We searched the scientific literature systematically and within the framework of this Review's main objectives: how health systems development has contributed to the implementation of universal health coverage, what are the outcomes of universal health coverage, what were the processes of expansion of financial risk protection to different population groups until the whole population was covered. We searched Google Scholar for literature relating to health systems development, with a specific
ReviewHealth systems development in Thailand: a solid platform for successful implementation of universal health coverage
Section snippets
Thailand: context, health achievements, and challenges
Thailand has become internationally known for its success with universal health coverage (UHC) policy and health development.1 In this Review, we analyse the historical evolution of health systems development that culminated in the implementation of UHC in 2002, focusing on the primary health-care infrastructure, health workforce training and distribution, and the extension of financial risk protection to different target populations. We also analyse the achievements of UHC and factors
Mental disorders: depression, screening, treatment, and suicide prevention
In 2013, the total burden of disease in Thailand was estimated at 10·6 million years of disability-adjusted life-years (DALYs; 6·1 million DALYs for men and 4·5 million DALYs for women). Mental disorders were the largest cause of DALYs lost in men as they accounted for 34% of total DALYs lost and 23·7 DALYs lost per 1000 population. Mental disorders ranked as the second largest cause of DALYs lost in women, accounting for 21% of total DALYs lost and 12·7 DALYs lost per 1000 population. In men,
Health systems development: a historical perspective
Health development since King Rama VI (1910–25) has been focused on controlling infectious diseases such as smallpox and yaws, improving access to safe water and sanitation, and extending health services through outreach activities in remote areas, which were gradually transformed into static facilities. Successive governments have established universities to train health professionals and other workforce cadres.22
Health delivery systems development: building a solid foundation
Large-scale investment in health infrastructure at district and subdistrict levels began during the fourth National Economic and Social Development Plan in 1977.27 Full coverage of district hospitals was achieved by 199028 and was followed by a decade of health-centre development in 1992–2001. By the 2000s, all subdistricts had a health centre.
The district health system, consisting of health centres and a district hospital, is the backbone of health development. A health centre serves 3000–5000
Functioning of district health systems: the development of the health workforce
The achievement of full coverage of health services provided by the district health system was accompanied by health workforce development by the MOPH. Adequate numbers of competent and committed health workers are indispensable for a well functioning district health system, and the provision of good quality services gained the people's trust. Thailand's health workforce policies integrated recruitment, training, distribution, and rural retention.31, 32
In 1972, the MOPH introduced a 3 year
Extension of financial risk protection mechanisms
While ensuring the availability of a functioning service delivery system, parallel policies extended financial coverage to certain groups of the population, with the application of a targeted approach.39
2001: a political window of opportunity for UHC
Different targeting approaches gave rise to a variety of benefit package designs and purchasing methods, which resulted in inefficiency and inequity. Despite much effort, 30% of the population was still uninsured by 2001. In January, 2001, a Universal Health Coverage Scheme (UCS) featured in the political manifesto of the general election campaign. After victory, the Thai Rak Thai party led the government-piloted implementation of the UCS in six provinces in April, 2001, and the scheme was
Ensuring accountability and responsiveness of UHC
Previous decades of health system development had ensured that services were available to respond to the health-care demands that would arise from UHC and that design features ensured cost control. Important features of any UHC design also include processes for accountability across stakeholders and responsiveness to citizens, thereby ensuring the continued society-wide support and trust needed for UHC to survive in the long term.
Budgeting: the role of evidence, participation, and transparency
The per-capita budgeting applied by the NHSO for the UCS changed the budgeting system substantially. Initially, the budget for the UCS had been estimated on the basis of unit costs and utilisation rates of different services, and this principle is still applied. Cost and use rates are projected for the budget year. Unit cost includes labour, medicines, supplies, and depreciation of major equipment. The total budget request is the product of per-capita budget and the population covered by the
Primary health care in UHC
The strong public health, primary care, efficiency, and equity orientation of UHC was driven by an exceptionally strong cadre of public health experts who have been influential health technocrats. The MOPH's investment in postgraduate training in key health policy and systems areas, using WHO and other funding sources, yielded a high pay-off when the public health experts returned to Thailand and served in positions of influence.61 Continuing capacity development in health systems and policy
Improved level and distribution of health service utilisation
The UCS has reduced the probability of its members not receiving formal ambulatory care when sick by 3·2 percentage points.70 The scheme has also increased the probability of members using outpatient care at public service providers by 2·7 percentage points (5%) and of hospital admission to a public hospital by 1 percentage point (18%). These effects have been largest in the population of elderly people.
