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RESEARCH EXCHANGE PROGRAMM BETWEEN UNIVERSITY OF HYDERABAD AND

MAHASARKHAM UNIVERSITY

RESEARCH REPORT

Healthcare Delivery Management To Improve The Primary Healthcare Services

And Universal Health Care In Thailand

MAHASARKHAM UNIVERSITY,

THAILAND

UNIVERSITY OF HYDERABAD,

INDIA

RESEARCH REPORT SUBMITTED TO THE MAHASARKHAM UNIVERSITY,

KHAMRIANG, KANTARAWICHAI, MAHASARKHAM 44150

SUBMITTED BY

NENAVATH SREENU,

SCHOOL OF MANAGEMENT STUDIES,

UNIVERSITY OF HYDERABAD,

UNDER THE SUPERVISION OF

Dr. SOMSAOWANUCH CHAMUSRI

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RESEARCH EXCHANGE PROGRAMM BETWEEN UNIVERSITY OF

HYDERABAD AND MAHASARKHAM UNIVERSITY

RESEARCH REPORT



RESEARCH REPORT SUBMITTED TO THE MAHASARKHAM UNIVERSITY,

SUBMITTED BY

NENAVATH SREENU,

SCHOOL OF MANAGEMENT STUDIES,

UNIVERSITY OF HYDERABAD, INDIA

Vic president For Planning And Internationa

Relations

Dean .

Supervisor.

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CONTENTS

1. INTRODUCTION

1.1 Definition of health care system in Thailand

1.2 Vision of Peoples Health Development.

1.3 Overview of health care system in Thailand

2. DEVELOPMENT OF THE HEALTH CARE SYSTEM

2.1 Health policies and strategies

3. HEALTH CARE DELIVERY MANAGEMENT

3.1 healthcare delivery management developments

3.2 healthcare delivery services

3.2.1 Self-Care Level

3.2.2 Primary Health Care Level

3.2.3 Primary Care Level:

3.2.4 Secondary Care Level:

3.2.5 Tertiary Care

3.2.6 The world healthcare system frame work4. .HEALTHCARE FINANCING MANAGEMENT IN THAILAND

4.1 financial resources for health care in Thailand

5. ORGANIZATION OF THE HEALTH SYSTEM IN THAILAND

6. PRIMARY HEALTHCARE MANAGEMENT ROLE IN THAILAND

6.1 Conceptual Model of the Primary Healthcare in Thailand

6.2 Management Model

7. STRATEGIES FOR IMPLEMENTING PRIMARY HEALTH CARE

7.1 Community Oriented Primary Healthcare

7.2 Uniting Stake holders through Partnership

8. Financing Primary Healthcare Services in Thailand

8.1 Strategies to Improve Primary Healthcare Services

8.2 Supporting Primary Healthcare Research

9. PRIMARY HEALTHCARE EFFICIENCY

9.1 Primary healthcare equity

10. Changing of health service administrative structure

11. CHALLENGES FOR THE FUTURE OF PRIMARY HEALTH CARE

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12. HEALTH SYSTEM STRENGTHENING USING PRIMARY HEALTH CARE APPROACH

13. FINANCING POLICIES TO ACHIEVE UNIVERSAL HEALTH CARE

13.1 Public Health Care and Protection Strategy in the 2001-2010

13.2 Universal Health Care Coverage Policy (30-baht Policy)

13.3 Implementation of the Universal Health Care Policy

13.4 Challenges for 30-baht Policy

13.5 Achievements of the UC Scheme

13.5.1 Beneficiaries of the UC Scheme

13.5.2 Improving access to healthcare

13.5.3 Prevention of medical impoverishment

13.5.4 Promoting equity in health

14 CHALLENGES AND STRATEGIES UNIVERSAL COVERAGE FOR HEALTH CARE

14.1 Aligning pluralistic public health protection system

14.2 Appropriate payment mechanism

14.3 Long-term financial sustainability

14.4 Improve equity, quality and efficiency

14.5 Recent Changes in the Thailand Health Care System

15. CONCLUSION

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1. INTRODUCTION

The health services systems in Thailand has evolved from self-reliance, in the past, by

utilizing local wisdom for curative care and health promotion, to the system of

modern bio-medical emphasis. In serving the new health care system, numerous

health personnel in response to various health disciplines have been produced,

including the procurement and development of health technologies. There is a clear

picture of role designation of providers and recipients, as well as more systematic

health services system. In the pluralistic health services system, the main service

providers are rendered by the public sector, while the private for-profit and non-profit

sectors are also involved. Nonetheless, many Thai people are still accustomed to

traditional way of self-care. Components of the health services system include

(1) Health resources,

(2) Management,

(3) Organizational structures,

(4) Financing, and

(5) Health services

The Structure of Health Service Systems

Health services

Categories

Levels

Specialized/general

Management Organizational Structures Financing

Policy and Plan Public /APO Social security

Law Private TaxMonitoring Social security Individual

Information Business

Health resources

Body of Knowledge

Medical supplies

Health facilities/equipment

Manpower

APO:Autonomous Public Organization

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Social security has become an issue of serious public concern now that Thailand has

climbed higher on the development ladder and its population is attaining higher

levels of education. Health-care services comprise one of the major forms of social

security agreed by the public as a priority. After Thailands major reform of the

healthcare system in 2001, it is obvious that both the public and the government are

paying more attention to the countrys health-care system. Thailand has developed

three main public healthcare schemes, the first of which covers government officials

and dependents (Civil Servants Medical Benefit Scheme, or CSMBS) and state

enterprise employees and dependents. The CSMBS provides subsidized healthcare

coverage and is considered by the public as a generous attractive fringe benefit for

government officials. The scheme is financed from government budget through the

Comptroller-Generals Office. Healthcare coverage for state enterprise employees is

not inferior to that offered under CSMBS. Each state enterprise has its own package

of health-care benefits. The second health-care scheme, the Social Security Scheme,

covers private employees in the non-agriculture sector. To receive health-care benefits

and other benefits, private employees and their employers must first pay contributions

into the scheme. This healthcare scheme is subsidized by the government through its

contributions to the Social Security Fund. The third scheme is the 30-Baht Health-

care Scheme, which covers residents of Thailand not covered by the first two

schemes. The name 30 Baht is derived from the user fee of 30 baht (about 75 US

cents) per visit, for a wide range of outpatient or inpatient hospital care. This scheme

is now four years old. Government expenditures on these three healthcare schemes in

