How Thailand got it right on UHC

In 2002, at the time Kenya was beginning a new political odyssey, Thailand was equally beginning their new journey.

As Kenya embraced regime change, the first in a long time, the country famed for its tropical beaches, royal palaces and ornate temples was beginning the implementation of Universal Health Coverage (UHC).

Sixteen years later, just when Kenya is beginning trials for UHC, Thai people are basking in the glory of a near 100 per cent coverage after a long, spirited but determined journey to get it right.

How did Thailand — the South East Asian country with just about the same land mass and population as Kenya’s — take this bold step despite a low gross national income per capita at the time?

In a recent trip to Thailand, Sunday Standard established the prerequisites for a successful UHC picked from the Thai experience and told through interaction and interviews with various players.

According to Dr Suwit Wibulpolprasert, the current Vice Chair of The International Health Policy Foundation (IHPF) and Health Intervention and Technology Assessment Foundation (HITAF), Thai’s UHC journey begun way back in 1975.

At the time, the government subsidised health services and invested in developing, equipping and improving public health facilities.  

“Only when the public sector service is good enough, distributed all over and accessible will it be successful. No one wants to go to a slaughterhouse,” says Dr Suwit, who served as a Deputy PS of the Thai Ministry of Public Health between 2000-2003.

From his experience, UHC means a truly reliable access to essential and quality health services and health technologies without financial barrier.

“First, you must have the facilities available. Second is financial protection. You don’t have to pay so much that you go bankrupt,” he says.

In those days when the government began the subsidies, Dr Suwit was the only doctor in a 10-bed facility with seven other staff. He had an operating budget of $1,000 annually for a population of 200,000.

The striking feature of the Thai experience was its phased approach. The first target was the poor people category at $400 capita per person.

Over time, they moved the less poorer segments of the populations and by 2001, when they achieved universal health coverage, they had progressed to $2,000.

And then schemes were equally well thought-out to clear any gaps in the way of UHC. The schemes are either tax-based or the social security scheme that is contributory.

Disease prevention

In this instance, those employed contribute 1.5 per cent of their salary to the scheme, capped at a salary of 15,000 Thai Baht ($500). For a salary beyond $500, one only pays up to the first $500.

“This system controls the price (of healthcare) very well because we put the risk in the hands of the health facilities which are given a fixed amount per person in the population they serve,” Dr Suwit said.

This fixed amount is about Sh11,452 per person.

For instance, Prapokklao Hospital Chantaburi serves a population of one million people and therefore gets 3.426 million Thai Baht per year. For inpatient, the payment is not fee for service, but what is termed as fixed rate diagnostic related group, paid in bundles as opposed to being itemised.

Dr Kriengsak Vacharanukulkieti, the Director of Prapokklao Hospital, says this allocation is sufficient.

And then there was the focus on maintaining quality and ensuring financial protection. “We needed to do more to prevent diseases to reduce congestion in hospitals by offering quality community health services. It has to be quality service so that people don’t go to private facilities,” he says.

The benefits packages were strategically crafted to range from health promotion and disease prevention to curative services for all diseases, including high cost treatments and rehabilitation services.

Chanthanimit Rural Health Centre has a catchment area of 12,821 people from nine villages.

It has two doctors that manage the Non-Communicable Disease clinics on Mondays and Tuesdays and conduct home visits in the afternoons and on the other days of the week. It has a total of 13 staff including its director.

Dr Kullawan Chaicharoenpong, a family medicine physician and acupuncturist, is one of the two doctors that visit Chantanimit.

“We attend to patients as a multidisciplinary team of the family health nurse, a care giver in chronic disease and a health volunteer.” She says. “We attend to minor trauma, dressing wounds and refer appropriately for follow-up.”

The facility offers primary healthcare services — vaccinations, contraception services, diabetes and hypertension screening, safe sex talks, monitoring growth and development in under-5s to visiting schools in case of outbreaks.

“For rehabilitation we offer the Traditional Thai massage for medical reasons, not for leisure,” she adds. “All these services are at no cost to all under UHC,” he says.

And to check on the runway drug prices that can choke such a system, the government thrust itself right in the middle of determining the drugs under the coverage.

“We have a national drug system committee chaired by the Prime Minister which determines which drugs are to be included in the system,” says Dr Suwit.

In a bid to maintain its health workforce, Thailand’s doctors have to work for the government for at least three years in a rural area.

“You have to improve the health service and make sure the health workers are committed, they love the people and they work hard for the people,” says Dr Suwit.

Public spirit

UHC cannot be successful without the commitment and public spirit of the health workforce, he says. To him, financial protection is just part of the equation -- the main equation is the health workforce and the health services.

“They cannot look at the patients like customers to sell as many services as possible and get as much money as possible,” he says.

Non-medical health workforce like nurse practitioners and public health officers handle more than 50 per cent of the primary healthcare in Thailand. They are trained and retained in the country. Their training in Thai language is restrictive of brain drain scourge that afflicts some countries like Kenya. 

The government also went out its way to promote the volunteer programme where up to 10 volunteers per village work to distribute essential drugs, refill oral pills, and make sure there are no water reservoirs that can breed mosquitoes among other such duties.

With such a spread and fairly refined public health system, the Thai private health sector is left to scramble for a meagre 10 per cent of the health infrastructure.

But there are also arguments that Thailand’s developments in the health sector did not happen in isolation.

For instance, the country had to shift from an import-led economy to an export-led one, becoming self-sufficient. In 1985, for example, 25 per cent of Thailand’s budget went into servicing debt incurred both internationally and locally through bonds. Twelve years later in 1997, public debt had shrunk to five per cent.

Secondly, Dr Suwit cites peace. With no civil wars, internal political strife and infighting within the country, or wars with other countries, the government cut down on security spending.

People and community participation, he says, is one of the four pillars of primary healthcare, after basic health services, appropriate technology and intersectoral coordination.

The concern of the Thai doctors now is the ageing community that is currently at about 16 per cent of the population, but projected to increase to 25 per cent in the next 10 years.

To Dr Kriengsak, this will demand up to four times more of the existing health system and they need to adapt to respond to this need.