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					           The Universal Coverage Policy of Thailand: An Introduction




        Health expenditure in Thailand has dramatically increased since 1980 from
3.82% of GDP to 6.21% in 1998. During this period the health expenditure per capita
increased from 544.90 Baht in 1980 to 4662.83 Baht in 1998 (Thailand Health Profile
1997-1998). In the mean time, about 20 million or about 30% of the total 60 million
Thai population remain uninsured. What should these people do when they are
confronted with high cost care for their illness? Section 52 of the Constitution (1997)
states that “ All Thai people have an equal right to access the quality health
services…” However, after the declaration of the new Constitution, no law has been
enacted to support this Article. Later on, a legal process was initiated which will soon
be completed to serve as a vehicle toward the implementation of the Constitutional
health policy. Further more, due to the problems with asymmetric information and
imperfect health care market, consumers cannot make rational choices and in other
instance, they do not have adequate choice of health services. At the same time the
cost of health care is rising rapidly even if the health system has not been able to
provide equal access and equitable financing to all. There fore there is a need for
institution of universal healthcare coverage.


    Many developed countries, such as United Kingdom, Canada, Australia, France,
Sweden, Netherlands have already launched policies of universal healthcare coverage.
Such a policy provides their people with access to high standard health services and in
many cases their personal health expenditure has become more affordable than before.
We should ask whether it is the right time to adapt this idea for Thailand, i.e. to
introduce universal healthcare coverage in which all Thai people have the same right
to access quality health care services and the health care expenditure is not a
constraint in obtaining the health services.         The main objectives for universal
coverage are as follows:
_____________________________________________________________________
This paper was prepared for Asia-Pacific Health Economics Network (APHEN),
19 th July 2001.
For feedback, comments, further information, please contact:
Nutta Sreshthaputra: pimnut@yahoo.com and
Kaemthong Indaratna: ikaemtho@chula.ac.th

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1. Equity: An equal sharing of health care expenditure and equity of access to the
    same quality of health services.
2. Efficiency: Efficient use of resources by good administrative and management
    practices.
3. Choice : People have the right to choose their health services in order to reduce the
    problem of an imperfectly competitive market.
4. Good health for all: Universal healthcare coverage aims not only to provide
    curative care but also to provide disease prevention and health promotion where
    appropriate.


    The Thai Ministry of Public Health has been examining the possibility of this
idea for several years. Based on research, discussions and brainstorming sessions, the
ideal universal coverage health system should have the following characteristics:
   Easy access and simplicity in order to benefit from this programme.
   People should be the part of the ownership, overseeing, access and cos t sharing of
    health services.
   The universal healthcare coverage should reduce the problem of overlap and
    inequity of healthcare schemes.
   It should be a transparent system. The providers, consumers and third parties/
    payers/ purchasers must be able to check easily the effectiveness, and the
    administrative power should be balanced among the three partners.
   There should be efficiency and equity of budgeting, planning, and development of
    the health services based on evidence and information.
   It should have appropriate methods of co-payment
   It should institute a reasonable role for insurers in order to pool the risks.
   Lastly, it should be a accountable, reliable and accepted scheme.


    From the above, the Universal Coverage Committee has suggested the three
possible alternatives toward universal health care coverage, as follows:


1. Expansion of existing systems
    Nowadays, there are several health insurance/welfare schemes in Thailand, for
example, Voluntary Healthcare Card Scheme, Civil Servants Medical Benefit/Welfare


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Scheme (CSMBS), Social Security Scheme (SSS; compulsory scheme for formal
sector) and Health Welfare for the low income group, the elderly, children under 12
and other underprivileged groups. Although these schemes have covered various
population groups, they have not yet covered 100% of the total 60 million Thai
population. Besides, there are still some weaknesses in terms of efficiency and
equity.. If we expanded the previous schemes to become universal health coverage,
we would need to:
   Set the universal standard regulation for health for all.
   Change their philosophy to offer health schemes of greater similarity.
   Readjust the legislation related to health insurance, especially private health
    insurance.
   Adapt a registration information system.
   Organize the payment mechanism and reimbursement standard to operate in the
    same direction.
   Set a more appropriate accreditation system and consumer protective system.


