Universal health coverage (UHC) and health systems context

Since 2002, Thailand has achieved UHC of the entire population through three main public health insurance schemes. Public sector employees and dependants (7.1% of total population) are covered by the tax-financed Civil Servant Medical Benefit Scheme (CSMBS), private sector employees (17.2%) are covered by the payroll tax-financed Social Health Insurance (SHI) Scheme, and the remaining majority (75.7%) are covered by the tax-financed universal coverage scheme (UCS).1 2

For the non-Thai population, registered migrant workers are covered by the payroll tax-financed SHI scheme while voluntary premium contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers documented migrants and their dependants, though on a voluntary basis. Hence, a substantial proportion of migrant workers, notably the unregistered and their family members, are not covered by any financial risk protection systems; services are paid for out-of-pocket.3

By the 1990s, the three decades of MOPH investment in health system infrastructures had achieved full geographical coverage of subdistrict health centres in all subdistricts (with a catchment population of 3–5000). Since 2009, these health centres have been reorganised into Tambon health promotion hospitals, which still serve as primary healthcare facilities without inpatient services.4 As of 2021, there are 9774 Tambon health promotion hospitals, 41 health centres and 775 district hospitals nationwide5; district hospitals cover a catchment population of 50 000 each. Citizens have better access to quality services provided by the district health system due to their proximity.

In parallel, capacity building of the health workforce by MOPH, notably physicians and nurses, resulted in increased health workforce density−40.7 doctors, nurses and midwives per 10 000 population as of 2021.1 The health workforce ensures health delivery systems function, which is the foundation for successful UHC implementation since its launch in 2002.6

Outcomes of UHC are favourable. The comprehensive benefit package2 and free-at-point of services result in low and continually decreasing incidence of catastrophic health spending defined by household out-of-pocket payment for health accounting for more than 10% of household expenditure or income.7 It was 6.7% in 1994 and reduced to 2.2% in 2017.8 The incidence of impoverishment, additional people below poverty line resulting from health payments, reduced from 1.4% in 1996 to 0.4% of the population in 2015 (using international poverty line of US$3.1 per capita per day).9 Extensive geographical coverage of district health systems facilitates adequate and equitable access6 with low levels of unmet needs.10

This practice paper analyses how Thailand has responded to the COVID-19 pandemic by applying the strengths of three UHC dimensions of population coverage that covers all non-Thai populations, notably migrant workers; a service package with a comprehensive set of COVID-19 related services and financial risk protection in the form of no copayment from users. We argue that using three dimensions of UHC and having a comprehensive benefit package with no copayment for everyone is one of the key contributing factors to pandemic containment.

Migrant workers: the vulnerability context

Thailand’s economy has attracted millions of migrants from bordering countries, a large majority from Myanmar, Laos and Cambodia. Migrants seek a better standard of living or have fled their countries due to national instability and end up working in fishing, agriculture, hospitality, domestic work and manufacturing/factory industries. However, migration challenges such as high costs and bureaucratic processes cause a significant amount of migrants (1–2.5 million of the estimated 4–5 million in Thailand) to enter Thailand illegally.11 These populations already face increased occupational health risks due to the industries they work in,12 and trafficking and illegal statuses decrease their access to care. The fishing industry, for example, sees high rates of injuries and serious health risks including mental health issues, but due to trafficking, migrant workers are often untreated.13

In addition to occupational hazards, living conditions contribute to health risks as well; migrant worker communities are crowded, often with three to five people in one apartment room. Some communities house up to tens of thousands of workers with poor sanitation14 and ventilation,15 becoming epicentres for disease outbreaks.16 In conjunction with living and work conditions, the low vaccination rates give rise to outbreaks such as measles in factory workers17 and school children along borders.18 Similarly, pulmonary tuberculosis (TB) is highly prevalent in migrant worker populations, but barriers in accessing care prevent them from getting proper treatment; illegal status and fear of arrest,19 difficulty in transportation, financial restraints and lack of knowledge on where to seek treatment are all contributing factors20 and migrant workers often end up self-medicating (this behaviour is not limited to TB). Lack of access to healthcare make migrant workers a potential host of infection for further transmission to their own communities and to Thai populations as carriers of diseases that are prevalent in their home countries but eliminated in Thailand, such as lymphatic filariasis.21

While public healthcare services are officially and legally available to migrant workers, utilisation remains low. Registered and employed migrant workers are eligible for the mandatory Thai social security scheme (SHI), but it covers only a small proportion of migrant workers.3 The MOPH has implemented the migrant health insurance scheme covering all registered and unregistered migrants for two decades, which expanded to include dependants in 2005. This scheme is voluntary and prepaid per annum by the migrant worker. Despite that, in addition to previously mentioned challenges, language barriers, lack of identification documents,22 and discrimination and alienation from healthcare workers have been reported as hurdles in accessing care.23 Recognising this, the Thai government has been implementing ‘migrant-friendly’ service programmes, such as cultural mediation services through migrant health workers and migrant health volunteers2 since 2003, though their health literacy remains a problem and needs to be promoted for the betterment of migrant health.24

Labour trafficking and the resulting fear of arrest is one of the social origins for COVID-19 outbreaks in Thailand. This is precisely what happened with the second wave of COVID-19 in Thailand originating in December 2020. Undocumented migrants who were not captured by border quarantine systems caused outbreaks starting in their industries, including fresh seafood markets.25

Five waves of COVID-19 between 2020 and 2022

Thailand responded effectively to the first wave of COVID-19, which began in March 2020. The epidemic was triggered by clusters from events at the boxing stadium and night clubs in Bangkok, which later spread to 68 provinces,26 while people returning from religious trips in Malaysia and Indonesia also spread the virus to various southern provinces.27 28 After 25 May 2020, evidence reported no local transmissions; all subsequent cases were identified from international travellers in state quarantine systems.

