Elsevier

The Lancet

Volume 391, Issue 10126, 24–30 March 2018, Pages 1205-1223
The Lancet

Review
Health systems development in Thailand: a solid platform for successful implementation of universal health coverage

https://doi.org/10.1016/S0140-6736(18)30198-3Get rights and content

Summary

Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

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

Search strategy and selection criteria

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

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