Universal Health Coverage:

Thailand experience

Ekachai Piensriwatchara, MD.

Walaiporn Patcharanarumol, PhD.
17 July 2017
Yokohama, Japan
 ASEAN-Japan 15 July 2017
Statement of the Minister of Public Health, Thailand
1. With strong political commitment, UHC can be started and
achieved at low level of income
2. Peace and sustained economic growth mobilized ‘more
money for health’
3. Universal access to good quality essential health services is
the real goal
4. Strong capacity on health system and policy research
5. Participatory governance systems ensures real ownership

2
1. UHC can be started and achieved
at low to middle income level

29% 42% 53% 70% 100% Population

coverage

3
2. Peace and sustained economic growth
mobilized ‘more money for health’

4
 From security and debt service budget to health
30

*Security 25.8
24.7 24.4
25
23.5
22.6 *Education
20 21.8
Percentage

16.1
17.9
15 16.9 13.713.5
*Debt serv.
13.1
13.2
12.5
10 9.1
8.1
8.2 5.1 *Health 7.8
4.4 4.2 4.1 4.3 7.6 7.1
5 3.4 3.2
4.4 5.0 5.3
2.9 Year
0
1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003
Source: Bureau of Budget; Dr.Suwit’s presentation 30 Sept 2011
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 More budget to health

986.6 mil. ฿ 16,225.1 mil. ฿ 77,720.7 mil. ฿ (78x)

(3.4%) (4.8%) (8.1%)

29,000 mil. ฿ 2011 Budget

for health rose
1972 335,000 mil ฿ to 13% of
1,028,000 mil ฿ government
(35x) budget
1990

2004

Government budget Budget for health 6

 Continued political commitment to UC Scheme:
Budget, Baht per capita, by Regime 2002-2017
8 governments, 13 Health Ministers, 11 Permanent Secretaries
3,500
3,109
3,028
3,000 2,895
2,755
2,546
2,500 2,401
2,202
2,100
2,000 1,899
1,659
1,396
1,500 1,308
1,202 1,202

1,000

500

-
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
2001 2002
G 1 2003 2004 2005
G 2 2006 G2007
3 G2008
4, 5 2009
G 6 2010 G2011
6, 7 2012
G 7 2013 2014
G 7, 8 2015 2016
G 8 2017
M1 M2 M3 M4 M 5-7 M8 M9 M9 M 10 M 11 M 12 M 12 M 13 M 13
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 3. Universal access to good quality essential
health services is the real goal
• Free but inaccessible health services and/or poor
quality is not UHC.
• Thai’s UHC focuses on Primary Health Care.
• Evolution of rural health systems since before UHC
– 780 district hospitals: one district hospital per district
– 9,777 health centers: one health center per rural commune
• Rapid increase in HRH training, i.e., doctors, nurses,
voluntary health volunteers, etc, through “rural
recruitment, local training and hometown placement”
and compulsory public work for graduates with
adequate motivation and incentives;
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 District health system: hub for pro-poor outcomes
The Lancet 2013;381:2118-33.

Primary health care

1. Health promotion

2. Disease control

3. Health care

4. Rehabilitation

5. Consumer protection
Rural health centers with 3-6 nurses and
paramedics cover 2,000-5,000 population
temple

Rural
community Health school
facilities

private Local Rural community hospitals with 2-8

authority
sector doctors cover 30-80,000 population 9
 Huge increase in access to primary care

46%
(5.5) Regional / General Hospital
24%
1977 (2.9) District Hospital
29%
(3.5) Rural Health Centres
27%
(11.0) Regional / General Hospital
35%
1987 (14.6) District Hospital
38%
(15.7) Rural Health Centres
18.2%
(20.4) Regional / General Hospital
35.7%
2000 (40.2) District Hospital
46.1%
(51.8) Rural Health Centres
12.6%
(18.1) Regional / General Hospital
33.4% District Hospital
2010 (33.4)
54.0% Rural Health Centres
(78.0)
Note: (number of OP visits in million) 10
Source: Suwit’s presentation on 30 Sep 2011 and updated 2010 data
4. Strong capacity on health system and policy research