The second wave was triggered by Thai workers working in entertainment complexes at a neighbouring country that illegally returned carrying the virus, causing it spread to several Northern provinces. In this wave, a large number of undocumented migrant workers spread the virus in factories and a large wholesales seafood market in Samut Sakhon province. The wave subsided in March 2021 through effective containment and trace-and-test implementations.25

The third wave was triggered by clusters at entertainment facilities, bars and night clubs in Bangkok and spread nationwide during the Thai New Year holidays in April 2021 as masses of people travelled to their provincial hometowns. This wave spread widely in communities, notably in crowded communities in Bangkok, factories and prisons, affecting mostly vulnerable populations.29 The delta variant (B.1.617.2) was identified in Bangkok in June 2021 and accounted for 25.7% of detected cases.30 The fourth wave was triggered by the delta variant, as it had 60% higher transmissibility than the alpha variant31; it resulted in an immense increase in the number of daily cases and deaths and almost overwhelmed the health systems. The fifth wave was caused by the omicron variant, starting in December 2021 with more cases but a lower mortality rate than the delta variant.

As of 14 March 2022, there were a cumulative 3.2 million COVID-19 cases, 23 781 deaths31 and 225 886 current active cases under treatment,32 which have greatly strained healthcare facilities, intensive care units and ventilators particularly in Bangkok.

The spread of COVID-19 is much more difficult to control in Bangkok, which is a complex metropolitan governed by the local government, ‘Bangkok Metropolitan Administration’.33 It has lower public health capacity to contain infections than other provinces, which are under the leadership of the provincial governor and provincial chief medical officer. Furthermore, Bangkok hosts more than 10 million people, with a population density of 6718 per square kilometre,34 and a high concentration of vulnerable populations—elderly, poor households in congested areas and migrant workers in cramped dormitories and construction sites. By 21 November 2021, Bangkok was the outbreak epicentre with 445 547 reported cases (22% of total 2.064 million national cases)35; Bangkok also had highest records of COVID-19 deaths at 6708 (33% of total national reported deaths).35

COVID-19 impact on vulnerable populations

Spread in prisons is caused by asymptomatic new prisoners despite the 14-day quarantine at reception sites and asymptomatic wardens causing infection during travel between prisons to the court of justice.36 On 19 May 2021, there were 12 676 out of total 311 639 prisoners nationwide that tested positive (4%). This figure is an underestimate compared to active case findings where 10 748 out of 24 000 prisoners tested positive (45%). Due to these prison outbreaks, in-person social visitations have been entirely suspended,37 potentially straining the mental health of prisoners. Furthermore, prisoners have a right to healthcare, and the Department of Corrections has long been working with MOPH and National Health Security Office (NHSO) to ensure access38; TB, for example, is highly prevalent among prisoners,39 and they are a target group for TB treatment. The spread also affects their access to care for non-COVID-19 related health services.40

Migrant workers are mostly affected by COVID-19 as they live in crowded dormitories with no social distancing and low coverage of face masks, poor ventilation15 and sanitation.14 These migrant workers do not have the choice to work from home30 and continue to work in factory assembly lines as well as fresh markets. Outbreaks in migrant worker populations have resulted in active case findings through mass testing followed by strict 14-day community quarantine, where the government and civil society organisations provide food, potable water and other necessities.29 30 As businesses struggle, similar to Thai workers, low-skilled migrants are often the first to get fired and have wages and work hours reduced.41 They have also reported being in debt and face psychological stress.30 Those caught by immigration patrols face prolonged detention in overcrowded facilities.29 There are no statistics on the proportion of infection among migrant workers specifically, but as of 25 October 2021, 336 639 cases or 18% of total 1.86 million cases were non-Thai. Among these, 38% were Burmese.

Policy response: universal access to comprehensive benefit package with high financial risk protection for everyone—real UHC in action

Lessons: UHC and pandemic containment

This paper offers several policy and practice lessons.

First, the pandemic tests how UHC policy can support pandemic response, in particular how the differences across three public health insurance schemes can be harmonised and how the vulnerable populations especially undocumented migrant workers are covered. Application of three dimensions of Thai UHC evidently demonstrates that universal access to COVID-19 related services with high financial risk protection for everyone contributes to effective containment of the pandemic.

Second, in the context of a public health emergency, the evidence reconfirms that no one is safe until everyone is safe; the major clusters among migrant workers in seafood markets during the second wave, construction workers and slum residents during the third wave reaffirm that effective pandemic control requires universal access to essential COVID-19 interventions by all. Vaccine provision to migrant workers in Samut Sakhon, the epicentre of the second outbreak, confirms the government statement ‘universal vaccination to all target groups who live in Thailand on a voluntary basis’.55 This is a major achievement and sets precedence for insurance coverage expansion to all migrants and dependants in the future.

Third, the same benefit package for all Thais and non-Thais across their respective insurance schemes, the same payment rates to public and private healthcare facilities and the adequate rates to recover the cost-of-service provision are key contributing factors for access to services by all. Monitoring from the public media shows no incidence of patient denials, except delays in admission in Bangkok at the peak of cases reaching the maximum threshold of bed capacity. The no-fault compensation of adverse events from COVID-19 vaccination calms the negative connotation against vaccines in social media platforms.

Fourth, the prerequisite to universal access to services is the extensive availability of qualified RT-PCR tests, steady supplies of laboratory reagents and timely reporting of results within 24 hours. The availability of essential services for clinical management and timely upscale of field hospitals and bed are equally important.

These policies are useful lessons for other low-income and middle-income countries on how UHC can be applied for effective pandemic control through ensuring equitable access to health services by everyone.