106 Human Resources for Health Development Journal (HRDJ) Vol. 4 No.

2 May - August 2000

Special Article

“Triangle That Moves The Mountain” and

Health Systems Reform Movement in Thailand

Prawase Wasi, M.D.

Professor of Medicine Emeritus
Former Chairman WHO/SEARO ACHR

1. Focus on the Member 2. Triangle that Moves the Mountain

Countries Thailand, as many other countries, has
The World Health Organization (WHO) faced extremely difficult problems-political,
System is potentially a very good system. It economic, social, cultural, environmental, etc.,
consists of the Headquarter (HQ), the Regional culminating in the phenomenon of social crisis,
Offices (ROs) and the member countries. If all severely affecting health. The problems are inter-
the components worked well in an interactive connected, complex and extremely difficult to
manner, the System could be a dynamic inter- solve. In fact, some feel that they are too big
connected network vibrant with knowledge and too difficult and beyond imagination on how
generation, learning and development, benefiting to solve them. But we have to find ways and
the health and well-being of mankind around means to get out of the crisis in order to be able
the world. to move forward positively. There is increasingly
well known in Thailand an approach structure
Although there are some deficiencies in
called “Triangle that Moves the Mountain”.
WHO such as bureaucracy and politics, the
The Mountain means a big and very difficult
greatest strength of WHO lies in it being highly
problem, usually unmovable. The Triangle, as
prestigious and its unlimited access to expertise
illustrated in Figure 1, consists of: (1) Creation
around the world. The HQ and the ROs have
of relevant knowledge through research, (2)
generated and collected a lot of concepts and
Social movement or social learning and (3)
methods, but the most difficult part is to
Political involvement.
implement those concepts and methods in
member countries. If knowledge-based health Creation of relevant knowledge through
development can not be implemented research is very crucial, but not adequate by
successfully in member countries, this will be itself; it must interact with social movement or
the bottleneck in the otherwise very good WHO social learning. Without relevant knowledge,
System. The concepts and methods developed at social movement cannot go very strong or may
the HQ and ROs will become congested there, deviate to something else. Knowledge derived
untested by real practice in member countries from research must be translated into forms and
and thus provide no appropriate feedback to the languages that can empower the public. Many
System. The System will not be as inter-active academicians shun politicians, thinking that they
and as vibrant as expected. Thus more attention are bad people and do not wish to do anything
should be focused on the member countries. How with them. But politicians have authority over
they can implement knowledge-based health utilization of state resources and in law
development successfully is the crucial issue. promulgation, which are very often needed in

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 Prawase Wasi • “Triangle That Moves The Mountain” and Health Systems Reform Movement in Thailand 107

Figure 1 Triangle that moves the mountain.

1. Creation of relevant knowledge

2. Social movement 3. Political involvement

development. Thus without political involvement Economic and Social Development Plan, which
the working structure is not complete. Politics was reorientated from economy dominated
without knowledge and social movement will development to human centered development.
not do. In developing countries, and sometimes In 1999 the National Education Act for education
even in developed countries, the lack of this reform was issued. Again this very difficult task
“triad” leads to failure in solving difficult was successful through the application of the
problems. “Triangle” approach.
In Thailand this triangular approach has The “Triangle that Moves the Mountain”
been used successfully to move a few approach is now being applied in health systems
“mountains”. The most difficult one was to reform, another mountain to be moved. This will
rewrite the Constitution for political reform. This be briefly described as follows.
type of political reform is usually not possible
without country losing a war or finding itself at 3. Health Systems Reform
the brink of a civil war. No political party really Movement in Thailand
wanted to under take the reform because the
new Constitution would limit their power. The The crisis
author of this article was responsible for Thailand has a relatively good health care
recommending that Thailand needed to write a service infrastructure with hospitals in all its 76
new Constitution for political reform. When he provinces and over 700 districts, and health
was appointed chairman of the Democracy stations in all its 7,000 subdistricts or tambons.
Development Committee which recommended It has done well in communicable disease control;
political reform, the Committee implemented the plague, small pox, cholera, leprosy, diphtheria,
“Triangle”. Research results were used to pertussis, yaws, poliomyelitis have disappeared
empower public movement which turned the or are very much reduced in prevalence.
New Constitution for political reform into a However, if looked at from a system dimension
political issue that was nonstoppable and which the Thai health system is in crisis. National health
finally led to promulgation of the New expenditure this year amounts to nearly 300,000
Constitution in 1997. The triangular approach million Baht, increasing at a rate of over 10 per
has been used in drawing up the 8th National cent annually in the past several years. The excess

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 108 Human Resources for Health Development Journal (HRDJ) Vol. 4 No. 2 May - August 2000