• Home grown technical capacities

– Designing and implementing UC scheme
• Provider payment methods: capitation, DRGs, fee schedule
• IT to support UHC
• Medical audit
– Priority setting using many tools, including health technology
assessment, budget impacts, supply side readiness,
– Monitoring progress of UHC
• Population coverage using citizen ID of CRVS; everyone is count
• Service coverage -> effective coverage of 6 conditions: HIV, TB,
cervical cancer, DM, Hypertension, cerebrovascular disease
• Financial risk protection: catastrophic and medical impoverishment

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 UC Scheme achievements
• Some key achievements
• Improved equity in financing healthcare;
• Health Research Policy and Systems 2013;11:25

• Increased access to care by beneficiaries;

• Journal of Public Economics 2015;121:79-94

• Pro-poor utilization and benefit incidence;

• BMC Public Health 2012; 12(suppl 1): S6

• Preventing non-poor households become poor from medical bills;

• Bulletin of the World Health Organization 2007; 85: 600–6

• Gaining efficiency and cost containment;

• Economic & Political Weekly 2012; 47: 53-7

• UCS flourishes despite eight rival governments, six elections, two

coup d’etat, thirteen health ministers, between 2001-2015
• UCS gradually owned by the people, not political party who initiated it.

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 New interventions assessed for service coverage
Contribution by IHPP and HITAP

Interventions Cost-effectiveness Budget UC Scheme

(Indication) impact coverage
Lamivudine Cost-saving Low Yes
(Chronic hepatitis B)
Cyclophosphamide + azathioprine Cost-saving Low Yes
(Severe lupus nephritis)
Peg-interferon alpha 2a + ribavirin Cost-effective High No
(Chronic hepatitis C) (ICER=86,600*)
Adult diapers Cost-effective High No
(Urinary and fecal incontinence) (ICER=54,000* )
Anti IgE (Severe asthma) Cost-ineffective High No
Implant dentures Cost-effective Low No
(ICER= 5,147*)

Note: * Threshold: ICER = 160,000 ThaiBaht per QALY

Source: UC Benefit package project

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 Incidence of catastrophic health spending
>10% of household expenditure, before and after UC Scheme in 2002

Health Research Policy and Systems 2013;11:25

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Sub-national health impoverishment 1996 to 2008

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5. Participatory governance systems ensures real ownership

• Voices of people
– Board of UC scheme: 5 seats from civil society (out of 30),
chaired by the Minister of Health
– satisfaction survey of providers and patients
– Call Center 1330 of UC Scheme
– Annual public hearing at the national level, regional level and
now extend to provincial level

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Call Center 1330 of UC Scheme Public hearing of UC Scheme
Satisfaction of UC beneficiaries & health care providers
(%)
100
95.5 96.62
90 89.8 92.8 90.8
88.3 89.3
80 83 83.4 83.2 84.0 83.1
78.8
70
66.9 68.5 67.6 64.4
60 60.3
56.5
50
45.6 47.7 50.9 50.7
UC people
40 39.3 provider
30
20
10
0
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Source: NHSO
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 Summary
• UHC is context specific – learn from others and adapt but not
copied

• Political and financial commitment is the key factors – on

both health systems development and financial protection

• Ensuring equitable access to and good quality of health care

services is as important as the financial protection

• The success of UHC depends much on the spirit of

committed health workers not only money

• National capacity for evidence based policy is really needed

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 Situations that lead to reform
1997 Constitution
2001 general
Politics election
(Window of
opportunity)

1993, HSRI
1996,1997 Triangle
1992 that moves
HCF
workshops the mountain
Experien Evidences Social
ces SSS & capacity UC working mobilization
& HCS group 2000 A civil
HCRP (EU)
SIP (WB) proposal on
1998-2000
1999-2001 UC
IHPP HISRO
HITAP
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Thank you for your attention

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