    The expansion of the previous health schemes would be cost saving from the
adaptation in the initial stage and would not greatly affect the structure of government
services. Furthermore, another strong point is the comparability between health
schemes. However, these advantages cannot be used for adaptation because of their
existing limitations, for instance, the basis of their capitation and their philosophy.
There are several weaknesses of the expansion concept. Firstly, there is inequity in
health care access and financing systems between the differing health schemes.
Secondly, there are differences in health cover efficiency because each scheme is an
individual independent system administered by different Ministries. Some schemes
are mandatory, other are not. Still many people are not eligible for insurance. Yet,
some people may belong to more than one health scheme to provide necessary gap
coverage because of practical difficulties on both consumer and provider sides.
Lastly, some commercial groups may oppose and try to block the legislation to make
possible the necessary changes seen as blocking their benefits.


2. Single-payer system




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   The philosophy of this system is a national health insurance, which is managed by
government. This system is suitable for starting when there are no existing health
insurance schemes. In this system, the government can organize health legislation so
all people can access the same basic       health services, with pooling of risks for
providers and vertical equity of health financing. The difficulty in a country which
already has health insurance schemes is in the transition stage and the question of how
to integrate all existing health insurance schemes together, since each scheme has
their own funding, concept, package and payment methods.


   The strength and weakness of the single-payer system should be analyzed in three
parts, namely equity, efficiency and choice/quality of system. The strong point lies
with equity, in that all people can access in the same basic of health services. With
respect to efficiency, such a system can reduce the adverse selection problem, reduce
the overlap/gaps between previous health schemes and introduce a standard to
administration and to information systems. Lastly, with respect to choice and quality
of care, it offers a way to stimulate the providers to compete with each other in order
to increase the quality of services. A weakness is that, if the administration of the
legislation is not adequate, it will lead to equitably poor care. This system would
possibly fail if the administration were not appropriate since it is based on a
centralized funding system.    Moreover, there is no competitive pressure to help
maintain adequate quality or contain the budget.


3. Dual health insurance system for formal and informal sectors
   In this system, there is a parallel between the formal sector, (e.g. civil servant and
state enterprise officers health insurance) and the informal sector (e.g. farmers, self-
employed, elderly, monks children health insurance). For the formal–sector health
insurance, the methodology is the same as previously, but it s hould expand to include
spouses and children less than 18 years in the Social Security Scheme. The system of
Civil Servant and State Enterprise Medical Benefit Scheme should change to the same
direction as the Social Security Scheme with respect to part contribution to funding.
The informal-sector health insurance should be managed under the universal health
fund with support of government, locality organization and resident co-payment.
Poor groups may need to be exempted from co-payment.



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   A strong point of this system is that, by reducing the weakness of the single payer
system, for example, it can be compared with each existing health schemes and
adjusted accordingly to save costs and to improve the system. However, even though
this system seems to be appropriate, it still has some weaknesses. Thus, it might
encompass some of the inequity and inequality in benefits and budget present in the
existing health schemes.     Secondly, the lack of administrative experience in the
informal sector funding may lead in the initial stages to overlap of benefits to the
families of formal sector health insurance recipients. Lastly, it is very difficult in the
political and administrative sense to bring each system of funding together.


   In summary, the study has suggested that the appropriate way to move towards
universal health care coverage is to start from the dual health insurance system for
formal and informal sectors before leading to the single-payer or national health
insurance in the future.


