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- Draft Background Paper 10 -

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social dsocial dsocial dsocial determinanteterminanteterminanteterminants of hs of hs of hs of healthealthealthealth

Thailand

Jadej Thammatach-aree

Director of Bureau of Policy and Planning,

National Health Security Office (NHSO); Thailand


2

Disclaimer

WCSDH/BCKGRT/10/2011

This draft background paper is one of several in a series commissioned by the World Health Organization for the

World Conference on Social Determinants of Health, held 19-21 October 2011, in Rio de Janeiro, Brazil. The goal of

these papers is to highlight country experiences on implementing action on social determinants of health. Copyright

on these papers remains with the authors and/or the Regional Office of the World Health Organization from which

they have been sourced. All rights reserved. The findings, interpretations and conclusions expressed in this paper are

entirely those of the author(s) and should not be attributed in any manner whatsoever to the World Health

Organization.

All papers are available at the symposium website at www.who.int/sdhconference. Correspondence for the authors can

be sent by email to [email protected].

The designations employed and the presentation of the material in this publication do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,

city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps

represent approximate border lines for which there may not yet be full agreement. The mention of specific companies

or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health

Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the

names of proprietary products are distinguished by initial capital letters. The published material is being distributed

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material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its

use.


1

Introduction

The development of society can be reflected in the quality of its population’s health, how reasonably

health is distributed across social level, and the effectiveness of health care risk protection provided

from public policy (World Health Organization. 2008). These determinants have effects on health in

complex ways. Social determinant of health associated with the socioeconomic and political context

such as governance, social and public policies. It influences social living and behavior of people

(Dedmon 2010). Health inequalities arise from unequal distribution of such determinants, which create

or limit the ability of the poor to seek for health care and healthy behaviour.

In order to reduce health inequity, taking action on well-planned disease control and treating existing

diseases might not be only ways to improve health equity. Social and economic concerns are also crucial

determinants (Marmot 2005). In Sweden, for example, incorporated social, economic and health issues

into public health objectives to ensure good health on equity for its entire population. Of which, these

factors determine the consequences of social structures toward personnel health-related behaviours.

The objectives are set in eleven domains which are; (1) Participation and influence in society (2)

Economic and social security (3) Secure and favourable conditions during childhood and adolescence

(4) Healthier working life (5) Healthy and safe environments and products (6) More health-promoting

services (7) Effective protection against communicable diseases (8) Safe sexuality and good

reproductive health (9) Increased physical activity (10) Good eating habits and safe foods (11) Reduced

use of tobacco and alcohol, in order to build a society free from illicit drugs and doping and a reduction

in the harmful effects of excessive gambling (Hogstedt, Lundgren et al. 2004).

Equality in health is mainly determined by the increasing access to care and the decreasing catastrophic

expenditure in population (Kutzin 1998). Conceptual framework for actions of social determinant of

health proposed by Solar and Irwin (2007) indicated that there were two main factors affecting inequity.

They are structural and intermediary determinants. Structure determinant incorporated context,

structural mechanism and individual resultant socioeconomic position while intermediary determinants

embodied material circumstances, psychosocial circumstances, behavioural and/or biological factors,

and health system (Solar and Irwin 2007). Examples of health system affecting determinant of health

are human resource, health care financing, and health service delivery. Evidence showed that health


2

system movement is the key role of improving equitable access to care and protect impoverishment of

people from health expenditure (Marmot 2007).

Thailand is an example of improving social determinant of health by implementing universal health

coverage (UHC). It took a big bang change to universal health coverage (UHC) by extending coverage to

nearly 30 percent of overall population who were previously uninsured (Towse, Mills et al. 2004). The

important action was the financial reform that moved funding from supply side allocation to demand

side by using budget per capitation for responsible catchment area resulting in shifting fund from urban

hospitals to the building up of primary care units. The goal of the reform was to balancing health

opportunities across the different socioeconomic groups and to narrowing the gap between the rich and

the poor. The processes of this movement could be ideas for other countries for the moving of policy, not

only for achievement of the UHC but can be applied to other policy issues. The aim of this report is to

determine the process of health system to support the social determinant of health relating to universal

health coverage implementation.

