Health access for all Thailand’s.The Thai citizens gain universal access to essential health services at zero cost, and reap significant benefits as babies get healthier, workers increase productivity, and households reduce financial risk.

1. Health access for all Thailand’s.
The Thai citizens gain universal access to essential health
services at zero cost, and reap significant benefits as babies
get healthier, workers increase productivity, and households
reduce financial risk.
Presented by Mr Witsathit Somrak: MSc Tourism Management; Budapest Metropolitan University, Hungary.

2. Population – 67.2 million (July 2014)
GDP (2014) US$ 5,519 per capita, Gini 39.3 (2013)
Fiscal space:
• TaxtoGDP17.6(2011),
• Revenue to GDP 21.3 (2011)
Total Health Expenditure (2010NHA)
US$ 194 per capita, 3.9% GDP
Sources of finance: Public 65%, SHI 8%, Private
25%, OOPs 14% of THE, GGHE 13.1% GGE
Health status
Total fertility rate 1.5 (2013)
Life expectancy at birth 74.2 years (2014)
Infant mortality rate 11/1000 liver birth (2014)
MMR 28/100,000 live birth (2014)
Physicians per capita 5/10,000 pop (2014)
ANC & hospital delivery 99-100% (2014)

3. Background
When a family’s primary
breadwinner suffers from a respiratory
infection, he may miss work for a week or
longer. In Thailand before the days of universal
coverage, They often had to choose between
paying for a visit to the doctor and paying for
food and clothing for their family. Many Thais
decided to forgo health care, leading to missed
work and reduced productivity. But too many
absences could cost their job, reinforcing the
vicious cycle between poor health and poverty.
Worldwide, many health systems fail to
protect families from the financial risk of
obtaining health care. In 2012, over 35 countries
relied on out-of-pocket payments for more than
half of total health spending. Faced with the
urgent need to help a dangerously sick family
member, people do what they need to get help. In
many settings, more than one in four people are
forced to borrow money or sell their belongings
to pay for healthcare.
Ref: WHO (World Health Organization). 2014. Global Health Expenditure Database: NHA Indicators. Accessed February 8, 2016.
http://apps.who.int/nha/database/ViewData/Indicators/en
Kruk, M.E., E. Goldmann, and S. Galea. 2009. “Borrowing and Selling to Pay for Health Care in Low- and Middle-Income Countries.” Health
Affairs 28 (4): 1056–66. doi:10.1377/hlthaff.28.4.1056

4. In Thailand in 2001, nearly one in four people were
uninsured. Others were covered by insurance that
offered only partial protection. The result: over 17,000
Thai children under five died each year, two-thirds
from easily preventable infectious diseases, and out-of-
pocket health spending tipped one in five of the most
impoverished Thai households below the national
poverty line.
Achieving universal access to healthcare has been a
goal of most high-income countries since the postwar
era. Recently, the introduction of comprehensive health
coverage, a system whereby all people can obtain
health services without suffering financing hardship,
has gained momentum in low- and middle-income
countries. Advocates and researchers highlight the
enormous potential of universal health coverage to
promote health and human rights.
Ref: Limwattananon, Supon. 2007. “Catastrophic and Poverty Impacts of Health
Payments: Results from National Household Surveys in Thailand.” Bulletin of the
World Health Organization 85 (8): 600–6. doi:10.2471/BLT.06.033720.

5. "30 Baht Treats All Diseases”
Thai campaign slogan,
and promise to cover the uninsured

6. “Program Rollout
In Thailand followed a long string of efforts to improve
equity in health. In 1975, the government had made health
services available to the poor free of charge. Recognising
the problem of a lack of health centres in rural areas, the
government froze all new capital investment in urban
hospitals between 1982 and 1986. It reallocated those
resources to rural district hospitals and health centres,
trained and employed doctors and community health
workers, and recruited and trained village volunteers to
strengthen primary care.

7. Program Rollout: continue
Despite progress, about 25 percent of Thai people were still
without insurance in 2001. Coverage was inequitably
distributed, and medical indicators reflected this
imbalance. Where massive proportions were enrolled in
the Medical Welfare Scheme - which covered people
living poverty, the elderly, children, veterans, monks and
priests - rates of infant mortality were higher than in
other areas. The 1997 Asian financial crisis exacerbated
the effects of inequitable health coverage, weakening the
Thai economy along with its health system.
Ref: Gruber, Jonathan, Nathaniel Hendren, and Robert M. Townsend. 2014. “The Great Equalizer:
Health Care Access and Infant Mortality in Thailand.” American Economic Journal: Applied
Economics 6 (1): 91–107. doi:10.1257/app.6.1.91.

