Universal Health Coverage (UHC) is part of the Sustainable Development Goals. How is the implementation of the UHC concept going in Thailand? Can the implementation of health care reform also help poorer residents? Has the situation in the healthcare sector changed in this developing country or not and in whose favor?
According to the World Health Organization (WHO) report from 2010, at the beginning of the 21st century, almost one billion people worldwide did not have access to quality healthcare. Some of them still do not even have the opportunity to see a doctor. Through UHC (Universal Health Coverage), quality health care should become available to everyone.
The term UHC is often interpreted and translated differently in the literature. According to the WHO, the definition of UHC from 2017 is primarily based on equality in access to health services, i.e. that everyone should have access to health services, and not only those who can afford it financially. The concept of UHC is part of the Sustainable Development Goals (SGDs), specifically goal 3, which reads: "Ensure a healthy life and increase its quality for all at any age." This goal then has several sub-goals. One of them is 3.8.: "Achieve universal health security, including protection of financial risks, access to quality basic health care and access to safe, effective, high-quality and affordable basic medicines and vaccines for all." Thailand is one of the low- and middle-income countries that strives for universal care. Using her example, it is possible to show the implementation of the health reform in practice.
At the beginning of the new millennium, Thailand was in a health crisis. Almost one quarter of the then more than 67 million inhabitants did not have health insurance. In 2000, more than 17,000 children under the age of five died, and almost two-thirds of them died of easily preventable infectious diseases. Due to "Out-of-pocket" (OOP) payments spent on health services, up to 20% of the population found themselves below the poverty line. In 2001, the Thai government introduced the Universal Health Scheme (UHS), which was described as one of the most ambitious health reforms planned for a developing country. At that time, Thailand still fell into the category of countries with a lower middle income (GDP at the time was 1,900 USD per inhabitant). During the following year, 2002, UHS expanded to all provinces in Thailand and provided inpatient, outpatient and emergency care for all as needed. By 2011, the program covered 48 million Thais.
What caused the expansion of this program so quickly? This was due to the consolidation of power in the 2001 elections, when the Thai Rak Thai party, which was behind this reform, strengthened its power in the general elections. The representatives of this political party themselves acknowledged that the program spread very quickly and to all corners of the country due to enormous political pressure.
However, UHS was not created in one year, it was gradually formed since the 70s of the 20th century. Since 1970, a total of three health insurance systems have been established in Thailand - The Civil Servant Medical Benefit Scheme (CSMBS), the Social Security Scheme (SSS) and "Baht 30", today named precisely as UHS. Although Thailand had the lowest per capita income of all countries that achieved universal coverage of health services, it subsequently recorded strong GDP growth during the first ten years of UHS implementation, which supported the maintenance of this program both financially and by developing the necessary infrastructure.
After 2001, the government spent funds on hospitals, staff salaries and financial incentives for doctors to provide their services to unpopular rural areas. The child mortality rate, the number of sick days of working people and the burden of the financial burden on families were effectively reduced. The current challenge in Thailand is not the availability of health care, when the state's expenditure on health care per capita is growing, but increasing its effectiveness - that is, to have more and better health services with the help of new technologies, medicines, etc., at lower costs.
Decline of "impoverished" families' costs of health services
Based on the summary of case studies from Thailand (from the workshop of authors Tangcharoensathien et al. from 2014), three main changes in favor of UHS can be observed. Fairer access to health services, a lower level of unmet health needs and a high level of protection against financial crisis due to direct payments spent on health services. It is precisely the direct expenditure on household healthcare that fell from 45% in 1994 to 35% even before the implementation of the UCS itself. Then they fell further, below the 20% mark. In 2010, they amounted to less than 15%. The occurrence of the so-called "catastrophic" expenditures on health services (when PPE makes up more than 25% of the total family expenditures) also decreased. A decrease in the cost of health services for families "impoverished" was also recorded, which shows that without the implementation of UHS, the situation of families in the country would be much worse.
The number of outpatients and hospitalized patients also increased. What is very important, however, is that poorer residents benefited from the implementation of the UHS, and the program was not aimed more at the rich. Outpatient services were used from the lowest economic quantile to 26% to 28%, while from the richest quantile "only" 8% to 10%.
However, this could be expected to a certain extent, since after the launch of UHS, 47 million people were insured, almost half of whom belonged to the poorest third of Thailand's population. On the basis of previous and ongoing studies, it became clear that the government was oriented more in favor of the poor population than the richer ones.
Why the health care reform mainly benefits poorer residents
Through UHS, Thailand was moving more and more towards equitable access to health care. According to studies by the authors Limwattananon et al. from 2012, there are three main reasons for targeting subsidies for general health care, from which poorer residents benefit in particular.
The first reason was improved access to health services provided by the district health system, when most of the population using the new UHS lives in rural areas. The density of health centers per inhabitant has increased, and they are also adequately financed. The obligations of personnel employed in the healthcare sector have also changed, when new doctors, nurses, dentists and others must complete a three-year working period in the countryside. This led to a significant reduction of regional differences in the density of human resources.
The second reason was the very low share of OOP payments, for two reasons – benefits resulting from the coverage of UHS services, which includes, for example, the coverage of drugs from the national list of drugs, chemotherapy, radiotherapy, prevention and health promotion. At the beginning, a minimum amount of payment for a doctor's visit ($1) was established, but in 2006 this fee was abolished. The lowest possible OOP payments are primarily for the benefit of the poor.
And finally, the third reason was the government's financial commitment. Between 2003 and 2009, a 36.2% increase in funding to the health services sector can be observed. This was of course supported by the GDP growth that Thailand has recorded since the beginning of the 21st century. Between 2002 and 2014, a gradual growth trend can be observed - increasingly higher government spending on individuals in the healthcare sector. GDP is also growing in the same way. Even though Thailand has its own national UHS concept, it still spends a very low percentage of expenses in relation to GDP. However, it is also necessary to add that they are at least among the leaders in their region. Thailand can be an example to many countries that a well-designed program based on good research and strong leadership can improve the health level of the country.
Text: Luboš Sladký, student of the Department of Development and Environmental Studies of the Faculty of Arts, UP in Olomouc