-positive cases. The cheapest standard regimen of isoniazid (H), thiacetazone (T) and streptomycin (S) costs $17, and the cheapest short course regimen is $52. However, the tuberculosis drug budget was used only for an estimated 30,000 cases treated annually by the Division of Tuberculosis. This is equivalent to a drug cost of $26 per case. The remaining cases were either treated by nongovernmental health care facilities or were not detected. An underdeveloped health care infrastructure is another problem. Prior to 1960, adequate health care facilities were available only in Bangkok and in a few other urban centers. In the rest of the country, health care was provided by one single hospital in each of the 72 provinces, serving a vast area and a huge population. Adequate health care facilities were virtually nonexistent at the district level, where an estimated 80% of the population lived. This resulted in inadequate tuberculosis case finding and low treatment coverage. To make matters worse, physicians working at the provincial hospitals were overwhelmed by acutely ill patients, and tuberculosis was relegated a low priority. This resulted in poor or ineffective treatment programs at most provincial hospitals. The maldistribution of the already inadequate number of physicians was another major problem. A survey in 1982 showed that there were 10,062 physicians for the whole Kingdom serving a population of 48 millions. The overall doctor to population ratio was 1:5539. This could be broken down to 1:1050 in Bangkok, 1:2547 in the Central region, 1:7965 in the Southern region, 1:9802 in the Northern region and 1:19679 in the Northeastern region. Three thousand more medical graduates were added to the workforce since then. This is unlikely to alter the doc-