Thank you, Dr. Komatra for the kind introduction. I would also like to thank Professor Vicharn and the PMAC Secretariat for all your hard work in organizing the conference; the Royal Thai Government for their hospitality; Professor Rachata; Lincoln Chen and our fellow conference co-hosts and partners in JICA, USAID, WHO and the Rockefeller Foundation; and to my good friends, Dr. Suwit and Paul Farmer.
Yesterday I was honored to share the Prince Mahidol award with a distinguished group of individuals who have spent many years fighting to end the HIV-AIDS epidemic. I accepted the award on behalf of a broad and diverse group of advocates who worked as part of a global movement to make treatment accessible to people everywhere, no matter their income or geography.
Sadly, our work is unfinished. Millions are still becoming infected each year, and many are shut out of treatment because of inadequate services and frankly, discrimination. Yet a new generation of activists has joined the fight, and I am confident that in our lifetimes we will end the scourge of AIDS and unlock the potential of millions caught in its grip.
When that happens, we will owe tremendous thanks to many people living with AIDS, health workers and activists in Thailand. They were early and visionary leaders in this fight.
Thanks to their work, Thailand was the first developing country to mount a successful HIV prevention response. It reduced new HIV infections by over 90 percent, from 150,000 in 1990 to about 10,000 in 2013. This prevented a stunning 7.7 million HIV infections, and saved over $18 billion dollars -- a monetary return over 40 times the investment.
Over 250,000 people are on AIDS treatment in Thailand, reducing HIV deaths by at least half. Yet AIDS still ranks high on the list of causes of premature death in Thailand, so there is more to be done in Thailand and globally – and we will continue working together until the last person living with HIV receives life-saving treatment.
Thai health care policy makers, health workers and activists have shown a strong commitment to the poor and vulnerable. Thailand’s successful universal health care scheme, which includes AIDS treatment, commands global respect and influence.
It’s easy now to look back at these amazing successes and think they were inevitable.
Many of you in this room who lived through the early days of the AIDS fight know it was far from certain that we would ever succeed.
In my first year of medical school we began to understand the devastation of the AIDS virus -- it seemed an impenetrable enigma. The epidemic threatened us like an approaching cyclone. AIDS was projected to kill tens or even hundreds of millions of people. It was an incomprehensibly large and complex public health challenge.
Yet, more quickly than we could have ever imagined, we developed effective treatments. HIV activists attacked every link of the value chain for drugs and treatment, starting from nowhere until we had developed drugs that treated the disease. Tony Fauci was instrumental in the race to get drugs to market, from the first antiretroviral drug approved for the treatment of HIV in 1987, then single and double combinations of drugs, followed by David Ho’s pioneering work in the use of highly active antiretroviral therapy.
Those infected went from just 28 weeks median survival to perhaps 50 years for a young person. A broad team effort in science and advocacy turned the world’s greatest public health crisis into one of the most extraordinary accomplishments in the history of public health and medicine.
But when we thought about bringing those treatments to the poorest people around the globe, the mood changed. The conventional wisdom was that treating people with AIDS, in places like Thailand and elsewhere in the global south, was too expensive, too difficult, and offered slim prospects for success.
In fact, some of the most important leaders in public health angrily opposed and even ridiculed our efforts, and talked about focusing on the next generation through an emphasis on prevention.
Thankfully, many others saw the suffering and were compelled to act -- to act up. They had aspirations as high as the people living with HIV/AIDS everywhere in the world. Indeed, some of these activists were themselves living with HIV/AIDS.
As a result, millions were treated, millions of lives were spared, and incalculable human and economic costs were avoided.
The visionary leadership of Thai health professionals and activists saved lives here, and around the world. They showed us what was possible. People like Mechai Viravaidya – or Mr. Condom as he is known here – and my friend Dr. Wiwat Rojanapithayakorn, broke the taboos on talking about condoms and sex. Thailand’s commitment to treatment and prevention, and its integration within the universal health scheme, were prescient and spared many, many lives.
Just as Thailand’s successes in AIDS prevention and treatment were not inevitable, neither was its quest for universal health coverage. In fact, it seemed quite unlikely at the time of its inception in 2001.
A few years earlier, in 1997, Thailand’s economic bubble burst. Growth plummeted. The baht was devalued by 45 percent. Unemployment soared, and the stock market lost three-quarters of its value. The government committed to a $21 billion IMF bailout, and the imperative to stabilize the economy made it very challenging to propose new programs.
Few people saw this as an auspicious time to advocate for universal health coverage for all Thais. Yet a handful of Thai visionaries had been dreaming -- and scheming -- for decades, and would not be denied.
They had many opponents. Not the least of which was the World Bank Group. That’s right. The institution where I now serve as President was an outspoken opponent of Thailand’s aspiration to provide all of its people health coverage. The Bank and others said it was the wrong time for universal health, that it wouldn’t work, and that it was fiscal suicide.
Another major opponent was the World Health Organization -- whose constitution says it exists for “the attainment by all peoples of the highest possible level of health.”
Yes, I used to work at the World Health Organization, too.
I’ve tried to imagine what those conversations must have been like.
“I’m sorry Thailand, but when we talked about ‘Health for All’ by the year 2000, that was actually a typo. We actually meant Health for All by the year 3000.
So, with powerful opponents like those, some might lose faith and walk away.