2003 totaled 68.3 billion baht,1 which represents approximately 6 percent of total

government spending. The 30-Baht Health-care Scheme accounts for 59 percent of

the expenditures on the three health-care schemes. Even with such very high

expenditures on the 30-Baht scheme, many stakeholders have raised the issue of

inadequate budget allocation to the program needed to achieve the standard quality of

health care. Many hospitals insist that they have gone into debt because of the

program and, if prosperous enough, some of them would use their own savings to

keep the hospitals running effectively. Many doctors and health-care professionals

complain about their workload, which has increased because the 30-Baht Health-care

Scheme increases health-care utilization. The arguments pro and con concerning the

program have been around for four years; however, there is consensus among the

stakeholders that the program is under funded. The purpose of this study is to review

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the expenditures on the 30-Baht Health-care Scheme to analyze how much more

budget the government should allocate to the program and to provide

recommendation on possible sources of funding. And deliver of healthcare

management to improve the primary healthcare

1.1 Definition of health care system in Thailand

A proactive health system that emphasizes health promotion of the people, in

parallel with a satisfactory health insurance system, so that the people will have

access to health care that is solicitous and of good quality when necessary; whereas all

sectors of society at all levels have potential and participate in the creation and

management of the health system according to the sufficiency economy philosophy,

through learning and utilization of Thai and international wisdom in a well-informed

manner, so as to make Thai society survive in a self-reliance and healthy manner in

the global society that is interconnected and extensively influential to each other

1.2 Vision of Peoples Health Development.

All Thai citizens have security to live a happy life in a healthy condition, with access

to health care in an equitable manner, in a family, community and society that is self-

sufficient in terms of health, with potential, learning and participation in managing

health problems, using international and Thai wisdom in a well-informed manner.

1.3 Overview of health care system in Thailand

Health care system in Thailand is an entrepreneurial health system with public and

private providers. Public health facilities were rapidly expanded nationwide since

1961 when Thailand launched the first five-year National Economic and Social

Development Plans (1961-1966). Private hospitals also play role in health services.

However, they are mostly in Bangkok and urban area. There are also wide spread of

private clinics and polyclinics in urban areas, most of them are owned and running out

of hour by public physicians. Since 1994, the numbers of hospitals and beds have

been remarkably increasing Bed to population ratio came up to 1:469 in 2004. While

the doctor to bed ratio has dropped from 1: 15.3 in 1991 to 1: 7 in 2004. Average bed

occupancy ratio was 73%, Number of health care personal i.e., Doctors, dentists,

pharmacists, and nurses has trended to gradually mount every year due to the strategy

to increase emphasis on training of qualified health care personnel in the national

plans. Nevertheless the distribution of health personnel still is one of major problems

in Thailand. There was significant different between Bangkok, the Capital of

Thailand, and other provinces. There are more doctors in Bangkok. The workload was

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lower for the doctors who worked in other ministry hospitals or private hospitals

rather than hospitals of the MoPH.

2. DEVELOPMENT OF THE HEALTH CARE SYSTEM

2.1 Health policies and strategies

The MOPH is authorized and responsible for the strengthening of the public health

and hygiene, preventing and controlling diseases and recovering the energy-level of

the population. It has established its goals and a 3-year strategy for pursuing the goals

so that the subordinating agencies adhere to the principal goals and their strategy is in

operation according to estimates of the public health budget required for achieving the

goals.

The followings are the target of MOPHs policies:

1. To improve the organization structure, culture and the operation procedure in order

to have good administrative system and to become a learning organization of public

health.

2. To develop and provide mechanism in facilitating the involvement of all concerned

Parties in monitoring the public health system as a whole.

3. To increase the capability of the medicines, public health and biology of health, in

order to be on the front line of world competition.The middle-term goals of the MOPHs services are following:

1. The important public health problems in different age groups of the population are

to be lowered.

2. The people have health security with standard and quality health services, and to

Encourage people to take part in taking care of health and the public health

environment.

3. The healthcare products and services are to be of the quality and up to the standard

of international requirement.

4. To have good governance in the public health administration.

The MOPHs strategies in pursuing the goals according to the policies are:

1. Improving the sanitation behaviour of the people and to prevent and control

diseases with involvement of all concerned parties.

2. To increase the varieties and capacity of the research, including bio-medicines,

Development, transfer, applications of technology and knowledge.

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3. To develop the system of health security and public health services to be

holistically efficient with equal quality services for all.

4. To promote peoples involvement in developing public health, managing public

health environment accordingly and efficiently.

5. To encourage innovations, develop mechanism of facilitating innovations of health

Products and services, which make use of domestic resources to further enhance the

Thai traditional wisdom so that the products and services are of better quality and

meet the international standard.

6. To develop and improve the systems and procedures of operations of public health

Management to make them better and more efficient.

The devising of the public health strategic plan: The strategic plan is very important

for the result-oriented management (or Management by Objectives). Therefore, the

strategic plan will be designed carefully in order to conform to the desired goal and

the strategy of achieving the goal of the superior operation unit, so as to achieve the

goal successfully.