UHC has increased the likelihood of having annual check-ups, particularly for women, and has
Satisfaction and concerns with the UCS: monitoring for improvement
The satisfaction with the UCS has been surveyed annually since 2003 by an independent agency. The results of these surveys show a high level of satisfaction by members of the UCS (8·0 out of 10). Provider satisfaction was lower (at 6·2 out of 10) in 2003 but increased to 7·6 out of 10 in 2010 and has been sustained.87 The main patient concerns are long waiting time and service quality, whereas providers are worried about lack of financial and human resources to meet the patients' high
Challenges and solutions
Achieving UHC in Thailand has not been without difficulties. The first challenge was to manage the survival of the financing model for UCS throughout a turbulent political climate. Between 2001 and 2015, the UCS survived eight rival governments, six elections, two coup d'états, and 13 health ministers. Political analysts foresee continued protracted conflicts in the current political climate. Despite political turmoil, GDP growth fluctuation, and the 2009 economic crisis, the total budget for
Conclusions and lessons
Lessons learned from Thailand's UHC are summarised in panel 5. The progress and achievements of Thailand's UCS have been substantial. Increased fiscal space from favourable economic growth (even with some interruptions), when matched with political and financial commitments to health development, has ensured favourable resources for health infrastructure and health workforce development. The 5 year planning process ensured long-term policy continuity despite short-lived governments. Full
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References (114)
- et al.
The development of universal health insurance coverage in Thailand: challenges of population aging and informal economy
Soc Sci Med
(2015) - et al.
The commercial determinants of health
Lancet
(2016) - et al.
Family planning policies and programmes in eight low-income countries: A comparative policy analysis
Soc Sci Med
(1998) - et al.
The response of providers to capitation payment: a case-study from Thailand
Health Policy
(2000) - et al.
PD First Policy: Thailand's response to the challenge of meeting the needs of patients with end-stage renal disease
Semin Nephrol
(2017) - et al.
Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for end-stage-renal disease: evidence for coverage decisions in Thailand
Value Health
(2007) - et al.
Moving towards universal health coverage: lessons from 11 country studies
Lancet
(2016) - et al.
Essential medicines for universal health coverage
Lancet
(2017) - et al.
Thailand eliminates mother-to-child transmission of HIV and syphilis
Lancet
(2016) - et al.
Universal coverage with supply-side reform: The impact on medical expenditure risk and utilization in Thailand
J Public Econ
(2015)
Household catastrophic health expenditure: a multi-country analysis
Lancet
Universal health coverage at the macro level: synthetic control evidence from Thailand
Soc Sci Med
Speech by World Bank Group President Jim Yong Kim on Universal Health Coverage in Emerging Economies
Everybody business: strengthening health systems to improve health outcomes: WHO's framework for action
The Kingdom of Thailand health system review
World Development Indicators database
Worldwide Governance Indicators 2016
Thailand overview
The evolution of Thailand's health system after three crises, three adjustments, and three decades of growth
Thailand's health ambitions pay off
Bull World Health Organ
Infectious disease mortality rates, Thailand, 1958–2009
Emerg Infect Dis
Global tuberculosis report 2016. Annex 2. Country profiles for 30 high-burden countries
Alcohol marketing and youth drinking in Asia
Addiction
Economic burden from smoking-related diseases in Thailand
Tob Control
Success counteracting tobacco company interference in Thailand: an example of FCTC implementation for low- and middle-income countries
Int J Environ Res Public Health
Tobacco industry tactics for resisting public policy on health
Bull World Health Organ
Tailoring tobacco control efforts to the country: the example of Thailand
Global status report on road safety 2015
Disability-adjusted life year in Thailand 2013
Services for depression and suicide in Thailand
WHO South-East Asia J Public Health
Preventing suicide: a global imperative
Rxy welā: the health history
Why and how did Thailand achieve good health at low cost? Chapter 7
Thailand health profile 2001–2004
The anatomy of Thailand's successful family planning program
ICMH News
Evolution of primary health care in Thailand: what policies worked?
Health Policy Plan
Universal health coverage: case studies from Thailand
Thailand: private health care out of control?
Health Policy Plan
The 2015 survey on health and welfare
Thailand's health workforce: a review of challenges and experiences. Health, nutrition and population (HNP) discussion paper
Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience
Hum Resour Health
Production of graduates from the Collaborative Project to Increase Production of Rural Doctor (CPIRD)
Number of students in ODOD by teaching hospitals in 2012
Thailand special recruitment track of medical students: a series of annual cross-sectional surveys on the new graduates between 2010 and 2012
Hum Resour Health
Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors (CPIRD): a 12-year retrospective study
Health Policy Plan
History of CPIRD
Nurse workforce requirement in healthcare facilities under Office of the Permanent Secretary, Ministry of Public Health in the next 20 years (2017–2036)
From targeting to universality: lessons from the health system in Thailand. Chapter 16
Dealing with the cost of illness: the experience of four villages in Lao PDR
J Int Dev
Health card…before Thailand achieving UHC (in Thai)
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