Developing of universal Developing of universal Developing of universal Developing of universal health coverage in Thailand health coverage in Thailand health coverage in Thailand health coverage in Thailand

The development of Thai universal health coverage could be traced back to 1974 when it established

workmen compensation fund to cover private employees who were injured from working. The coverage

for employees who have illness not related to work came later in 1990 denoted as social security

scheme (SSS). At the beginning, it covered only companies with more than 20 employees and expanded

to cover more than 10 employees in 1994. Then the benefit covers every company with more than one

employee in 2002. Another public health insurance scheme, the Civil Servant Medical Benefit Scheme

(CSMBS) was set up in 1978 covering all government employees and dependants which are spouses,

parents, and not more than two children under 18. At the same time, government set up the low income

card scheme (LICS) for poor people in 1975 and expanded to community base health insurance scheme

(CBHI) based on maternal and child health in 1983. This led to change from community base financing

to voluntary health insurance by moving the management of funds from village level to involvement in

sub-district level by introducing health card scheme (HCS) in 1991. The newest scheme; the Universal

coverage scheme (UCS), was set up in 2001 by combining all the rest of population who were LICS, HCS,

fee exemption groups, and uninsured people. Consequently, after 2001, Thailand health care coverage


3

is mainly three schemes including SSS, CSMBS, and UC scheme. The details of universal health

coverage in Thailand are shown below.

Before 1974

Fee Exemption

1974 WCF

1975 LICS

1980 CSMBS

1981

Type B fee exemption

1983 CBHI

1990 SSS

1991 HCS

Traffic Accident Protection Program (TAP) 1993

Poor people

Near poor

Uninsured

2002 UCS implemented nationwide

Year Private employee Government

employee Population covered by Universal Coverage Scheme (UCS)

Adapted from: NHSO 2010

The historical milestone is described against the economic capacity of the country measured in term of

Gross National Income per capita between 1970 and 2009. The development of health insurance

coverage relates to GNI per capita, for example in 1975 Thailand introduced LIC when the GNI per

capita was $390 USD. During the period of low income state, Thai health system moved by introducing

LIC, CSMBS which Thailand experiences showed that in the situation of low GNI per capita in 1975.

Community based health insurance scheme was introduced in 1983 when GNI was $760 USD. Finally,

UHC was implemented in the period of economic crisis when GNI per capita is about $1,900 USD.


4

390

710

760

1490

2,700

1,900

0

1,000

2,000

3,000

4,000

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

US $

1997: Asian

financial crisis

1990 SHI

introduced

1980 CSMBS

introduced

1983 CBHI

introduced

1975 Low Income

scheme introduced

2002 Universal

Coverage for entire

population achieved

2001: 29% of

population are

uninsured

From: Tangchareonsathien 2010

Health expenditure has increased steadily since UHC were implemented. The ratio of private financing

source reduced from approximately 45% in 2000 to 25% in 2008. The proportion was nearly the same

as OECD countries which were 73.6% of health financing across EU countries in 2008 (OECD 2010). The

percentage reduction of private financing implied the decline risk of household expenditure in health

care.


5

From: Prakongsai et al. (2009)

The diagram below showed how health system in terms of financial reform played an important role in

improving equitable access of health service and health outcomes of the population. Household and

individual pay tax or contribution to government in order to pooling financial risk depends on their

working status. Private employees in formal sectors pay contribution to SSS while government officers

and the rest of population pay tax. Government allocated the collective fund to different schemes by

using different mechanisms which were tripartite contribution for SSS and general tax for CSMBS and

UC scheme. Different insurance schemes contracted provider in different payment system with some

different benefit packages, for example, UC scheme covers prevention and promotion of services for all

people in the country while SSS and CSMBS cover only curative and some rehabilitation services. UC

scheme also had matching fund with local government to provide preventive care especially in

behavioral modification activities.

56%45% 47% 47% 54% 55% 55% 56%

63% 63% 64% 64%

75%

73% 68%

55%53%

53% 46%45%

45% 44% 44%

36%36%

37%37%

25%

27% 32%

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Year

Millio

n B

ah

t

Public f inancing sources Private f inancing sources


6

HA = Hospital AccrditationContribution

enterprise

Government

Insured/Uninsured

population

Benefit

package

Direct &

indirect tax

ContributionService

SSS CSMBS UC scheme

Equity and Access

Financial resources

Performance

Activity

health and well-

being

Local government

General Tax

General Tax

Capitation

OP&IP Capitation for OP

DRG with global budget for IP

Public and private contract

FFS for OP

DRG for IP

Matching fund for Prevention&Promotion

Payroll tax

Contribution

Initiative of UC scheme in equity using matching fund with local governmentInitiative of UC scheme in equity using matching fund with local governmentInitiative of UC scheme in equity using matching fund with local governmentInitiative of UC scheme in equity using matching fund with local government

Financial arrangement of the implementation of UC scheme is mainly four approaches. Of which, are

shifting the main source of health care financing from out of pocket payment to general tax, removing

financial barriers to health service by limit co-payment at 30Baht or one dollar (exchange rate of 30

Baht= 1 dollar) per episode of service (abolish copayment in 2006), changing provider payment from

historical allocations to closed ended payments, and promoting the use of primary care by contract PCU

as the main contractor. UC scheme is designed to offer comprehensive benefit package covering from

prevention& promotion, curative, and rehabilitation. The prevention& promotion can be divided into

three main activities including National Priority Program, P&P for expressed demand, and P&P for area

base problem. The P&P area base aims to promote people participation process and efficient use of

resource by people in the sub district level to manage the prevention and promotion problem in the area

(National Health Security Office 2011).


