In 2000, Thailand was in the midst of a healthcare crisis. The year marked the death of more than 17,000 children under the age of five, of which two-thirds were suffering from easily preventable communicable diseases. 20% of the poorest households in the country also slipped Below Poverty Line due to hefty payments on healthcare.
In 2001, massive reforms were undertaken by the winning party, Thai Rak Thai, which led to the introduction of Thailand’s Universal Coverage Scheme (UCS). The UCS, which spread to all provinces the following year, provides outpatient, inpatient and emergency care, which is available to all according to need. Within a decade, the program covered 48 million citizens or 98% of the Thais.
The scale of their achievement must not be understated. Even today, developed, high-income countries such as the US struggle with schemes like universal health insurance coverage. But Thailand, a developing country, with its meagre per capita income of $1900 (in 2001, at the time of the initiation of this policy) achieved astounding improvement in access and quality of healthcare without putting too much pressure on the fiscal vaults. So, how did Thailand achieve the near-impossible?
History of Thailand’s UHC
Beginning three decades ago, Thailand’s health care policy first covered the poor, then the near-poor, the formal sector employees, and finally the children and the elderly, through various publicly funded and contributory schemes until it reached 71% of the entire population in 2000.
In 1975, Thailand launched its ‘first medical care programme.’ The starting population coverage was 30%, 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. From 1982 to 1986, despite the economic crisis, the government decided to freeze all capital investment in the urban hospitals and shifted the limited resources to build rural district hospitals and health centres with extensive training of community-level health professionals and rural doctors. This resulted in the rapid, nationwide expansion of rural health services and broadened access to 15 essential health services at the community level. Around one million village health volunteers were recruited and trained to assist health personnel in providing basic healthcare and health education to their communities. The volunteers helped distribute essential drugs and get children vaccinated; they also built sanitary latrines and clean-water reservoirs and implemented nutrition programmes.
The formal sector employees were covered by the contributory Social Security Health Insurance in 1992. Across developing countries, assurance of the quality of healthcare continues to be the most persistent challenge of government-funded schemes. But programs initiated in the 1970’s helped Thailand invest heavily in infrastructure, build hospitals and clinics and train medical personnel to support universal coverage. After the implementation of the Universal Coverage Scheme, this long-term investment in the sector finally paid off as relationships between doctors and patients transformed completely. Before, patients paid a fee to their doctors when they visited the hospital. After 2001, the government paid hospitals, including salaries for staff, and financially incentivised medical professionals to serve unpopular rural areas.
The country’s health scheme is primarily funded by general income tax and costs only $80 billion annually (2011). The system has successfully reduced infant mortality, decreased workers’ sick days and lightened families’ financial burden.
The policy provides a benefits package that encompasses a comprehensive set of health interventions stipulated in a contract with the National Health Security Office and the providers, at every level of health service. Further, it is made up of two different components: the health promotion and disease preventive package, and the treatment and care package.
For budgeting of the programme, it was decided in 2001 that the UCS would use a capitation payment method. In a capitated contract, the physician, hospital or clinic receives fixed, pre-determined monthly payments per patient enrolled in a health plan. The expenses of the UCS are budgeted under an annual close-ended capitation system that includes each facility’s labour costs to ensure tight budget control. The rate of capitation budget of the UCS increased gradually in the first few years, and, more rapidly, since the fiscal year 2006.
Another unique feature of Thailand’s healthcare system has been its encouragement of active involvement of CSOs (civil society organisations). These have provided volunteers to the government and have also assisted in policy formulation by providing data on healthcare and in implementation through direct intervention in underdeveloped areas of the nation.
At a time where the just and equitable distribution of healthcare services is becoming an increasingly contentious issue around the world, Thailand has shown that even a middle-income developing country can attain fiscally-responsible universal healthcare. Thailand has cut child mortality rates alongside saving adult lives by providing treatments like antiretroviral therapies and renal replacement therapy. Catastrophic health spending that tends to push people into poverty has been significantly slashed. The correlation between poverty and infant mortality has disappeared and an improvement in the number of people that were prevented from going to work through illness, particularly at the older end of the workforce has been observed.
With 400 million people across the globe still lacking access to healthcare, Thailand’s universal coverage scheme emphasises on focusing on primary health care units by employing methods that are fair, efficient and sustainable. Governments must show immense political commitment, and accountability must be introduced at multiple stages through the creation of several stakeholders and involvement of CSOs to create a system that is fast, effective and equitable.
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