8. Program Rollout: continue 2
▷The government proceeded with rapid implementation,
despite the recommendation of World Bank and WHO
advisors to pursue a gradual introduction. Although Thai
leaders were cautious, they believed a quick rollout would
build confidence in their leadership.
▷To prevent overlap and inequity, the government
planned to merge resources from four existing health
coverage schemes the Medical Welfare Scheme (MWS),
the Health Card Scheme (HCS), the Social Security
Scheme (SSS), and the Civil Servants Medical Benefits
Scheme (CSMBS). However, they met resistance from the
departments responsible for each. To avoid losing
momentum, the government compromised and only
pooled the budgets for the MWS and HCS - schemes for
the poor and near-poor.
▷Ref: Hughes, D., and S. Leethongdee. 2007. “Universal Coverage in the Land
of Smiles: Lessons from Thailand’s 30 Baht Health Reforms.” Health Affairs 26 (4):
999–1008. doi:10.1377/hlthaff.26.4.999.

9. Program Rollout: continue 3
▷The compromise allowed for the passage of the National Health
Security Act in 2002 and rollout was swift: starting with six provinces in
mid-2001, the scheme was extended to nearly all Thailand's 75
provinces by the end of the year reached an additional 18 million people
by combining existing pools form the MWS and the HCS, the group of
uninsured Thais shrunk dramatically. By 2001 was covering 48 million
members and their families, leaving less than 2 percent of the Thai
population without health insurance coverage. One of the scheme's
central administrative features was that the provider and the purchaser of
health services were two discrete entities. The Ministry of Public Health
was responsible for providing health services, and a new independent
body, the National Health Security Office (NHSO).All citizens were
eligible to enrol, people registered with a contracting unit (usually a
district healthcare provider network), and received a gold card. The card
entitled enrollees to free care at health centers in their home district and
contracted hospitals, plus referrals to provincial or tertiary care hospitals
in urban areas. Members were entitled to a comprehensive benefits
package, which provided similar coverage to the pre-existing health
insurance schemes, and later extended to cover more expensive services.
▷Ref: Towse, A. 2004. “Learning from Thailand’s Health Reforms.” BMJ 328 (7431):
103–5. doi:10.1136/bmj.328.7431.103.

10. Program Rollout: continue 4
▷General income taxes primarily financed the
scheme, so it was proportionately more heavily
funded by the rich than the poor. Initially, users
paid a co-payment of 30 Thai Baht (US$0.70)
per visit. However, the collection of the co-
payments ultimately cost more than the revenue
it generated. Following a military coup in 2006,
eliminating the co-payment also helped the
incoming public health minister'.
▷Ref: Tangcharoensathien, Viroj, Siriwan Pitayarangsarit, Walaiporn
Patcharanarumol, Phusit Prakongsai, Hathaichanok Sumalee, Jiraboon
Tosanguan, and Anne Mills. 2013. “Promoting Universal Financial Protection:
How the Thai Universal Coverage Scheme Was Designed to Ensure Equity.”
Health Research Policy and Systems 11 (1): 25. doi:10.1186/1478-4505-11-25.

11. Thailand's coverage scheme
Helped erase the equity gap in infant health

12. In the decade after its launch, Thai
increased access to health care mainly
among babies and women aged 20 to 30
years old, and its members have gotten
healthier. When the financial barriers to
health services were lowered, previously
uninsured Thais, especially those with
the lowest income, increased their use of
health services. The most miserable
women of reproductive age and their
infants benefitted the most. Indeed, the
association between poverty and infant
mortality disappeared, suggesting that
Thai's succeeded in erasing the equity
gap in infant health.
Impact
One year after Thai's launched, people
were less likely to report that illness had
prevented them from going to work than
before an improvement that researchers
attributed to the nation. The effect was
far more substantial for workers over the
age of 65. By keeping Thailand’s ageing
workers healthy, it is conceivable that
the country improved labour
productivity.
Ref: Gruber, Jonathan, Nathaniel Hendren, and Robert M. Townsend. 2014. “The Great
Equalizer: Health Care Access and Infant Mortality in Thailand.” American Economic
Journal: Applied Economics 6 (1): 91–107. doi:10.1257/app.6.1.91.