7

According to the National Health Security Act 2002, it announced that in order to provide good health for

all, the National Health Security Office (NHSO) has mandate to promote the collaboration in local levels

to ensure health access for people in community. Under the provision of the act, from 2006 NHSO

provides fund to the sub-district administrators. The sub-district or “Tambon” administrators who have

interested in the fund will enroll and be financed by per capita payment (40 Baht or $1.3 USD in 2010).

Each sub-district authority needs to pay contribution to the fund according to the size of the authority,

20%, 30% and 50% for small, middle and large size respectively. Private financing can be included if

available.

The most important rule for using the fund is there is essential to set up a collaboration group consisting

of local administrators, their residents and delegations from local health authorities. Fund is managed

by the committee and can be paid for only four purposes; managing the fund effectively, providing

services according to the benefit packages, supporting health facilities in the area, and solving the

health problems in community. In 2010, there are 5,504 local authorities or 70% of overall Tambon

included in the project (Samnuanklang, Srithamrongswat et al. 2011). The fund helps fostering

preventive activities such as chronic diseases screening, epidemic control, intensive health care for

elderly and disabled, also sanitation such as eradicating the mosquito larvae and rubbish recycle, all of

which, roots from the locals’ ideas.

Empowerment is the key success of this project, not only one but all three local clusters; the local

administrators, the health officers and the locals. Achievement is proved thru the information gained,

working in team, transparency and building up the same goals. Although, the achievement of the

program in terms of health outcome could not be concluded, some evidence showed progression of

some issues. For example from health examination survey, no access to screening for hypertension

declined from 71% in 2003 to 55% in 2008 (Srithamrongswat 2010).

Different characteristic of three public health insurance schemesDifferent characteristic of three public health insurance schemesDifferent characteristic of three public health insurance schemesDifferent characteristic of three public health insurance schemes

Since Thailand has three main public health insurance schemes after UC implementation covering

99.47% of its entire population (National Health Security Office 2010), the different characteristic of

these schemes led to health inequity of beneficiary between schemes.


8

The CSMBS and UCS are financed by general tax whereas the SSS is financed by payroll tax with

tripartite contribution, shared by employer, employee and the government with 1.5% of salary.

Population coverage under CSMBS was about 5 millions (8% of population) and SSS was about 10

millions (16% of population) while UC scheme covered about 47 millions (75% of population). For

service delivery, CSMBS beneficiaries can receive services at any public hospitals with the retrospective

FFS payment on outpatient service and DRG on inpatient service. For SSS, they must receive services at

the registered contractors’ hospital with more than 100 beds, which can be either private or public

hospitals and are mostly located in Bangkok and urban areas. The payment method for the SSS is

inclusive capitation for both outpatient and inpatient, with the adjusted compensation according to

volume of use and risks. The UC scheme members require to receive services at the registered

contracting units for primary care which almost all of them are public facilities. If the registered facilities

cannot provide proper treatment, the patient will be referred to the higher level of health facility. The

different characteristics of the three public health insurance schemes are shown in the table below.


9

CSMBS SSS UC scheme

Scheme nature Fringe benefit Mandatory Citizen entitlement

Population Government employees, pensioners and their dependants (parents, spouse, children under 18)

5 Million (8%)

Formal-sector private employees, establishments/ firms of more than one worker since 2002

9.84 Million (15.8%)

The rest of population who are not covered by SSS and CSMBS

47 Million (75%)

Source of finance

General tax

(~323 US$/Cap*)

Tripartite from employer, employee, government rate 1.5% of salary

(maximum salary: 441 US$)

(health care 37 US$ /Cap, total 63 US$/Cap)

General tax

(62 US$/Cap)

Management organization

Comptroller general under ministry of finance

Social security office under ministry of labor and welfare

National Health Security Office (NHSO)

Benefit package No preventive care

No explicit exclusion

Special bed

Small number of limited condition e.g. Non medical plastic surgery

Small number of limited condition

Include Prevention & promotion

Service delivery Public provider only, Private in emergency, selected disease (2011

Public and private hospital more than 100 beds (50% private

Public and private contracting unit for primary care(CUP)

Payment OP: Fee-for-service

IP: DRGs

Capitation both OP and IP OP: Capitation

IP: DRGs with global budget


10

Adapted from: (Mills, Tangchareonsathien et al. 2005)

The characteristic of beneficiary under each scheme is different. The UCS mainly covers poor people.