3. HEALTH CARE DELIVERY MANAGEMENT

Health Policies for continuous improvements of economic growth and for promoting

government during the cold war period are major drivers for expansion of public

health facilities nationwide. Before 1932, main concerns of the Thai Government

were only prevention services and controlling communicable diseases. Therefore a

few public hospitals were established. The health policy was changed to improve

access to modern medical care after Thailand changed from the Absolute monarchy

state to a democratic state in 1932. However, the infrastructure of the health care

system expanded slowly. In 1942, there were only 15 provincial hospitals and 343

health centers. It was until 1956 that every province had a provincial hospital and

there was a regional hospital in each region to act as a referral centre of provincial

hospitals. These public health care facilities were financed by government budget

which was not enough. For this reason, they were allowed to keep their own revenue

for run their own business. Coverage planning for public health care infrastructure

was successfully done by using an administrative area approach. There were 217 and

267 grade-I health centers at the end of the first and second plan respectively. Each

grade-I health centers had a medical doctor working as a permanent staff member, and

took care of people at the district level. In the third plan, grade-I health centers were

changed to community hospitals and government set targets to reach one hospital for

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every district and one health center for every sub-district (Tambon). It took time until

the fifth plan that Thai government could achieve districts coverage. In 1993 public

health centers were close to people that they could access for services within one hour

by walking. However, the problem of maldistribution of health care providers among

rural and urban areas still exists, and it affected equity in peoples access to care.

In the public sector, the largest agency is the MOPH with two-third of all hospitals

and beds across the country. The other public health services are medical school

hospitals under the Ministry of University, general hospitals under other ministries

(such as Ministry of Interior, Ministry of Defense). In 2004, 68.6 percent of hospitals

and 65.4 percent of beds belonged to the MoPH. There are general hospitals (120-500

beds) or regional hospitals (501-1,000 beds) and few special centre/ hospitals in

provincial level, community hospitals (10-120 beds) in district level and health

centres in sub district areas. Health services in health centers, which mainly concern

primary care, are provided by nurses, midwives, and sanitarians. Some of health

centers, which are call Community Medical Unit (CMU), now have a doctor work as

full time or part time staff. The lowest level is self-care and primary health care which

is provided by health volunteers or people take care themselves. Currently, MoPH

owns 891 hospitals which cover more than 90% of districts; and 9,762 health centers,

which cover every sub-district, Tambon (Wibulpolprasert, 2008). Local governments

play very limited role in health services now. However, under the decentralization act

the MoPH has to transfer most of their health facilities to local government within

2010. Until now there is no concrete action plan for this decentralization.

3.1 HEALTHCARE DELIVERY MANAGEMENT DEVELOPMENT

Thailand has invested to improve all aspects of the health system. This has ensured 4

out of 5 out-patients to use the community health system. However, there are still

differences in the quality of the health system, particularly between Bangkok and

other parts of the country. The Thai health system has been expanded to provide

health care services at all levels from primary to tertiary. At the primary-care level,

there are community health facilities which are easily accessed by the community,

providing basic medical care, health promotion and prevention of diseases. The

coverage of the primary-health care system in Thailand is widely regarded to be

excellent. At present, there are over 9,000 community health centres nationwide.

Every district has a community hospital, so there are over 700 community hospitals.

Tertiary care consists of health facilities which are fully equipped with expensive

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medical instruments, resources and specialized staff to provide sophisticated medical

services and treatment. Recent statistics indicate that community health centres and

community hospitals are the most popular source of health care and about four in five

patients used the out-patient health services at the government health facilities.

Ideally, a heath care system should be focused on health facilities at the primary level

because the provision of health services at this level is cost effective and appropriate

for the majority of the population who are facing minor illnesses. Due to their

proximity to the community, primary health providers understand the socio-cultural

backgrounds of the families and communities in which health services are provided.

Government hospitals under the administration of the Ministry of Public Health

(MOPH) also play a crucial role in providing health services at the provincial and

regional levels. The significance of these government hospitals is evident in the

Central and Northeastern Regions of the country. Government hospitals account for

62 percent of all hospitals in the Central Region and 85 percent in the Northeast. In

contrast, the share of the private hospitals is as high as 67 percent, or around two

thirds, of total health facilities in Bangkok. The second largest share of private health

facilities is in Central Region, at 30 percent. The regional disparity in health facilities

reflects the extent of differences in social and economic conditions in the regions. For

example, the ratio of hospital beds to population is 1 to 740 in the Northeast compared

to 1 to 223 in Bangkok, a factor of over three between the two regions. One possible

explanation of this disparity is that there is a higher concentration of private hospitals

in Bangkok than in other regions. About one in four private hospitals are located in

Bangkok. Most of the Bangkok hospitals are relatively large hospitals, with over 200

beds.

The disparity in health care facilities, and the importance of economic status, is also

evident when comparison is made between provinces in the same region. Wealthy

provinces are better off in terms of the number of hospitals and the ratio of population

to hospital beds than poor provinces. Moreover, teaching hospitals and medical

schools are located in a few politically and economically important provinces in each

region, which contributes to the unequal distribution of health care services between

Provinces. Differences in health care facilities also affect the use of health services.

For instance, the number of in-patients is much higher in the provinces with a higher

number of hospital-beds than lower hospital-bed provinces. In other word, access to

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health services is better in the former provinces than the latter, indicating to some

extent the existence of inequities in access to health care.

3.2 HEALTHCARE DELIVERY SERVICES

Health services in Thailand are classified into five levels according to the level of

care, indicated as follows

3.2.1 Self-Care Level: Services at this level include the enhancement of people's

capacity to provide self-care and make decisions about health. Thai people trend to

realize more about their health such as reducing smoking and performing physical

activity. However, self-care approach is lessening due to greater utilization of public

and private health facilities.

3.2.2 Primary Health Care Level: The primary health care services include those

organized by the community in providing services related to health promotion, disease

prevention curative care and rehabilitative care. The medical and health technologies

applied at this level are generally in response to the community's needs and culture.

Service providers are those people in the area, VHVs or other non-governmental

volunteers. Clearly, the services provided are close to self care and primary care

service provision.

