Thailand is one of the few developing countries in the world that have successfully implemented Universal Health Coverage (UHC). Beginning three decades ago, Thailand’s UHC first covered the poor, then the near-poor, the formal sector employees, and the children and the elderly, through various publicly funded and contributory schemes until it reached 71 percent of the entire population in 2000. The government elected in 2001 implemented full-population coverage, when the GDP per capita was a mere $1,900. Today, every Thai citizen is assured of universal access to a comprehensive benefit package of essential healthcare services. Overall improvements in health have been evident, and health expenditures are significantly reduced. Challenges remain, however, in the form of increased workload to providers and the burden of financial management for hospitals. This paper examines the history of Thailand’s UHC and lists specific lessons that can be learned by other transitioning economies.
Introduction
Thailand is an upper middle-income country with a population of 64 million; of these, 60 percent live in urban areas. The citizens enjoy access to comprehensive essential healthcare with full financial protection. The population coverage of the country’s Universal Health Coverage (UHC) gradually progressed over three decades, beginning with the “free medical care programme” in 1975 (Figure 1). At that time, Thailand’s Gross Domestic Product (GDP) per capita was a mere $390. [1] The starting population coverage was 30 percent, but the service coverage, although comprehensive, was not deep. It then gradually covered the near-poor in 1985, based on a voluntary, publicly subsidised healthcare scheme. The formal-sector employees were covered by the contributory Social Security Health Insurance in 1992. Following this, the children and the elderly were covered with social welfare health insurance in 1995–1996. By 2000, 71 percent of Thailand’s population was covered. [2] After the general election in late 2000, the new government decided to move forward to full-population coverage in January 2002, when the country’s GDP per capita was still relatively low at $1,900. [3] Private health insurance, meanwhile, covers only a small proportion of the population at less than two percent. (Figure 1)
Figure 1: Evolution of finance protection coverage towards UHC in Thailand
In 2001, in the midst of the Thai government’s serious policy implementation of UHC, two analysts of the World Bank made a strong recommendation to reconsider it, warning of potential financial unsustainability. [4] The government, however, after taking stock of WB’s comments, made a decision to continue the UHC policy, armed with strong commitment from the bureaucrats and health professionals, adequate technical capacity on health systems and policy research, and the involvement of civil society organisations (CSOs).
Cost sharing is minimal or almost nil in Thailand’s UHC model. Following the implementation of UHC, previously massive health impoverishment has been significantly reduced; and healthcare has improved significantly, and with more equity. Challenges remain, however, with regards to ensuring a just system of financial contribution, as well as reducing geographic and social disparities in the access to essential services. [5]
This paper examines how Thailand’s UHC policy was formulated and what factors contributed to the favourable outcomes, in an effort to provide policy lessons for other developing countries.
Thailand’s health and health insurance profile
Thailand is an upper middle-income country, with a GDP per capita of $5,814 in 2015. [6] The economy depends mainly on exports, as well as manufacturing and service industries while maintaining big agriculture systems. The country’s healthcare system is pluralistic and dominated by the public health facilities. The Ministry of Public Health is the major healthcare provider and owns most of the health facilities (60 percent in total and more than 95 percent in the rural areas). The private sector, with around 20 percent of health resources, participates by providing for 20 percent of the outpatients and 10 percent of the inpatients, for the more affluent urban population and for foreign nationals. [7]
There have been significant shifts in the country’s health profile, and an increasing burden of chronic non-communicable diseases (NCDs). [8] Life expectancy at birth increased from 57/61 years in 1964 to 70/77 years in 2010 for men/women, respectively. The Infant Mortality Rate (IMR) declined from 49 per 1,000 live births in 1980 to 10.5 in 2016. The Maternal Mortality Ratio (MMR), meanwhile, declined from 98.5 per 100,000 live births in 1980 to 20 in 2015. [9]The leading causes of morbidity are cardiovascular diseases, traffic accidents, cancer, diabetes and HIV/AIDS. [10]
Healthcare services are largely financed by general taxation paid through three major public health-insurance schemes. The main characteristics of the three schemes are shown in Table 1.
Table 1: Characteristics of Thailand’s health insurance schemes, 2016
Civil Servant Medical
Benefit Scheme (CSMBS)
|
Social Security Scheme
(SSS)
| Universal Coverage Scheme (UCS) | |
| Population coverage | 4 Million (6.25%) | 12 Million (18.75%) | 48 Million (75%) |
| Beneficiaries | Civil servants + spouse + immediate relatives | Employees in private and public sectors | Those not covered by the CSMBS and SSS |
| Source of finance |
General tax revenue
(15,000 Baht/capita)
|
Tripartite: 1.5% of payroll each,
(2,500 Baht/capita)
|
General tax revenue
(3,344 Baht/Capita)
|
| Financial supporters | Comptroller General’s Department, Ministry of Finance |
Social Security Office,
Ministry of Labour
| National Health Security Office (independent public agency) |
| Provider choice | Free choice of public providers, some services especially emergency and elective surgeries are also provided by the private providers | Annual choice of public and private hospitals (more than 100 beds) as main providers | Annual choice of mostly public primary-care based providers with referral system, mostly in the public systems |
| Benefit package | Comprehensive, excluding prevention and promotion services | Comprehensive, including some specific prevention services | Comprehensive, including extensive prevention and promotion services |
| Payment mechanism |
OP: Fee-for-service
IP: Diagnostic Related Group without budget ceiling
Open-ended budget
|
Capitation with DRG for some in patient care
Close-ended budget
|
OP: Capitation
IP: Global budget + DRG
There are some fixed fee schedules to reduce providers’ risks and promote access
Close-ended budget
|
It is clear from Table 1 that there are disparities in the per-capita expense, benefit package, service deliveries, payment mechanisms, as well as access to care among the three schemes. This is one of the main challenges facing Thailand’s UHC. While there have been various movements towards the ‘harmonisation’ of the three schemes, progress has so far been slow.
Development of Thailand’s healthcare system
In the 1970s, the public health infrastructure could provide health services to only 15 percent of the population, while 51 percent still practiced self-care or else sought care from private providers and traditional healers. The rest were left untreated. In the early 1980s, the government started a “rural health development programme” to ensure adequate health services throughout the country. [14]
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