Nearly 50% of population in the scheme are categorize into poorest quintile one and two while SSS

covers poorest quintile only 7% nearly the same as CSMBS which is 6%.

From: Limwatananon et al.(2009)

The difference of payment methods leads to the inequity of services given among the three schemes.

There has been evidence supporting the belief that services provided to beneficiaries under the three

schemes are different. For example, from the data of health and welfare survey 2005, SSS increased

the probability of ambulatory care visits by 41% compared to UC scheme membership, while there was

no significant difference between UC scheme and CSMBS groups (Thammatacharee 2009). In terms of

quality, evidence from claims data showed that readmission in chronic complication of DM patient in UC

scheme had 23% higher chance of readmission compared to SSS and CSMBS.

Greater access to selective care by the CSMBS patients is also obvious for two selected health

interventions based on the national IP data from all types of hospitals during 2004-2007. Both

Cesarean section and laparoscopic cholecystectomy were much more common in CSMBS than in UC

and SSS. These gaps are consistent over the 4-year period. One explanation of this result was that there

24%

1%9%

26%

1% 3%

24%

4%

6%

24%

7% 6%

18%

34% 21%

16%

38%

23%

11%

48%55%

12%

35%

57%

0%

20%

40%

60%

80%

100%

UC SS CS UC SS CS

2003 2007

20% poorest Quintile 2 Quintile 3 Quintile 4 20% richest


11

was incentive for physicians to provide services more frequent than the other schemes because of the

fee-for-service payment system (Limwattananon, Limwattananon et al. 2010).

49% 48%51%

47% 47%

52%50%

51%53%

55% 55% 55% 56%54%

51%

24%22% 23% 23%

25% 24%22%

18%

30%

26% 26%28%

27% 27%26%

23%21%

22%20%

24%22%

24% 24% 24%26%

28%27%

29%28% 28%

0%

10%

20%

30%

40%

50%

60%

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

2004 2005 2006 2007

CS

SS

UC

45%47% 48%

50%52%

50% 51%53% 54% 55% 56%

54%56% 58% 59%

17% 17% 16% 17%18%

20% 20%22% 21% 20% 19% 20%

16% 16% 17% 17% 18% 18% 19% 20% 20% 20% 20% 20% 20% 21% 21%

0%

10%

20%

30%

40%

50%

60%

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

Qtr

4

Qtr

1

Qtr

2

Qtr

3

2004 2005 2006 2007

CS

SS

UC

Cesarean section Laparoscopic cholecystectomy

From: Limwatananon et al. (2009)

This pattern is also consistent in the prescription of expensive drug. Propensity to receive expensive

drugs is shown by monthly time-series over five years in the graphs below. CSMBS patients utilized very

much more expensive drugs than patients in SSS and UC scheme. For example, Angiotensin receptor

blockers were prescribed to CSMBS patient more than 20% while SSS and UC scheme were less than

10% during four year period from 2003 to 2007. This prescription pattern was the same as other

expensive drugs such as Statins, Coxibs and the anti-platelet drug, Clopidogrel.


12

Angiotensin II receptor blockers

0

5

10

15

20

25

30

35

40

45

50

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

2003 2004 2005 2006 2007

CS

SS

UC

Single source statins and new antihyperlipidemia

0

5

10

15

20

25

30

35

40

45

50

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

2003 2004 2005 2006 2007

CS

SS

UC

Clopidogrel

0

5

10

15

20

25

30

35

40

45

50

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

2003 2004 2005 2006 2007

CS

SS

UC

Coxibs

0

5

10

15

20

25

30

35

40

45

50

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

Ja

n

Ap

r

Ju

l

Oc

t

2003 2004 2005 2006 2007

CS

SS

UC

From: Limwatananon et al. (2009)

In general, CSMBS consumes more resources than other two schemes. With its fee-for- service

reimbursement model, the total expenditure of CSMBS was dramatically increased every year especially

after 2001. The main incretion was outpatient service while inpatient service seemed to be stable after

implementation of prospective payment by using DRG payment in 2006.


13

From: Comptroller General Department, Ministry of Finance

These findings have allowed the inequity issue among the schemes become more intense. The major

critics are; who pay more and who pay less, or what kind of benefits should be added for scheme which

paid more. The rationale behind SSS is that beneficiaries contributed for health service each month

from salary and they also pay general tax while UC scheme pay only tax without contribution but SSS

seems to get the same service or less in some situations. CSMBS members believe that they accepted

low salary compared to private since they needed to have more privilege of health service when they

retired. UC scheme by law had a section to allow merging fund from CSMBS, SSS and TAP but they did

not enough knowledge how to move in the way as mention in the act although some propose that this

should be a basic benefit package that everyone in the country could receive while each scheme can

add some privilege benefit to their beneficiaries such as special room. This issue might still the debate

in Thai society for a long time.