3.2.3 Primary Care Level: This level of care provided by health personnel and

general practitioners (GPs). The feature of Thai primary care system, in addition to

provided in health centers and community hospitals is not identified exactly

responsible areas as well as is not holistic care services for the family level. The

Universal Health Insurance Policy of the present government aims to develop holistic

primary care services system at the family level. In the near future, the picture of

holistic primary care services can have been seen. The components of primary care

level units are indicated as follows:

1) Community Health Posts. A community health post is a village level health service

unit established specifically in remote areas, covering a population of 500 to 1,000,

and staffed by only one community health worker (a MOPH permanent employee).

Services provided at this level include health promotion, disease prevention and

simple curative care.

2) Health Centers. A health center is a sub-district or village level health service unit

first line unit, covering a population of about 1,000-5,000, with health staff including

a health worker, a midwife and a technical nurse. The MOPH is now in the process of

assigning a dental auxiliary, a professional nurse, and a health technician to each large

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health center. Services provided at this level also include health promotion, disease

prevention, and curative care. Health center staff nurse health programs according to

the standard procedures established by the MOPH, under the technical supervision

and support of the community hospital.

3) Health Centers of Municipalities, Outpatient Departments of Public and Private

Hospitals at All Levels, and Private Clinics. At these facilities, outpatient care is

provided by physicians and other health professionals.

4) Drugstores. This is the primary care level that provided by pharmacist or

pharmaceutically- trained personnel.

3.2.4Secondary Care Level: Health care at this level is provided by medical and

health personnel with various degrees of specialization. General and specialized

facilities include the following:

1) Community Hospitals. A community hospital is located in a district or sub-

district with 10 to 150 inpatient beds, covering a population of 10,000 or

more. There are doctors and other health professionals. Generally, services

provided are mostly curative care, compared to those at primary care facilities.

2) General or Regional Hospitals and Other Large Public Hospitals. A general

hospital in this category is equipped with 200 to 500 beds, while a regional

hospital has over 500 beds and medical specialists in all fields.

3) Private Hospitals. Most private hospitals are operated as a business entity with

both full-time and part-time staff, and clients are required to pay for services.

3.2.5 Tertiary Care. Health services at this level are provided by medical and

health professionals, mostly with specializing expertise. Tertiary Care facilities

include:

1) Regional Hospitals

2) General Hospitals

3) University Hospitals and public large hospitals belong to Ministry as Local

Administrative Organization.

4) Large Private Hospitals have all fields of medical specialists. Most are over

100- bed private hospitals. The classification of health facilities mentioned above

is relatively rough as a matter of fact that the tertiary care facilities also provide

primary care services.

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The Thai health care system has been developing in all the dimensions listed above.

The provision of health services in particular covers all levels and localities. There is

a good referral system that links the different parts of the health care together to

increase access to health services. In addition, Thailand has had universal health care

coverage since 2001, which has resulted in excellent access to health care including

access to preventative and basic medical care. The system has also provided social

and financial risk protection for households. Nevertheless, coverage by some parts of

the health system has remained low, including screening services such as cervical

screening, high blood pressure screening, diabetics, and hyperlipidemia. This has

reduced early detection and prompt treatment. Issues requiring continual development

include the equal distribution of the health workforce to prevent disparities between

rural and urban

3.2.6 THE WORLD HEALTHCARE SYSTEM FRAME WORK

System building block overall goals/outcomes

---------------------------- -------------------------------

Service delivery ACCESS

COVERAGE

Healthcare worker improved health (level and equity)

Information responsiveness

Medical products social and financial risk protection

Vaccines & technologies

QUALITY

Financing improved efficiency

SAFETY

Leadership/ governance

Source: WHO. Everybody Business: Strengthening Health System to Improve Health Outcomes:

WHOs Framework for Action. 2007. Geneva, World Health Organization.

Areas and between cities where social, economic and political differences exist.

Health providers and medical technologies are highly concentrated in big cities rather

than small towns and rural communities. The government should take measures to

strengthen the motivation and status of health providers working in disadvantaged

rural communities. At the same time, the government should conduct cost-benefit

analyses of medical technologies, particularly diagnostic and therapeutic, including

cost and distribution. The quality and safety of health care, including incidences ofmedical errors, is an important factor in the survival of patients. Statistics from

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hospital records reveal that 35 percent of deaths in the hospitals result from medical

errors. About half of the errors can be prevented. Emphasis should be placed on

improving adherence to hospital-acquired infections standard. National health

expenditures have increased significantly, from 147,837 million baht in 1995 to

248,079 million baht in 2005. Curative care accounts for about three quarters of total

health expenditures, compared to only 5 percent for prevention and health promotion.

The proportion invested in health promotion and disease prevention programs should

be increased. Thailand has a relatively good health information system, which leads,

to some extent, to evidence-based policy formulation. However, improvement in the

Information system is needed, particularly in relation to the coverage and timeliness

of data.

4. .HEALTHCARE FINANCING MANAGEMENT IN THAILAND

The amount of money spent on health, per capita increased by 1.6 times, increasing

from 2,486 baht in 1995 to 3,974 baht in 2005. The majority of the increase has been

for hospital care rather than for health promotion.During the previous decade, health

expenditure in Thailand increased dramatically, rising from 147,837 million baht in

1995 to 248,079 million baht in 2005, an average annual growth of 6.6 percent which

was similar to the annual Gross Domestic Product growth rate of 6.4 percent. As a

percentage of Gross Domestic Product, Total Health Expenditure was 3.5 percent in

1995, reaching 4 percent in 1997, the year Thailand faced an economic crisis. After

the crisis the ratio decreased to be 3.3 percent in the year 2001. After the

Implementation of the Universal Coverage Scheme the ratio increased and reached

3.7 percent in 2002 before stabilizing at 3.5 percent GDP by 2005. Per-capita health

expenditure rose from 2,486 baht in 1995 to 3,974 baht in 2005, a 1.6-fold increase

during the decade. Thailand has expanded health welfare in order to reduce household

spending such as the Free Medical Care Scheme for the Poor, the Low-Income Card,

the voluntary Health Card Scheme and the Universal Health Care Coverage Scheme

in 2001. After 2002 till 2005, public-financing agencies played the major role at 63-

64 percent of total health expenditure. Of this, the household expenditure declined

from 43 percent in 1995 to 27 percent in 2005 of the. Considering health functions,

health expenditure dominantly spent for curative services at three quarters; resulted in

only 5 percent of total health expenditure were for preventions and health promotion

services in 2005. This implied that government spending on health would be

affordable in the long run. One of policy message is that Thailand should invest more,

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especially significantly increase in investment on health promotion and disease

prevention program which should be used for cost-effective interventions. One main

challenge of health care financing in Thailand, especially the UC scheme, is the

affordability and sustainability of the government subsidy.