13. Thailand's entirely funded by the
government, mostly through general
tax revenue

14. Cost
The government’s overall expenditure on health increased
from BHT84.5 billion (US$2.6 billion) in 2001 to 1116.3
billion Thai Baht (US$3.6 billion) in 2002 and continued to
improve steadily to 247.7 billion Thai Baht (US$7.6 billion) in
2008. Thai is entirely funded by the government of Thailand,
mostly through revenue from general taxes.The national
budget, determined by the number of beneficiaries multiplied
by a standard per-person rate, also increased in absolute and
per capita terms. In 2002, the government allocated roughly
1,200 Thai Baht (US$35) per beneficiary and raised this to
about 2,700 Thai Baht (US$80) by 2012. Meanwhile,
government expenditure on other schemes, such as the SSS,
remained flat. Thailand has achieved near-universal coverage
at slightly lower cost to the government relative to the
country's GDP than upper-middle-income other nations such
as Colombia and South Africa.
Ref: HISRO (Health Insurance System Research Office). 2012. Thailand’s Universal Coverage
Scheme: Achievements and Challenges. An Independent Assessment of the First 10 Years (2001–
2010). Nonthaburi, Thailand: HISRO.
http://www.hsri.or.th/sites/default/files/THailand%20UCS%20achievement%20and%20challenge
s_0.pdf.

15. Thailand was a success due
to sustained leadership, learning from past experience, and
its evidence-based, systematic process for determining which
health services to cover.
Thailand

16. Sustained political commitment, sound
public financing and oversight policies,
and civil society engagement helped make
it possible for Thailand.

17. Many countries have pursued quality healthcare for all. Some have found
success, such as Colombia and Turkey; others, such as the Philippines, have
seen reforms stall. In comparison, Thailand's UCS was rolled out rapidly,
showing that a lower-middle income country can achieve universal health
coverage under the right circumstances. Sustained political commitment, sound
public financing and oversight policies, and civil society engagement helped
make it possible.
Thailand is a leader in the use of evidence to inform health policy decision making.
HITAP is one of the few agencies in a low- and middle-income countries to
systematically assess whether health technologies will be eligible for coverage. To make
policy development participatory, a diverse panel of health professionals, academics,
patient groups, and civil society organisations oversee the prioritisation of health
interventions. This process is attractive due to its built-in accountability and cost-saving
advantages, and the Thai government is working to share its experience with others.
Ref: Glassman, Amanda, and Kalipso Chalkidou2012. Priority-Setting in Health: Building Institutions for Smarter Public Spending. A
Report of the Center for Global Development’s Priority-Setting Institutions for Global Health Working Group. Washington, DC: Center
for Global Development. http://www.cgdev.org/publication/priority-setting-health-building-institutions-smarter-public-spending.
Implications:

18. Implications continue 2
The growing health care budget casts some
doubt on its sustainability. To address this
concern, researchers have suggested that the
health care system devote more of its budget to
preventive and health-promotion services,
which currently account for just under 20
percent of the budget. They also recommended
health planners continue to carefully analyse
new and available interventions based on cost-
effectiveness evidence and their implications
for the budget. Other countries will observe to
see how Thailand tackles the sustainability
challenge.
There are many ways to finance
universal health coverage. Thailand's
experience adds to a growing body of
evidence that health-financing
systems do not have to rely on fees
from health-system users. The
majority of Thais receive health
coverage without fees, their benefits
financed by tax revenues. Some Thais
private company and temporary public
employees contribute directly to
universal health coverage.
Ref: Yot Teerawattananon, personal communication with the author, January 15,
2015

19. Implications continue 3
▷Expanding health
coverage can improve
health by developing
access and by providing
financial protection.
Experience shows that free
healthcare alone does not
guarantee better health;
other elements are needed
to improve health
outcomes. By providing
free and cost-effective
services while at the same
time strengthening its
health system, Thailand
managed to keep workers
healthy and save young
lives. While challenges
remain, it can provide a
model and inspiration for
other countries on the path
to universal health
coverage.
▷By providing free and
cost-effective services
while at the same time
strengthening its health
system, Thailand managed
to keep workers healthy
and save young lives.

20. Conclusion.

21. Conclusion 2.
Ref: seahealthcare-whitepaper-131220081649-phpapp01

22. Thank you