How healHow healHow healHow health inequity issues moved in th inequity issues moved in th inequity issues moved in th inequity issues moved in Thailand?Thailand?Thailand?Thailand?

The inequity in Thailand has begun to be a policy issue since 1975. The government introduced the low

income card in order to help the poor patients obtained health care from public facilities without charge.

The initial idea was not complicated since it covered only the poor who had income per year lower than

-2%

23%

12%13%

20%

12%

6%

10%

-2%

15%

12%

16%

20%46,588

61,304

37,004

54,904

46,481

17,058

26,043

20,476

16,44013,587

9,954

3,1566,000

4,316

62,196

13,905

21,896

30,833

38,803

9,5097,007

1,729 2,3373,374

5,8664,826

45,531

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Annual grow th (real term) Total expenditure (million Baht) Outpatient (million Baht) Inpatient


14

1,000 Baht ($30 USD approximately in 2010 rate) (Suksiriserekul 1998). Normally, the National

Economic and Social Development Plan have been implemented through the government policies. When

it came to the era of the fifth five-year National Economic and Social Development Plan (1982-1986),

the inequity problems were apparently emphasized in the plan that it aimed to solve impoverishment of

the people in the specified areas. Consequently, public facilities have been widespread to the rural, for

example, community hospitals covered in most districts (Termpitayapaisit and Paem 2009). Health

welfare scheme was reconsidered to separate the card holders into 3 types; elderly, children and the

poor (Suksiriserekul 1998).

In the sixth five-year National Economic and Social Development Plan (1987-1991), the plan stated to

increase the country development capacity, the economic grew prosperously reflected in the GDP growth

around 10.9% per year. Nonetheless the political and social movements to improve inequity, income

disparity has become wider (Termpitayapaisit and Paem 2009). Gini coefficient1 for income distribution

has increased more rapidly from 0.45 in 1975 to 0.49 in 1988 and to 0.54 in 1992 (Sakunphanit and

Suwanrada 2011). Many of the poor dared not to use the low income cards due to doubt in the quality of

care given for free. Insufficient and inappropriate budget distribution of low income card also presented

(Suksiriserekul 1998).

Social problems and inequity became more explicit after the global economic crisis in late 1997; in

addition, the circumstance also brought the Thai health care reform to light. An independent institute,

Health System Research Institute Research (HSRI) with an assistant team from Asian Development

Bank (ADB) provided evidence-based recommendation that Thai health system needed to be reformed

in order to achieve equity, efficiency and quality (Pannarunothai and Srithamrongsawat 2000). The

reform plan originally was to combine the three public health insurance schemes into one universal

coverage scheme. However this idea met resistance from civil servants in other government sectors who

benefited from running the other two schemes(Towse, Mills et al. 2004).

1 Gini coefficient is a measurement of inequality of distribution. The value is between 0 and 1, 0 means total

equality which 1 means total inequality.


15

Apart from the financial issue, distribution of health workforce was also problematic. The ratio of

population per doctor was different across regions in Thailand. Northeastern area has the highest

population per doctor proportion in the country which emphasis the disparity gap when comparing with

that in Bangkok area. However, the situation tends to improve so far. There were a few policies to ease

the problem such as the increasing production of doctors and the new university admission system that

promote the rookies to work in rural areas. As a result, the ratio of population per doctor in the

Northeastern region increased from 7,614 in 2001 to 2,870 in 2009.

Region 2001 2002 2003 2004 2005 2006 2007 2008 2009

Bangkok 760 952 924 879 867 886 850 955 565

Central 3,375 3,566 3,301 3,134 3,054 2,963 2,683 2,839 1,864

Northern 4,488 4,499 4,766 4,534 3,768 3,351 3,279 3,386 2,002

Southern 5,127 4,984 4,609 3,982 4,306 3,789 3,354 3,694 2,250

Northeastern 7,614 7,251 7,409 7,466 7,015 5,738 5,308 5,028 2,870

From: (Wibulpolprasert 2010)

Universal Coverage Move in Thailand Universal Coverage Move in Thailand Universal Coverage Move in Thailand Universal Coverage Move in Thailand

To move important policy such as universal coverage in Thailand, there is an approach proposed by Prof.