4.1 FINANCIAL RESOURCES FOR HEALTH CARE IN THAILAND

The governments financial source has been the biggest funding source of the MOPH,

yet during the years 1980 1989, the allocated budget decreased from 29.9 percent in

1980 to 19.7 percent in 1989. However, after 1989 the governments allocated budget

for the MOPH started to rise again and reached 37.1 percent in 1997 and 63.4 percent

in 2003. It is due to the fact that during the said period, Thai economy started to

recover, the economic growth was steady and rapid plus the governments policy of

human-cantered development. Efforts were put into the health insurance to cover all

people and promote good health for all. Budget allocation for public health increased

from 4.2 percent in 1989 to 7.7 percent in 1998. However, after the Financial Crisis,

the government had to lower the budget allocation in order to comply with the IMF

agreements. In 2001, the budget allocation was 6.7 percent of the countrys total

budget. It is seen that the budget for MOPH were quite high in the past decade.

Budget data shows that during 1969-01, the allocation was about 2.7 7.7 percent of

the total country budget, or about 0.4 to 1.0 percent of the GDP. This is because the

foreign debt burden and the budget for security have decreased, until the outbreak of

the Financial Crisis in 1997, which has hiked the foreign debt from 5 percent in 1997

to 10.9 percent in 2001. The MOPH, consequently, has been allocated lower budget,

in the fiscal year 2001 - 58,692.2 million baths plus another 2,400 million baths from

the Health Insurance Funds, totaling 61,097.2 million baths, or about 6.7 percent of

the total country budget. In the fiscal year 2003, MOPH received 69,133.94 million

baths or 6.915 percent of the total country budget. However, in term of real value of

the budget, it is found that the 2001 budget was lower than the 1996 budget. It is note-

worthy that during 1997 to 2001, there was a lot of foreign loan. In 1997 the loan was

1,360 million baths, 1998 =1,360 million baths, 1999 = 3,560 million baths,

2000=2,360 million baths, and 2001 = 446 million baths.

From the perspective of expenditures, it can be seen that about 31-53 percent of

budget was for the salary, 28-50 percent for the operation, while a portion of

investment was dependent on the economic situation i.e. about 11-39 percent. The

Private Financial Sources: initially, private sector was the largest financial source for

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the public health financing. Since the coverage of the health insurance has not been

100 percent, 30 percent of the population is without health insurance. This suggests

that these people are to pay for their healthcare. Also, Thai people are used to taking

care of their own health, like buying ones own medicine, when sick. This suggests

that the household financial source for the healthcares is very important in the

MOPHs determining the provision of public health services.

In Thailand, total health expenditure was around 3.5 percent of GDP in 2003. Public

health expenditure of total expenditure on health was 63.4 percent in 2003, whereas

private health expenditure of total expenditure on health was 36.6 percent during

same period. The financial sources from the households in healthcare account for 73.9

percent of the total health care expenditure. In the year 1989, the households

contribution to the health care increased to 80.1 percent due to the fact that the

government had reduced public health budget, resulting in increased financial burden

on the households in taking care of their health. After 1989 until the 1997s Financial

Crisis, the households financing health has a decreasing trend i.e. 62.9 percent, but it

increased to 66.8 percent in 2000.In the future, the economy is expected to be better

and thus the government will be able to provide more financial support for the public

Health plus the policy of public health reformation, which aims to increase the health

insurance to cover every one and improving the quality of the public healthcare

establishments and services. More people are expected to use public health services,

instead of buying their own medication. This also contributes to the decreasing trend

of households healthcare spending. The financial aids from abroad: it is found that

the foreign health financial aids tend to decrease, from 1.44 percent in 1980 to 0.15

percent in 1990, and the decrease propensity is continuing to be 0.14 in 2000. On the

contrary, Thailand is now becoming a financial aids provider rather than a receiver. In

the efforts to heighten the public health insurance, the MOPH, as the principal

responsible agency, has pushed forwards many programs to respond to the

governments policy. One of them is the program of 30 baths for Every Disease,

which started in the April of 2001. It has begun with the participation of the MOPH

healthcare establishments by launching a pilot program in 6 provinces covering 1.3

million eligible people. the program was expanded to the 75 provinces and some

districts of the BKK Metro with participation of 1,017 government healthcare

establishments and 103 private establishments covering 38.8 Million rightful people.

In April of 2002, the program of 30 baths for Every Disease has successfully covered

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all the districts of Thailand with 45 million eligible people under its coverage and

participation of healthcare establishments in all the covered districts. As a result, the

rightful people now have easier and cheaper healthcare access. Further, the MOPH

also encourages people to have their own families dedicated healthcare

establishments, which are near their homes by allowing people to register their

choices of their dedicated healthcare establishments at their nearby Community

Health Centres. Regarding payments for the Health Insurance for All project, the

Office of the Permanent Secretary of MOPH will be responsible for allocating the

fund to each Provincial Public Health Office according to its population size. The

Provincial Public Health Office will in turn allocate the fund to each of its healthcare

establishments, according to its population size.

