The first 10 years of the Universal Coverage Scheme in Thailand: review of its impact on health inequalities and lessons learnt for middle-income countries

Abstract

Aims

We aim to assess the impacts of Thailand Universal Coverage Scheme (UCS) of health insurance on health service use and healthcare finance in the past 10 years.

Methods

We review the impacts of the UCS on preventive and health promotion including dental care and reproductive health as well as on vulnerable population subgroups.

Results

Three decades after the implementation of low income health insurance in the 1970s, Thailand finally introduced a UCS in 2001. It has brought under its umbrella the uninsured 30% of the Thai population. Many empirical studies of illness expenditure confirm that the Thai UCS substantially reduced the financial burden of healthcare among the poor. The Thai UCS mechanism boosts use of primary healthcare facilities and has substantially reduced catastrophic medical payments and consequent impoverishment.

Conclusions

The UCS relies on a solid primary healthcare foundation. Continued investment into primary healthcare resources will help to ensure sustainable development of the UCS and reduced health inequity. The UCS development in Thailand can provide some valuable lessons for middle income countries pursuing the goal of equity in health and healthcare.

Background

For the past few decades, many countries have been working toward ‘health for all’ and improving equity in access to healthcare and equitable healthcare financing through conceptualising and implementing universal health coverage.^{1, 2} Such is the case for middle-income Thailand with a goal of equity in health and health care being an integral part of its development strategies over many decades. This article provides background and reviews the impacts of the Thai Universal Coverage Scheme (UCS) on health service use, healthcare financing, and vulnerable population subgroups. The evidence from Thailand provides some lessons for other countries particularly those in middle-income settings.

Thailand is a developing country in Southeast Asia which has gone through rapid economic growth (1950-1997), economic crisis (1997-2000) and steady economic recovery (2001 onward). Like many developing countries it faces the accompanying challenge of widening inequality. The UCS was introduced in 2001 following collaboration by many stakeholders, both within and outside the health system.^{3, 4} This was in response to section 52 of the 1997 Constitution which stated that “All Thai people have an equal right to access quality health services”, and aimed to provide Thais with health services that were both accessible and equitable. The UCS was an extension of existing public health insurance provisions, which were expanded to cover uninsured individuals. It replaced two previous public insurance schemes: the public-financed free care for the poor (Medical Welfare Scheme) initiated in 1975, and a subsidised public voluntary insurance program (Voluntary Health Card Scheme) that had operated since 1983.

The UCS brought under its umbrella the uninsured 30 percent of the population who fell outside the two previous schemes. After 2001, two types of universal coverage provision emerged: the UCS with fee exemption and the UCS with 30 Baht copayment (30 Baht ~ 0.75 USD). Then, from 2006, the government abolished the copayment. Policymakers use capitation payments for purchasing ambulatory care and Diagnosis Related Groups — a patient classification system for inpatients that has been used as a healthcare finance mechanism and National List of Essential Drug was adopted as the basis of pharmaceutical benefits. UCS policy requires scheme members to be registered at a primary healthcare facility, and except in an emergency to first access the healthcare system where registered. The primary care network, contracted units for primary care, acts as gatekeeper to higher level hospitals.

Impacts of the UCS on health service use and healthcare financing

The UCS consists of three main benefit packages: a curative package covering most common diagnoses and treatments, a high-cost care package, and a preventive package. Overall, the system has been working well and no informal under-the-table payments have emerged.⁵ Since the implementation of the UCS, several Thai studies have reported increase overall use of health services.^6-9 After the UCS in 2003, the rate of ambulatory care was 4.93 episodes per capita per year, 20.1% higher than that before UCS.¹⁰ The implementation of the UCS also changed patterns of health services use, particularly for rural people and the urban poor, by placing greater emphasis on primary healthcare.¹¹

Other dimensions of inequalities have also been improved including a major reduction of healthcare costs, substantial reduction of catastrophic payments, as well as great reduction of impoverishment due to medical care costs. Benefit incidence analysis has indicated that public subsidies for healthcare benefited the poor more than the rich when compared to the situation before the UCS.¹² Households using inpatient care experienced catastrophic expenditures most often (31.0% in 2000, compared with 15.1% and 14.6% in 2002 and 2004, respectively).¹³ Use of certain services not covered by the UCS benefit packages (e.g., cosmetic surgery) or bypassing designated providers (prohibited under the capitation contract model without proper referrals) are the major causes of the small number of Thais still experiencing catastrophic medical expenditure and consequent impoverishment.

Overall we now know that the UCS not only prevented households from incurring liability for catastrophic health payments, but also protected them from becoming impoverished. Estimates revealed that 1.01% of Thai households fell below the Thai poverty line due to out-of-pocket payments for healthcare in 2000 before the UCS; the corresponding proportions after the UCS were 0.62% and 0.49% in 2002 and 2004, respectively.¹⁴

Impacts of the UCS on population subgroups

Initially antiretroviral treatment for HIV/AIDS and renal dialysis therapy were excluded from the UCS benefits, but due to strong social movements these were included in October 2003 and January 2008, respectively.^{15, 16} The UCS preventive package covers immunizations, annual check-up, dental healthcare,¹⁷ as well as antenatal care and other reproductive health services.¹⁸ In addition, a most important complementary program for the preventive aspect of the UCS was established in 2001—the Thai Health Promotion Foundation. The Foundation is a health promotion funding mechanism that draws upon a 2% surcharge levied on alcohol and tobacco excise tax, approximately USD 50-60 million a year to promote healthy living at school, in workplace and within the community.¹⁹

The UCS also attempts to reach specific population group targets. For the elderly, the UCS and healthcare delivery appears to provide relatively equitable access to health care, but issues of inadequate hospital access for rural residents due to geographical barriers still persist.²⁰ Access to inpatient care was inequitable, most likely due to problems of physical access and travel costs for these rural residents. The UCS not only includes Thai citizens, but also covers registered foreign workers via a health insurance program.²¹ The results show that the UCS also plays a major role in improving the use of health care for ethnic groups, especially for Thai ethnic minorities. However, a gap still existed in health service use in 2004 among ethnic minorities, migrants and Thais. Better coverage of minorities and foreign workers is still needed.

Lessons learnt and ways forward

The Thai UCS relies on a solid primary healthcare foundation.^{22, 23} The necessary infrastructure was largely set in place during the 2-3 decades preceding its implementation, but it is important that these infrastructures are constantly monitored. Lessons learned from other countries include the need for a nationally agreed package of prioritised and phased primary health care that all stakeholders are committed to implementing, management systems at district level and consistent investment in primary healthcare resources.²⁴ Effective and efficient primary health care can be assisted by community and village health volunteers.²⁵ Nurses are also key providers of primary care services, particularly in remote areas and play an important role in improving the health and well-being of the Thai community.²⁶ Primary healthcare resources have also improved in parallel to the UCS. For example, health centre workers now accept information technology freely with widespread use of computerised records and internet reporting and feedback systems.²⁷ These results are similar in all of the country’s geographic regions.

Conclusions

Internationally and in Thailand, many empirical studies of illness expenditure confirm that a UCS system of finance substantially reduces the financial burden of health care among the poor. Because the UCS mechanism focuses on health promotion and disease prevention through community health volunteers, and boosts use of primary healthcare facilities such as health centres and community hospitals, strengthening of these human resources and health facilities is vital to sustainable development of the UCS. As use of health services is determined by their availability in an area, the geographic distribution of health resources among rural areas and among regions will be a vital part of the overall and long term plan to address inequalities in the health system.