of the increase in the rates of expenditure over Health research capability building is
those of income indicates that the system is most crucial for making health system reform
running into crisis, i.e. the country will run out possible. In the last two decades or so health
of money while many people are ill or die of research capability has been strengthened through
diseases or conditions which are preventable such different means. These include TDR research
as heart diseases, cancer, accidents, HIV/AIDs, strengthening program, Rockefeller Foundation’s
drug addiction, etc. Access and quality of health the Great Neglected Diseases of Mankind
care are not good enough, the people are not program, CDC collaborated Field Epidemiology
satisfied, while the health personnel are over- Training program, the Rockefeller Foundation
worked. In brief, the system is not cost-effective initiated INCLEN, the National Epidemiology
and is in need of reform. Board supported by the Rockefeller Foundation,
Need establishment of the College of Public Health at
Chulalongkorn University under the leadership
The passive “ill-health-oriented” system of Charas Suwanwela and Chitr Sithi-amorn and
needs to be reformed to a “good-health-oriented” their, as well as other Thai academic leaders’,
system. For this, the health promotion system involvement with the international health
needs to be fully developed and the disease research movement. The Health Care Reform
control and prevention system must be reformed project under the leadership of Dr.Sanguan
to be fully efficient. Health care finance must be Nitayarumphong, supported by EU, has
developed to guarantee access to adequate and pioneered research and development in health
quality health care for all. Consumers must be care system reform.
adequately protected and empowered. Health
personnel development needs to be reformed as The chronic problem in most
do the technology, the information and the developing countries is the lack of good research
research systems. In the reformed health system management mechanisms. To overcome this
responsibility for good health will not solely lie deficit Thailand in 1992 established two effective
with the Ministry of Public Health, but with all national research promoting and funding
sectors of society — All For Health. Thus there agencies, namely the Thailand Research Fund
is a need for a body to coordinate health policies (TRF) and the Health Systems Research
for all sectors. Not all, but a good part of the Institute (HSRI). It should be pointed out that
reform components need to be put into law. Thus both the TRF and the HSRI have been especially
a National Health Act is needed. All these are designed to be effective in research management.
extremely difficult or next to impossible. Much Both were established by special Acts which
knowledge needs to be generated and social allow them to use the government budget but be
participation as well as political commitment are independent. They are not bureaucratic
crucial to the process. organizations, but governed by independent
boards. However, even though independent by
Research and development law, in practice as in many developing countries,
At this point the author wishes to give credit the organizations may suffer from creeping in
to WHO. His as well as other Thai’s involvement bureaucratic politics and politically motivated
with WHO in various capacities caused a lot of politics. Having senior academics respected by
inspiration that have led to a variety of health politicians, bureaucrats and media is very crucial
research and development activities in Thailand. in helping the organizations to steer through such
Non-smoking campaign, health economics a scenario.
capacity building, and the idea for health systems The HSRI has been established with
reform, for example, are all traceable to WHO- an intention to be a tool for health system reform.
led inspiration. In the past seven and a half years under able

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 Prawase Wasi • “Triangle That Moves The Mountain” and Health Systems Reform Movement in Thailand 109

leadership of two successive directors, 4. Conclusion and Recommenda-

Dr.Somsak Chunharas the former director, and tions
Dr.Wiput Poolcharoen the current director, the
1. Concepts and methods for health
institute has mobilized the creation of much
developed at the global and international level
health system knowledge. Although this
are important, but focus should be at real
knowledge is not yet complete, it is adequate to
actions in the countries.
support a health systems reform movement.
The results from real actions in the
The Board of the HSRI has the Minister of
countries and emerging needs for more
Public Health as its chairman, with members
knowledge will provide feedback into the global
comprising permanent secretaries of relevant
system, thus making the international networks
ministries and their equivalents and respected
for health research and development actively
senior academics. Having the Minister of Public
interacting in a most creative manner.
Health as its chairman the HSRI has a direct
channel to the Cabinet. When the Board agreed 2. In the countries special attention should
recently that it was time for Thailand to launch be paid to creation of functionally effective
a health system reform movement the matter research promotion and funding mechanisms.
went to the Cabinet. The Prime Minister has The Thailand Research Fund (TRF) can be an
given whole hearted support and has issued the example. To generate health system knowledge
Prime Minister Office’s Regulation establishing necessary for health system reform a research
the National Health System Reform Committee. institute such as the Health Systems Research
The Committee has the Prime Minister as its Institute (HSRI) may be necessary. The
chairman and the Minister of Public Health as international health research promotion networks
deputy chairman. A National Health System should give political support in creation of
Reform Office (HSRO) has been set up to effective health research management
catalyse the “Triangle”, i.e. research, social mechanisms in member countries, if they do not
movement and political interaction, to issue a exist.
National Health Act for health system reform 3. Research is fun. But research should
within 3 years. The government will be providing not just create more research and go on without
all necessary resources for the movement. end. Research should lead to development and
Although a National Health Act is necessary for development lead to more research relevant
health system reform, not all the reform activities to development needs. Research should not be
have to wait for the law. For example, an floating or ‘go to the shelf’, but tested and receive
independent Office for Health Promotion Fund feedback from real applications.
has already been established and the Ministry of
4. Health development in the countries is
Finance has sponsored a “Health Promotion
extremely difficult. It depends on complex
Fund” bill, to provide 2 per cent of tobacco and
interactions between knowledge, culture, politics,
alcohol excise taxes, amounting to 1,400 million
bureaucracy, media, society, etc. Expertise in any
Baht per year, for the Office to support innovative
one particular academic field is not adequate to
health promotion initiatives throughout the
mobilize health development. It needs leaders
country.
with systems perspectives and management skills
Thus we are now witnessing the long with strong commitment and some charisma.
desirable interaction between research, social Such persons are rare, if not lacking, in many
participation and political support at work for societies.
health development of all Thai people - in the
5. Thus it is recommended to the
name of health systems reform.
international health research and development
circles to pay more attention in finding and

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 110 Human Resources for Health Development Journal (HRDJ) Vol. 4 No. 2 May - August 2000

developing health policy leaders who can that health research and development will really
mobilize resources for health development in the take place in the countries. Interaction between
countries, whether it is to be labeled health the countries and the international health research
system reform or not. forum will form a vibrant global network with
Regional or international courses in health knowledge generation, learning and development
policy leadership might be considered to provide to benefit the health and well-being of mankind
opportunities for interactive learning through around the world.
action and network building. With this it is hoped

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