Total health expenditure (2005)

Indicator 2002 2003 2004 2005The million baht 200,768 210,368 225,652 248,078

The % GDP 3.68 3.55 3.47 3.49Public financing agencies% 63 63 64 64Out-of-pocket 28 25 26 27Other private financing

agencies %9 12 10 9

The baht per capita 3,197 3,335 3,641 3,974

Source: national health accounts in Thailand 2005

5. ORGANIZATION OF THE HEALTH SYSTEMIN THAILAND

The organizational structure at the central level of the MOPH consists mainly 3 task

clusters, described below:

1. The Office of Permanent Secretary of MOPH is responsible for the drafting of

policies, plans, and supervising, monitoring and appraising the outcomes of the

operation units of the Ministry. It also administers to ensure that the execution is in

line with the law, undertakes legislation of laws regarding the health establishments

and other related affairs and is also responsible for the production and development of

public health personnel.

2. The Task Cluster for the development of medicines is responsible for the

development of medical science, the therapeutics and recovery of potency,

development and transfers of medical knowledge and technology for therapy and

recovery of health. The cluster is also responsible for establishing healthcare

standard, and developing alternative medicines for the provision of quality public

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health services to the public for the purpose of good mental and physical health of

the people. The Task Cluster comprises 3 departments - the Department of Health,

the Department of the Development of Thai Medicines and Alternative Medicines

and the Department of Mental Health.

3. The Task Cluster for development of Public Health is responsible for the

development of public health science for promoting health, controlling and

preventing diseases, research and development of knowledge and technology,

transfer of knowledge for promoting health and controlling and preventing

diseases for the purpose of good mental and physical health of the people. It

comprises 2 departments - the Department of Disease Control and the Department

of Health.

4. The Task Cluster of Health Service Support is responsible for supporting the

public health service providing units, the systems and mechanism facilitating

public health service provision and the public health system. They are also

responsible for administering the protection of consumers of healthcare services

and drug products for the purposes that the general people can take care of their

health efficiently and receive standard and quality health services and products.

The Cluster consists of 3 departments - the Department of Service Support, the

Department of Medical Science and the Food and Drug Administration.

The organizational structure of the regional agencies which are under the

administration of the Office of Permanent Secretary of MOPH, consist of Provincial

Public Health Offices, hospitals, Public Health Offices, the PCUs and the community

clinics. The above agencies are the major healthcare service providers who help the

people promote health, control and prevent diseases, and provide medical treatment

and recover health. They utilize the knowledge and technology that have been

developed and transferred from the technical Department and adjust and apply them

appropriately according to the specific requirements of their regions. The

organizational relationship between the technical Department at the centre and the

regional public health operation agencies is basically staff relationship in which the

centre provides support to the regional agencies. For healthcare at the primary level,

there are the PCUs providing the services within the scope of Tambon and village.

They are responsible for arranging a suitable aggregate of health services for the rural

people in their responsibility areas which normally have 1,000 5,000 people. There

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are fulltime public health personnel stationed at the public health units such as

Sanitation Officers, Midwife Nurses and Technical Nurses. In addition, Dental

Officers, Technical Nurses and Public Health Officers are also working there. Public

Health Offices are responsible for the assistance, supports, supervision, monitoring

and appraisal of their accomplishments.

6. PRIMARY HEALTHCARE MANAGEMENT ROLE IN THAILAND

Thailand has a long history of primary health care (PHC) development which started

before the Declaration of Alma Ata in 1978. TheNational PHC programme was

implemented nation-wide as part of the Fourth National Health Development Plan

(19771981) focusing on the training of grass-root PHC workers consisting of

village health communicators and village health

volunteers. Since then PHC hasevolved through many innovative health activities: community organization,

community self-financingand management, the restructuring of the health system and

multi-sectoral co-ordination. Many of the essential elements of PHC have been

achieved. Improvements in the nutritional status of children under five households

accessibility to clean water, immunizationcoverage, and the availability of essential

drugs have been observed. PHC has been successful in Thailand because of

community involvement in health, collaboration between government and non-

governmentorganizations, the integration of the PHC programme, the decentralization

of planning and management, intersectors collaboration at operational levels, resource

allocation in favor of PHC, the managementand continuous supervision of the PHC

programme from the nationaldown to the district level, and the horizontal teaining of

villagersto villagers.

6.1 Conceptual Model of the Primary Healthcare in Thailand

Public policies specific government programs may be formulated analyzed and

evaluated without necessarily taking into account the actual organization. Interest

group further strengthening of the basic health infrastructure to support PHC. A

system of family health facilities which will be the facility for each family and

work with the community and family to improve health related risks and addressing

all new diseases. Ups, this analytical framework is based on two conceptual models of

the implementation process (voradej chandarasorn 1999)

6.2 Management Model

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The model hypothesizes that success of an implementation depends upon the capacity

of responsible implementing organizations the ability to implement policies,

therefore, may be hindered by the following factors

1. inappropriate design of organization and work systems

2. inadequate and poorly trained staff

3. the agencys inability to deploy the personnel to their appropriate place

4. under utilization of resources as well as the utilization of resources in the

wrong direction

Apart from the aforementioned model and theories, this study also benefits from

review of related literature in particular the primary healthcare development for rural

villages require a new management approach. The approach stipulated that.

1. Basic healthcare services could be delivered most cost-effectively if integrated

2. The demand for medical care services could be met, to a great extent, by up

grading existing healthcare personnel to be clinically competent Para

physicians

3. The need for healthcare promotion and disease prevention services could be

more broadly and effectively met through community participation.

The approach proved to be a successful one. Under its guidance primary healthcare

development and personnel development a number of innovations and modifications

of the existing healthcare system which constituted.

1. reorganization and strengthening of the primary healthcare services

Infrastructure by

(I) integrated curative, disease prevention, and healthcare services by

coordinating and administration them a single primary healthcare

administration.