Prawase Wasi called “Triangle that moves the mountain”. Mountain is a symbol representing tough

problem. Triangle stands for a system consisting three mountain movers, working together, such movers

are; 1) research-based knowledge, 2) social movement or social learning and 3) regulations form

political movement (Wasi 2000). Thailand has long been invested in research and capacity building

before proposing policy option in moving to universal health coverage. For example, cumulative

experience provider payment both fee for service in CSMBS and capitation in SSS result in moving to

capitation payment in UC scheme(Tangcharoensathien, Prakongsai et al. 2007). Social movement from

NGOs to mobilize more than 50,000 people to support universal health coverage bill played an

important role for parliament to consider the bill. Political movement was a crucial part of universal

health coverage in Thailand. Leadership of politician with influenced campaign of “30 Baht cure all


16

disease” and bridging political movement with evidence helped universal health coverage moved

rapidly.

Dr. Sanguan Nitayarumphong, who was a very first campaigner of universal health coverage move in

Thailand gave details of universal coverage program move in his book “Struggling along the path to

universal health care for all” into three phases as shown in diagram below (Nitayarumpong 2006). The

main three steps comprised of policy move, implementation, and sustainability of the program. The

policy move was based on the concept of triangle that moves the mountain of Dr. Prawas Wasi as

mention above. From his experience, he proposed two important policies to various political parties

during election which were 1) generation of revenue into public health finance program by using sin tax

and 2) universal health care (UHC) coverage. Of which, the Thai Rak Thai party leader accepted the

second one to be policy of the party.

The other important issue was how to apply that policy of UHC. This implementation plan was crucial as

a policy movement. The UHC implementation composed of three reform issues which were new health

care financing, new budget allocation, and new health care delivery model. The proposal of new health

care financing was based on objective of reduce out of pocket payment system and equalize health care

financing by collective financing mechanism.

Tax finance was one of easily way to generate the adequate level of government revenue. Since 1978,

past experiences from the public insurance schemes have provided ideas for the new budget allocation

mechanism. For examples, CSMBS payment by fee-for-service proved that it encouraged the increasing

health care costs. SSS provided a successful story of using capitation both in outpatient and impatient

service to limit the costs. Low income card gave experience of using prospective case based payment by

diagnosis related groups (DRGs). Furthermore, a global budget in provincial level under a number of

beneficiaries provided information of closed end budget management(Towse, Mills et al. 2004).

Another important movement was the new idea of direct contracting to the primary care units (PCUs);

the fund could flow directly to the PCUs instead of general or regional hospitals. A PCU was a unit in the

network of primary care consisting of a district hospital and health centers in the catchment area. A new

concept of creating health by people was introduced to promote good health.


17

However, this movement is still in a long way to success since there is need to change attitude of both

beneficiaries and providers.

Adapted from: Wasi P. (2000), Nitayarumphong (2006)

As mentioned above, policy move and implementation is a tough and long process of movement not only

the UHC program but also other important policy issue. However, the harder movement is how to sustain

the program in the system in order to achieve the policy objectives. The crucial sustainability of a policy

move is to manage the triangle continuously. Further knowledge of how to improve health system and

popular support of the program must be maintained while the political decision making must not be

allowed to decline. In UHC movement, there are three challenges that support the program including

assuring quality of care, job satisfaction for healthcare provider, and effective management. Quality of

care of the UHC in Thailand is the most important measurement to assess the value of UHC. Lacking of

quality of care would turn people back to the old system and end up with collapse of the program. To

develop full confidence for the society on UHC, the quality of personnel and technical service should be

enhanced; timely diagnosis with effective treatment should be improved.


18

Concurrently, UHC could not survive without sustaining the worker confidence. The UHC has created

tremendous workload and misunderstanding about job security and technology advancement.

Therefore, maintaining satisfaction of healthcare personnel by using both financial and non financial

incentive is a prime concern of the government. The last burden of sustaining UHC is that social want to

receive high quality of care with proper tax burden. The system needs to be transparent, accountable,

and incorporate public participation. The addressed problems need to rapidly solve to maintain

atmosphere of ongoing improvement. The budget allocation needs to be more efficient. The system

needs to be more equitable and efficient.

Even though the UHC achievement in Thailand has progressed constantly, there are still problems of

some issues, for example, whether Thailand should follow the solidarity idea as the European countries

or based on ability to pay as leaded by the USA. The solution of any problems in health system cannot

solve easily without comprehensive knowledge, good planning of implementation, sustaining solutions

and continuous improvement of implementation.

Adapting this conceptual framework into the implementation, UHC in Thailand was planned as a rapid

move by dividing the implementation into four phases to coverage people all the country within two

years. The first phase was to cover beneficiaries in six provinces. After that, the scheme expanded to

fifteen provinces within six months. The third phase was to spread out to all provinces in the country

except Bangkok. Then the final phase was to implement in Bangkok.