Not the Thai people.
The Thai people have a deep commitment to economic justice. They had worked for decades to provide universal coverage to their people. In fact, Thailand’s constitution guarantees the right of every Thai citizen to health care, even the poorest.
By 2001, when Thailand introduced its universal coverage scheme, nearly a third of its people were still uncovered. Many of these were poor people whose families could be made destitute by a serious illness.
It took civil society activists, as well as civil servants and health professionals, to build broad grass-roots support for reform. The Universal Coverage Scheme -- or UCS -- has remained a top priority through several changes in government. Thailand’s health professionals have made smart choices and used evidence-based decision-making to build a system that works for its people.
Today, UCS provides comprehensive health services, and it has made the nation healthier and more productive. Within one year it added 18 million previously uninsured people to the rolls of the insured. As in many other nations, the integration of AIDS treatment and prevention has only strengthened the system’s breadth and effectiveness.
One key reason for Thailand’s success was the acceleration of a two-decade-long shift of resources and health staff from urban to rural areas, where more of the poor and uninsured lived. Successive governments have provided strong and positive incentives for health workers to work in these previously undeserved areas, and to increase their motivation, skills and effectiveness. They even paid them more than their urban counterparts.
We should acknowledge the contributions of Prawase Wasi, the great hematologist who established the rural doctors’ movement in Thailand and who wrote a seminal monograph entitled "The Triangle that moves Mountains". The triangle referred to three points of engagement that are critical in enacting reforms: wisdom, state, and society. This combination of forces certainly provided strong stewardship for universal coverage in Thailand.
In the first 10 years of UCS, Thailand had strong GDP growth. This provided the fiscal resources for the reforms to survive and take hold. And this growth has been shared with the poorest. A recent study showed that over the past decade, among all Southeast Asian nations, Thailand is the only country that offers universal health coverage, and the only nation where lower income consumers have increased their share of total consumption.
UCS is a gem beloved by the Thai people -- 90% of them are satisfied with it -- and their strong voices ensure it is funded and nurtured. And this despite the fact that when UCS was launched, Thailand had the lowest per capita income of any nation ever to achieve universal coverage.
It’s not a perfect system. It faces growing pains as more people use its services; as people age; and as injuries from road accidents and non-communicable diseases like diabetes rise. This is normal. Managing health care systems is like tending a tropical garden. There will always be more weeds to pull, flowers to plant, and branches to prune. I have faith that Thailand will succeed in its pursuit of greater quality and equity in its health care. As it stands now, UCS is a remarkable, living legacy of many dedicated civil servants, activists and health workers, all who were committed to justice in health care.
As I travel across the world, I tell the Thai UCS story as an example to other nations who aspire for the same results for their own people.
I thank you, and congratulate you for your achievement.
So, what are the lessons from the fight for AIDS treatment and universal health coverage?
First, we’ve learned that investing in people is not just the right moral choice. It also results in real economic and political benefits. I have dedicated my life to demonstrating that not providing health, education, food, and social protection is fundamentally unjust -- and that it is also a bad economic and political strategy.
The Lancet Commission on Investing in Health estimated that up to 24 percent of economic growth in low- and middle-income countries was due to better health outcomes. The payoffs are immense: health spending yields a 9 to 20-fold return on investment.
And the Growth Commission, led by Nobel Prize-winning economist Michael Spence, reported that “No country has sustained rapid growth without also keeping up impressive rates of public investment” in things like education, and health -- in addition to physical infrastructure. These investments in people don’t crowd out private investment; they crowd it in. New enterprises are born, and returns rise because workers are healthy and educated.
The second lesson is that ambitious reforms require skillful balancing of competing demands; they also require continuous learning and adaptation, based on the best global knowledge and evidence. Thailand’s health workers’ and activists’ achievements in universal coverage and AIDS demonstrate important elements of what we at the World Bank Group are calling the science of delivery.
They paid careful attention to all the factors that affected success -- everything from the cold chain for vaccines to financial management of their health system; from roads and electricity for clinics to girls’ education.
Two days ago I visited Myanmar, which has just launched its own effort to achieve universal health coverage. Myanmar can learn from Thailand’s approach to effective health care reform.
To achieve such complex reforms, an unforgiving focus on results is imperative.
Good intentions alone are little use to a pregnant mother in a rural village. She needs an effective and stable health care system to give birth to a healthy daughter, to protect her from childhood diseases, and to help her child become an educated and productive member of her community. In addition, their leaders and health officials have to maintain a strong public commitment to delivering quality services, weaving through the political maelstrom, and fostering a change in behaviors which affects the health and livelihoods of everyone.
The third lesson is that even a handful of committed people with vision have the power to change the world. Believing in the possibility -- but not the inevitability -- of a better world is the first step in achieving it.
The global fight against AIDS was a triumph of a bold vision for fundamental human rights, combined with scientific progress, and global solidarity.
Here in Thailand, through the tenacity and grit of thousands of health workers and activists, you showed all of us how to pursue a vision for health equity. You built movements that saved lives, changed your nation, and provided a contagious hope to millions.
These lessons are universal -- and timeless.
We can achieve great things, if we learn from history, and contribute to a lasting evidence-based wisdom.
Our work is unfinished. Yet, as I look out at all of you here, I have an abiding faith that, together, we can build a world with greater opportunity…equity…and justice.
Thank you very much.