(ii) Establishing a department of community healthcare within the primary

healthcare hospital

(iii) Improving management and supervisory practices in part by developing

a practical management healthcare system.

2. Development of community healthcare from existing healthcare services

personnel, to be deployed to every district hospital and sub- district healthcare

centre

3. Development of community healthcare volunteers in every village including

training of a village healthcare volunteers in every village,

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4. Stimulating other community and private sector involvement by establishing

healthcare committees in every village and at every administrative level, and

by eliciting the interest and support of other private sector group.

7. STRATEGIES FOR IMPLEMENTING PRIMARY HEALTH CARE

In 1998 twenty years after the conference in alma-ata, WHO sponsored a follow up

meeting in ALMATY, Kazakhstan to explore new strategies to achieve health for all

in the 21 century. Participants described sustainable healthcare gains resulting from

the implementation of primary healthcare in many regions, but inadequate progress in

other areas where there had been deterioration in health statues. They concluded that

the PHCs approach had resulted in considerable improvements in health outcomes.

They recognized inconsistent implementation as a key challenges, and identified the

following prerequisites (WHO 2000b) for effective primary healthcare

1. supportive national healthcare policies with long term commitments

2. decentralized responsibility and accountability

3. acceptable conditions for health worker

4. financing to assure access for the poor

5. continuous efforts to improve quality

6. community empowerment and participation

7. sustainable partnerships

These elements when combined in a continuous cycle of planning implementation and

monitoring. Can be used to steer a health system towards better performance. A

variety of additional strategies will enhance the delivery of primary healthcare. They

include community oriented primary healthcare and improving collaboration among

stakeholders.

7.1 Community Oriented Primary Healthcare

Community oriented primary healthcare is a systematic approach to improving

primary healthcare services through integrating clinical medicine with public health at

the community level (kark 1998, Abramson 1998) this involves sequence of related

activities that include

1. defining a community by geographical, demographic or other characteristics

2. determining the health needs of the community in systematic manager

3. identifying and prioritizing healthcare problems;

4. developing programmes to address priorities within the context of primary

healthcare

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5. assessing outcomes

7.2 Uniting Stake holders through Partnership

Primary healthcare is also enhanced by sector wide approaches that unite key players.

Such as development banks, donor organizations and government agencies, around

shared goals and collective responsibilities. The assumption underlying this approach

ins that better use of available funds is likely to occur when healthcare services

delivery policies are developed jointly among involved parties and when those

policies are then reflected in consistent resource allocations and institutional

framework (cassels 2000).

8. Financing Primary Healthcare Services in Thailand

The implementation of government healthcare policies and health initiatives will only

succeed when health care systems are rationally funded to achieve priority objectives.

Apriority goal of primary healthcare is to provide easy access to essential healthcare

services for all with as few financial barriers as possible. A limited number of

physician payment options exist in any country or healthcare system. They include fee

for services. Salaries, capitation payments, integrated capitation and combination

payment systems. While the advantage and disadvantages of each option may vary

depending on social and cultural considerations particular to given country. Some

generalizations about the main system of payment can be made.

In healthcare system financed by free-for service payments, patients are usually not

registered with specification primary healthcare. In addition free-for-services

payments may be associated with relatively higher payments for diagnostic studies

and medical procedures but relatively lower reimbursement for cognitive services

such as counseling and education which characterize the practices of family doctors,

healthcare system that principally use fee-for- services payment have experienced

spiraling costs resulting from the unrestrained incentive to pay for any services

provided.

8.1 Strategies to Improve Primary Healthcare Services

provide sufficient funding to support a strong primary healthcare infrastructure

minimize financial barriers to essential healthcare services

provide financial and other incentives to attract family doctors to increases of

greatest need

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use a combination of payment methods to support and reward high quality

comprehensive, equitable primary healthcare services

measure performance and provide incentive for targeted services such as

prevention8.2 Supporting Primary Healthcare Research

Consistent with breadth of primary healthcare, primary healthcare research

encompasses a broad range of topics including producing in isolation (Van weel 7

knotterus.2000)

Examples of research that can best be done in primary healthcare settings include

1. epidemiology and natural history of common primary healthcare services

problems

2. effectiveness of diagnosis and treatment of healthcare problems in primary

healthcare

3. methods to improve the integration of community primary healthcare with

secondary and tertiary care

4. the relevance of evidence based medicine and treatment guidelines for

primary healthcare patients with multiple problems and in different care

settings

5. methods to integrating preventive services with ongoing illness-oriented

care

6. reduction in errors and increasing patient safety in primary healthcare

7. determinants of patients physician satisfaction in primary healthcare

9. PRIMARY HEALTHCARE EFFICIENCY

The Thai health system is very efficient when compared to other developing

countries, particular for primary health care and health insurance. The Thai health

care systems efficiency of resource use can be determined by comparing the

reduction in the child-mortality rate (death among those aged under 5 years)

compared to total health expenditure per capita. Scaling up primary health care (e.g.

universal coverage of immunization and skilled birth attendance) while creating a

health system with low inequity are likely to be the main reasons for such efficiency

achievements. The primary health care system plays a pivotal role in health

achievements and efficiency improvements of the Thai health care system.

Contracting the district-level health providers to provide primary care and close-to-

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client services for Universal Coverage beneficiaries is an important means of ensuring

efficient and rational use of services while ensuring proper referral systems. The

transport costs incurred by households using these close-to-client services are also

much lower. When the majority of Universal Coverage members who are poor and

residing in rural areas can actually exercise their rights in using a comprehensive

range of services provided by the primary health care network, it results in equity in

health service use and efficient use of public resources. Using fee-for-service

reimbursement to pay health care providers of the Civil Servant Medical Benefit

Scheme sends a strong signal to healthcare providers who are supreme commanders

of health resources to provide more diagnostics, medicines, and probably unnecessary

medical treatment. Empirical evidence consistently confirms Civil Servant Medical

Benefit Scheme beneficiaries receive more branded and more expensive medicines

than beneficiaries in other public health insurance schemes. Moreover, evidence

shows that Civil Servant Medical Benefit Scheme beneficiaries have higher hospital

admission and greater cesarean section rate than other schemes. It is found that even

though Civil Servant Medical Benefit Scheme finances five times higher per capita,

clinical outcome is more or less similar to beneficiaries of the Universal Coverage

scheme.