Case study of political move in stateless people rights Case study of political move in stateless people rights Case study of political move in stateless people rights Case study of political move in stateless people rights

One example of implementing conceptual framework of political movement related to UHC move was

the return rights of stateless people in Thailand.

In Thailand, there are groups of people who are identified as undocumented person, refugees, minority,

migrant workers or a common term, stateless person. Such of these people share one problem in

general, they do not have Thai nation. Many of them, for example minorities or undocumented persons,

were Thai born and have long been stayed in the country waiting in the process for citizenship.

Possession of Thai nationality is not only for living with respect in social, but also a crucial access to

fundamental rights especially, the right to healthcare services. Before the era of UC, stateless persons

used to have ‘low income health card’ that they used to get care in public health facilities with none of


19

charges. Nonetheless, after launching UCS, the low income health card became invalid and these

people were excluded from UC eligibility. The reason was because stateless people do not have Thai

nationality and by interpreting the National Health Security Act 2002 that universal coverage was

reserved only for Thais. As a result, 457,409 people were withdrawn from the universal coverage (NHSO

2010). Consequences of the UHC implementation, stateless persons were denied access to free health

services in public facilities. The reason given was that government did not allocate any budgets for them.

In one case, a severe patient had to tell a lie to healthcare officer that she had enough money to pay for

treatment, actually she did not otherwise she would not get the adequate services. Another case of a

cancer patient, he passed away and left a huge debt to his family which they did not know how they

could pay back.

In addition to unable to obtain personnel health care, social problems followed. Contagious diseases

such as malaria, tuberculosis, severe diarrhea and sex transmitted diseases were concentrated among

the stateless people. Rare cases were found in new areas, especially the borderlines. Bad debts were

financial burden for hospitals of humanity without any support from the government. In 2008, for

stateless persons who got services from public health facilities, the health expenditure of 468 million

Baht or 117 million USD was reported (NHSO MOPH and HISRO 2009).

This problem had been in public awareness and there were attempts from various sectors to move ‘the

mountain’ forward. In 2005, the National Security Council offered the cabinet the strategic plans for

dealing with citizenship and the rights of stateless person. Nonetheless, the strategies were agreed

especially in education problem, but there was lack of practical procedures to pursue in health issue. At

that time, the National Health Security Board (NHSB) proposed the cabinet to approve the health

insurance for stateless person, twice in 2005 and 2006 but both were rejected for the concern of

national security. However, the movement has gone forward by launching a series of six studies to

identify the health problems of statelessness in Thailand in order to scope the problems conducted in

2008 by NGO researchers, probe the current situations and design the appropriate solutions for this

matter. At the same time, the NHSB proposed the cabinet for reconsidering the health insurance issue,

again it was rejected and the cabinet advised to seek for stakeholders’ views. Therefore, the National


20

Health Assembly held a forum consisting of a range of government agencies, for examples, from the

National Security Council, Ministry of Public Health, Ministry of Education, Ministry of Labour, Ministry of

Interior, Immigration Office and the National Health Security Office. The forum agreed in principle that it

was the responsibility of the government to establish good health for its residences. Therefore, giving

health security for stateless persons would be providing fundamental rights of human to support and

strengthen the system as a whole. In 2010, NHSB once again tendered the proposal to the cabinet. The

cabinet finally approved. Accordingly, the targeted stateless people, 600,000 approximately were then

entitled to the UCS with the rights to access healthcare equally to Thai under UCS. The cost of health

care was 2,067 Baht/Capitation since this group of people is mainly in the working age group with some

of children as shown below; therefore, overall Baht/capitation was lower than Baht/capitation of overall

people. In addition, a communicable diseases control fund was set up particularly for bordered hospitals

in order to support their control of disease activities. This success story could prove that success

movement of important policy issue from three pillars, knowledge, political movement, and civic

movement.

From: NHSO 2010


21

Evidence of health equity achievement in Thailand from Universal Coverage SchemeEvidence of health equity achievement in Thailand from Universal Coverage SchemeEvidence of health equity achievement in Thailand from Universal Coverage SchemeEvidence of health equity achievement in Thailand from Universal Coverage Scheme

The implementation of the UCS as the attempt to provide access to health for all and protect household

catastrophic has shown the positive effects in a number of studies. For examples of financial evidence,

there were percentage reductions of financial health indicators. Of out-of-pocket paid for health per

household income gradually declined as the most obvious in the lowest income deciles, from 6.4% in

1992 to 2.3% in 2006 (Prakongsai, Limwattananon et al. 2009). This result corresponded to another

study (Somkotra and Lagrada 2008) which found that the richer income quintiles were at more tendency

to pay from their own resources.

