2014年-世界发展银行全球_Universal_Health_Coverage_for_Inclusive_and_Sustainable_Development___Country_Summary_Report_for_Thailand_15页_209kb

Summary of Thailand's Universal Health Coverage (UHC) Experience

Core Content

Thailand, an upper-middle-income country with a population of 69.5 million in 2012, has made significant progress in achieving universal health coverage (UHC) through a series of policy reforms. The country's journey to UHC is documented in the Japan-World Bank Partnership Program for Universal Health Coverage, which aimed to share experiences and lessons across 11 countries.

Thailand achieved UHC in 2002 by combining the Low Income Card Scheme (LICS) and Voluntary Health Card (VHC) into the Universal Coverage Scheme (UCS), which covers approximately 75% of the population. The UCS is the largest component of the UHC system, managed by the National Health Security Office (NHSO), and is funded by general tax revenues. The Social Health Insurance (SHI) and Civil Servant Medical Benefit Scheme (CSMBS) are also part of the UHC framework, with SHI being a tripartite contributory program and CSMBS a government-funded program with a broader benefit package.

Main Views and Key Information

1. Legal and Statutory Basis

• Thailand has three main legal instruments for UHC:

  • National Health Security Act (2002): Establishes the right to essential health services for all.
  • 2007 Constitution: Ensures equal access to public health services and mandates pluralistic service provision.
  • 2009 Statute on the National Health System: Guides the development of the national health system and outlines health security and protection.

• Additional legal instruments include the Social Security Act (1990) and the Royal Decree on Civil Servant Medical Benefit Schemes (1980).

2. Coverage Status

• Population Coverage: By 2002, all citizens had access to essential health services through one of the three schemes.
• Service Coverage: All three schemes (UCS, SHI, and CSMBS) offer comprehensive benefit packages, including inpatient and outpatient care, preventive services, and high-cost treatments such as chemotherapy, heart surgery, and ARV therapy for HIV/AIDS.
• Financial Protection: Public financing covers 60–75% of total health expenditure (THE), while out-of-pocket payments account for 14–30%. Copayments are not required for services received at registered facilities or through the referral system.

3. Governance Structure

• UCS: Managed by the NHSO, with a board chaired by the Minister of Public Health. It uses a capitation model for outpatient and promotion/prevention services, and DRG-based payments for inpatient services.
• SHI: Managed by the Social Security Office (SSO), with a tripartite board (government, employers, employees). It uses a capitation system with limited fee-for-service.
• CSMBS: Managed by the Ministry of Finance, with a fee-for-service model, and recently introduced DRG for inpatient services.

4. Financing and Cost Management

• UCS: Financed through general tax revenues, with a closed-end budget system that ensures fiscal sustainability.

• SHI: Tripartite funding, with a capitation system that helped control costs.

• CSMBS: Faces challenges in cost containment due to its fee-for-service model, though recent reforms like DRG and drug reimbursement limits have helped.

• Efficiency: The NHSO has successfully reduced costs through strategic purchasing and negotiation, leading to annual savings in essential medicines and services.

• Value for Money: The closed-end budget system encourages efficiency in service delivery and resource allocation.

5. Equity in Coverage

• Redistribution: There is no clear evidence of effective redistribution mechanisms across the three schemes.
• Subsidies: Government subsidies per beneficiary vary significantly, with CSMBS receiving the highest at around $366, followed by UCS at $97 and SHI at $71.
• Inequity: Inequities persist in health expenditure and subsidies across the three programs, with a need for reform to ensure fairness.

6. Human Resources for Health (HRH) Policies

• HRH Supply: Thailand has a relatively high number of health workers, but challenges remain in workforce distribution (urban vs. rural) and equity in training.
• Training and Qualifications: Medical professionals must pass national licensing exams, with physicians having lifetime licenses and nurses requiring renewal every five years.
• Specialization Trends: The proportion of specialists among medical doctors has risen sharply from less than 3% in 1971 to 85% in 2009, which has hampered the development of primary care and family medicine.

7. Labor Market Dynamics

• Financial incentives such as rural hardship allowances, nonprivate practice incentives, and special allowances for workers in affected regions have been introduced to retain and motivate health professionals.
• These incentives have helped reduce the "brain drain" from public to private sectors.

8. Flexibility of HRH Workforce

• Task shifting is common, with nurse practitioners handling basic care in rural areas.
• Career mobility between professional groups is limited, but clinicians can transition into administrative roles.

9. Sequencing of Reforms

• CSMBS initially covered government employees and their dependents.
• LICS provided free services to poor households and expanded to include children, elderly, and other vulnerable groups.
• VHC was a voluntary program that faced challenges in expansion due to adverse selection and moral hazard.
• UCS was introduced in 2002 to cover the remaining 30% of the uninsured population, combining LICS and VHC.

10. Political and Economic Context

• UHC was a bold political decision by the Thaksin administration, supported by evidence-based policy design and a budget model ensuring affordability and sustainability.
• The "Triangle that Moves the Mountain" strategy, involving knowledge, social engagement, and political involvement, played a crucial role in the success of UHC reforms.
• The economic context included a GDP per capita below $2,000 and post-Asian financial crisis recovery.

Key Lessons

• UHC is a continuous process requiring long-term commitment and political support.
• Comprehensive benefit packages and financial risk protection are essential for achieving UHC.
• Fiscal sustainability is supported by strategic purchasing and closed-end budgeting.
• Equity in subsidies and cost distribution remains a major challenge.
• Primary care orientation is critical for effective HRH policy and UHC sustainability.
• Task shifting and flexible workforce strategies are important for service delivery in rural and underserved areas.

Conclusion

Thailand's experience with UHC demonstrates the importance of a multi-stakeholder approach, evidence-based policy making, and sustainable financing in achieving health equity and quality care. Despite progress, challenges in equity, cost management, and HRH distribution remain, requiring continued reform and commitment.