   Proceeding from the above, on 26th February 2001, the government launched the
30 Baht health policy.     The first phase was established in six pilot provinces -
Nakhonsawan, Phayao, Patum Thanee, Samut Sakhon, Yasothron and Yala - on 1st
April 2001. The insured are all of the people who were not in any health scheme and
whose names are in the house registrations in those provinces. These people would
receive the universal health card or the gold card. This card must show consistency
with the individual’s identification card every time they access the health services,
which are the government health services or the private sector health services
registered with this project. The accessing health service has to follow the referral
system from the primary health center or the nearby hospital, which are registered
under the project.    For emergencies and accidents, the insured can access any
government health services.      To access needy health services, the insured must
contribute a co-pay of 30 Baht per episode. Under this 30 Baht Universal Coverage
Policy, the insured will receive the same quality health services as offered by other
health schemes. At present, the service package includes most health services except
cosmetic care, obstetric delivery beyond two pregnancies, drug addiction treatment,
hemodialysis, organ transplantation, infertility treatment, and other high cost
interventions. However, with more resources and disease priorities, the inclusion can
expand further over time. From the government side, the funding of the system is paid

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by capitation. The total payment per capita paid from tax revenue is 1404 Baht per
year, parts of which are paid to the health care facilities, according to the number of
local residents who are registered with them, hence to be served. This capitation
includes the costs for the curative, preventive, promotional care as well as the
administration. It can can be divided into
 574 Baht for out-patient care
 303 Baht for in-patient care
 175 Baht for prevention and control of diseases.
 32 Baht for high cost care. This amount of money will accumulate in the central
    office of budget. In the case of high cost care, such as neurosurgery, cardiac
    surgery, chemotherapy, radiotherapy, etc, the reimbursement can be done by
    following the price schedule.
 25 Baht for emergency and accident care. The system is the same as for high cost
    care.
 88 Baht for structural investment. This money will accumulate at the central level
    and will be distributed to the healthcare facilities in the appropriate way.
 10% of the total package for central and regional administration, developing the
    information system and quality assurance.
 10% of the out-patient and in-patient services budget for contingency funds.


    There are some criticisms from experts, which can be summarized as:
   Loss and bankruptcy of services. In the next 5 years, some hospitals would face
    the bankruptcy problem and will have to shut down. This problem may occur due
    to inadequate hospital management of the budget. Moreover, this problem may
    occur from adverse patient distribution, for example, some hospitals have a high
    percentage of chronic patients, which is costly.
   Quality of services. Quality of care is still a questionable problem for many
    experts. As in the past, there are still some criticisms o f the health care quality in
    some health schemes, such as the low- income card or Social Security Scheme. At
    this point, the government is attempting to compel all hospitals to participate in
    the Hospital Accreditation Programme to provide assurance of the quality of care.
    Presently, a Clinical Practice Guideline is now being developed to assure the same
    quality of services.



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   Lastly, this system is criticized in regard to the role of the locality in
    administrative decision- making. In this context the government still has not set up
    tangible methodology.


    To sum up, right now Thailand is in the transitional stage of establishing universal
healthcare coverage. The success of this programme depends on many factors and
many players: consumers, providers and third parties/payers/purchasers. Beside the
Ministry of Public Health, other Ministries and Public/Private Enterprise are also
providers or funders in health sector in Thailand. With the existing multiple schemes,
funders and providers, the harmonization process toward a new scheme will take time.
The road toward a full implementation of the Universal Coverage Policy will be long
which requires assessment, re-assessment, improvement and dynamism over time.
However, once the health policy has recently become, for the first time in Thailand, a
political agenda with strong political commitment, it is possible to anticipate a health
system which will provide quality health services more efficiently, equitably and
accountably.


References
Bureau of Health Policy and Plan Office, Office of the Permanent
       Secretary for Public Health (2001). a handout on Universal Health Care
       Coverage. Ministry of Public Health.
Ministry of Public Health (2001). The 30 Baht Project. Health Reform
       Forum. March-April, 2001.
Wibulpolprasert S. ed. (2000). Thailand Health Profile 1997-1998. Ministry
       of Public Health.




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