Kakwani index Share of healthcare finance Type of health

payments 2000 2002 2004 2006 2000 2002 2004 2006

Out of pocket

payments

-0.150 -0.076 -0.076 -0.045 33.7% 27.9% 26.4% 23.2%

Direct tax 0.391 0.416 0.442 0.362 18.0% 18.8% 20.8% 24.5%

Indirect tax -0.096 -0.069 -0.043 -0.083 33.4% 38.2% 37.1% 35.2%

Private insurance

premium

-0.362 -0.391 -0.323 NA 9.6% 9.2% 8.9% NA

SHI contribution 0.165 0.112 0.105 NA 5.3% 5.9% 6.8% NA

Private insurance

premium & SHI

contribution

NA NA NA -0.049 NA NA NA 17.1%

Overall Kakwani index -0.004 0.001 0.034 0.041 100.0% 100.0% 100.0% 100.0%

From: Limwattananon, Vongmongkol et al. (2011)

Catastrophic health spending which specified as a stage that out-of-pocket payment for health higher

than the threshold of 10% of total household consumption decreased steadily in all income quintiles


22

during the UC implementation with the power to reduce spending in the poor group the most (Somkotra

and Lagrada 2008; Prakongsai, Limwattananon et al. 2009). For healthcare induced impoverishment

indicator, usually, out-of-pocket cost borne by inpatient services was the main cause of impoverishment.

However, in the UC period this figure went down from 11.9% in 2000 to 2.6% in 2004 (Prakongsai,

Limwattananon et al. 2009). Data from Health and Welfare Survey in various year showed that the

incidence of catastrophic health expenditure reduced in both poorest quintiles and least poor quintiles

with more reduction on poorest quintiles as shown in the table below (Limwattananon, Vongmongkol et

al. 2011). Although there was still 2% of the population faced with catastrophic expenditure, this was

significantly lower in poorest quintiles which was 0.9%, compared to least poor quintiles which was

3.3%.

Income quintiles 2000 2002 2004 2006

Q1 (poorest) 4.0% 1.7% 1.6% 0.9%

Q5 (least poor) 5.6% 5.0% 4.3% 3.3%

All quintiles 5.4% 3.3% 2.8% 2.0%


Regarding the service coverage findings, after implementing the UC there was wider and greater

outpatient utilization, particularly the lower income quintiles at health centres and district hospitals as

demonstrated by negative concentration indices (CI) (Prakongsai, Limwattananon et al. 2009). The CI

ranges from -1 to +1. A CI of zero means an equal distribution of particular indicator throughout the

economic gradients. A negative CI indicates a concentration among who are poorer group while a

positive CI reflects concentration in richer group. Mother and child health also distributed quite well

though, the wealthy mothers appeared to have better access to antenatal and delivery care due to the

higher level of education (Limwattananon, Tangcharoensathien et al. 2010). In addition, child

malnourishments also concentrated on poorer group. The CI was between -0.065 in wasting to -0.219 in

under weight. Additionally, the high cost benefit packages which once were excluded from the UCS

caused either barriers to adequate treatment or bankrupt by health spending to poor patients


23

(Prakongsai, Palmer et al. 2009). Equity in service utilization in outpatient and inpatient were shown

below. The negative value meant that service pro poor while positive value meant pro rich. Data

analyzed from Health and Welfare Survey in various year showed that for ambulatory care in health

centres, district hospitals, and provincial hospitals were pro poor while university hospitals seem to pro

rich. This result can be implied that district health centres, district hospitals, and provincial hospitals

performed well in terms of pro poor utilization. This might be due to the geographical proximity to rural

population who are vastly poor. This pattern was consistent before and after UHC implementation meant

that pro poor utilization was maintained. However, the pro rich pattern of university and private hospital

might be explained that main customers of these hospitals are CSMBS and SSS patients who are better

off than UC scheme patients. This pattern was similar in hospitalization of inpatients.

2001 2003 2006 2007

Ambulatory care -0.167 -0.219 -0.148 -0.119

Health centre -0.303 -0.351 -0.285 -0.292

District hospital -0.291 -0.304 -0.258 -0.258

Provincial hospital -0.051 -0.085 -0.007

University hospital

-0.045a

0.295 0.437 0.364

Private hospital 0.419 0.395 0.482 0.525

Hospitalization -0.080 -0.138 -0.068 -0.090

District hospital -0.315 -0.288 -0.232 -0.284

Provincial hospital -0.123 -0.090 -0.129

University hospital

-0.070a

0.040 0.204 0.394

Private hospital 0.325 0.321 0.407 0.470



24

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