Thailand: At the forefront of Universal Health Coverage

By Piyasakol Sakolsatayadorn, Minister of Public Health, Royal Thai Government

Thailand has proved to the world that Universal Health Coverage (UHC) is achievable. Even with a GNI per capita of US$ 1,900 in 2002, the entire population was fully covered by publicly-financed health insurance schemes.

In Thailand, three dimensions of UHC have been achieved: coverage for 99.9% of the population, comprehensive coverage represented by a health package which includes curative services, health promotion, disease prevention and rehabilitation, and full protection of households from financial health risk. Moreover, empirical evidence has demonstrated that the outcomes are particularly favourable in terms of improved utilization of health services and substantive benefits in favour of poor and rural populations. An analysis of benefit incidence was conducted, to measure whether the poor or the rich benefit from public subsidies, which revealed that UHC was decidedly pro-poor.

Two important factors contributed to these outcomes. The first factor was the extensive geographical coverage of a functioning primary health care system which was the result of three decades-long investment by successive governments in infrastructure and the health workforce. This has continued to facilitate equitable access to health services. The second factor was the design of schemes to ensure a comprehensive benefits package and literally no copayment which resulted in reduced household spending on health, minimizing the prevalence of ‘catastrophic’ or ruinous health expenditure and preventing non-poor households from impoverishment.

The tax-financed universal health coverage scheme for 75% of the Thai population which included a generous benefits package, was financially feasible as a closed-end budget with the application of a mix of provider payments (in particular, capitation) and additionally, the use of the Diagnostic Related Group (DRG) which had a global budget and fixed fees for specific high-cost interventions. The closed-end payment methods of capitation and DRG with a global budget were effective in cost containment, while patient satisfaction was 82%-95% during 2003–2013, with provider satisfaction increasing from 46% in 2003 to 68% in 2013. It should be noted that most of the contracted providers were and continue to be non-profit public health facilities with the Ministry of Public Health playing a dominant role in service provision in Thailand. The committed health workforce in the public sector also contributed, therefore, to the favourable outcomes.

Given health status achievements, in particular, life expectancy at birth of 74 years, child mortality 12.3 per 1000 live births and total health spending at 4.6% of GDP, health systems in Thailand are efficient and classified as one of the best performing in middle-income countries. The favourable outcomes of Universal Health Coverage therefore, continues to foster the financial commitment of successive governments to the scheme, in particular, in so far as it critically addresses poverty as related to medical bills, in support of our commitment to reach the targets of Sustainable Development Goal 1.

Thailand has also built up and sustained institutional capacities able to assess the cost effectiveness of new medical interventions and medicines before they are adopted into the UHC benefits package or the National List of Essential Medicines — the List is the reference for medicines included in the benefits package of the three public health insurance schemes. In this regard, the Ministry of Public Health continues to support the role of health technology assessments in contributing to evidence-based priority setting.

Challenges remain with the high level of adult mortality, 207 among males and 105 among females, mostly due to traffic-related injuries and others, as well as with the impacts of rapid epidemiological and demographic transition. Furthermore, health systems need an appropriate transformation to be fit for the future through the creation of effective inter-sectoral actions for health.

During the last decade, Thailand has become a site for learning by countries in and outside the region on various topics and issues having to do with the implementation of UHC, such as strategic purchasing, medical auditing and monitoring systems of a UHC scheme, the functioning of primary health care and healthcare accreditation. Thailand has created learning modules on UHC implementation, designed to be suitable to policy making, as well as applications at the practitioner and operational levels. Hands on experiences with UHC and related issues are transferred to participants through learning sites hosted by several institutes within and outside the MOPH. The learning and sharing program is managed by the CapUHC and a recent Japan-Thailand collaboration effort focusing on strengthening sustainable capacities on UHC. The ASEAN Plus Three on UHC Network has been initiated and endorsed by the ASEAN Health Ministers Meeting in July 2012 and collectively established by members of ASEAN Plus Three (including Japan, South Korea and China) in 2014.

UHC has gone far beyond political advocacy, as it has been fully committed to by UN Member States in SDG 3.8. Now is an opportune time to translate these political commitments into reality. Evidence shows that lack of adequate access to functioning primary health care by citizens are main barriers in achieving the MDGs among off-track countries. South-South collaboration in support of strengthening institutional capacities on UHC design and implementation are critical to achieving favourable outcomes.

Thailand at a glance, 2016

Health status

Child mortality: 12.3 per 1000 live births

Infant mortality: 10.5 per 1000 live births,

Adult mortality: 207 (male), 105 (female),

Life expectancy: 74 years,

Skilled birth attendance: 99.6% of total births

Contraceptive Prevalence Rate: 79.3%

Health Financing Systems

Fiscal space: tax 16% GDP, revenue excluding grant 20% GDP

Universal coverage achieved since 2002

Total health expenditure: US$ 360 per capita, 4.6% GDP,

Public health expenditure: 86% of total health expenditure

Household out of pocket payment: 8% of Total Health Expenditure

Between 2001 and 2009, UHC protected 291,780 households (cumulative numbers) from medical impoverishment.

Author’s biography

H.E. Clin. Prof. Emeritus Piyasakol Sakolsatayadorn earned his MD from the Faculty of Medicine, Siriraj Hospital in 1971, and also earned a postgraduate diploma in general surgery from the Medical Council of Thailand four years later. He pursued two post-doctoral fellowships in the United States, one in critical care medicine at Johns Hopkins University in 1985, and another in injury and epidemiology at the US Centers for Disease Control and Prevention in 1988.

He has extensive experience in the field of medicine and public health. He served as Dean of the Faculty of Medicine Siriraj Hospital, Vice-President and Committee Member of the Board of Trustees of the Prince Mahidol Award Foundation, and President of the Board of the Cancer Foundation of Siriraj Hospital, Member of the Board of Directors of the Government Pharmaceutical Organization, Chairman of the Auditor Committee of the Government Pharmaceutical Organization, Committee Member of the Council of State under the Office of the Council of State and Honorary Advisor to both the Senate Standing Committee on Public Health and the Second Vice-President of the Senate. He was elected as the President of Mahidol University of Thailand during 2007- 2011. He has served as the Second Vice-President of the Administration Board of Siriraj Foundation since 2005.

H.E. Clin. Prof. Emeritus Piyasakol Sakolsatayadorn has been appointed as the Minister of Public Health of the Kingdom of Thailand since August 2015.