1. In the Thai health care system, the problem of over-use of medicine,

especially expensive antibiotic drug and new medical technologies is not only

found with the Civil Servant Medical Benefit Scheme, but it is also evident in

health service provision of private for-profit health care providers. The

limited capacity of the government to regulate private for-profit providers

facilitates inefficient use of public and private health resources.

2. The 10th National Development Plan of Thailand makes policy

recommendations for improving efficiency in public health resource use:

9.1 Primary healthcare equity

The investments in health have enabled greater numbers of Thais to receive health

care. This is especially the case for poor people who are able to gain hospital care as a

result of the Universal Health Insurance scheme. Everyone has clearly seen this

improvement. Infant mortality is an indicator of the quality of health care. Among

poor families the infant mortality rate has fallen from 40.8 per 1,000 births in 1990 to

23 in 2000. Thailand has made marked improvements in health equity due to the

expansion of the health insurance coverage provided by the three major public health

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insurance schemes. The Civil Servant Medical Benefit Scheme covers around six

million government employees and their dependants; the Social Security Scheme

protects approximately nine million employees in the formal sector from non-work

related health care expenditure; and the Universal Coverage scheme covering

approximately 47 million people (75 percent of the entire population) who were not

previously beneficiaries of the Civil Servant Medical Benefit Scheme or the Social

Security Scheme. During 1992-2006 the poorest of Thai households spent, on

average, a higher percentage of their household income than the richest. Nevertheless,

inequity in health spending has improved because the proportion of household

spending on health to income of the poorest. Significantly decreased from 8.17

percent in 1992 to 2.23 percent in 2004, whilst that of the richest has slightly

decreased from 1.27 percent in 1992 to 1.07 percent in 2004. The pattern of health

service use also indicates greater equity. For instance, the increase in utilization of

primary care and secondary care levels of the lower income quintiles lead to a

significant improvement of equity in ambulatory service use. Despite the above

mentioned improvements within the Thai health system inequalities still exist between

different socio-economic groups. The rich-poor mortality gap in under-five mortality

rates (U5MR) still occurs. Furthermore, the survey of self-reported health assessment

by the National statistical Office and International Health Policy Program,

10. Changing of health service administrative structure

In the past few years, many changes have occurred in the administrative structure of

health in Thailand. New autonomous organizations, with separate management board

have been set up by the law to take over various important responsibilities from

MoPH. Whether the new structure could create more efficiency of the health system

needed to be closely followed up.

1. The Office of Health Promotion Fund, established as an autonomous agency

under the Prime Minister, manages the 2% earmarked sin tax imposed on

alcohol and cigarette. The office has since become the major agency in

providing funding to various organizations in society for health promotion

activities. Practically, the health promotion budget was shifted from the

MoPH.

2. Office of National Health Security, established as an autonomous agency

under MOPH, with separate management board, manage almost all the health

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service budget which used to be under the MoPH. Whereas the MoPH still

maintain the administrative power over the health facility management.

3. The National Heath Commission Office, established as an autonomous

agency, under the Prime Minister in 2007. The responsibility of the office is

to get broader participation in health policy formation through support of

national and local health assemblies. With all these changes, the good system

of work is needed to be in place for good coordination among stakeholders.

Careful management during the transitional stage will prevent organization

conflict and guarantee future collaboration.

The present economic situation in Thailand is much different than the health situation

when PHC was introduced to the country. Implementation of PHC in the next decade

should be derived from lessons learnt and new initiatives to meet the socio-cultural

and economic growth. The continuous trend of decentralization and community

empowerment are essential factors that should be taken into account in moving

forward. The establishment of the sub district administrative authority to be the local

body for community development is the major milestone for community self reliance.

Community organization, and people themselves will have more potential to

undertake the most innovative schemes for social development. Thus PHC

management and implementation should be decentralized to the sub district

Administrative Organization which is closely linked to existing PHC program. To

ensure the continuity, the sustainability and the true spirit of PHC, future activities

should be initiated as follows:

1. Strengthening of the sub district administrative authority committee in

Health planning and management.

2. Establishment of basic health package, quality standard of health care and facility,

practice guidelines and peoples right in health.

3. Establishment of PHC Collaboration Center to coordinate all related organizations

to bring about multidisciplinary supports for empowering sub district Administrative

Organization in health management.

4. Redefine the roles of VHVs in the context of community self reliance in health.

With the vast experience, VHVs could be the important human asset in the

community in health planning and management.

5. Further support the movement from VHV to every household and every

individuals capacity for health development. This must also be done not only through

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the actions from the MoPH, but using public media as well as overall community

development supported by the Thai Health and the National Health Commission.

6. Further strengthening of the basic health infrastructure to support PHC. A system

of family health facilities which will be the facility for each Family and work with

the community and family to improve health related risks and addressing all new

diseases.

7. Further strengthening of intersectoral movements on health including Healthy

Public Policy/HIA and decentralization of health facilities.

8. Further strengthening of health equity through continuous reform of the Universal

Coverage systems.

11. CHALLENGES FOR THE FUTURE OF PRIMARY HEALTH CARE

National governments and the international community are renewing their efforts to

expand access to PHC and they have committed a lot of financing for this purpose.

But there have been many major changes in these last three decades that pose big

challenges for the future of PHC. The drafters of the Alma Ata Declaration drew

largely on the experiences of those post-revolutionary and post-colonial regimes,

which were rapidly overcoming a lack of health facilities, health workers and drugs.

Whilst some remote areas still lack health services many settings have both trained

and untrained people, providing health care and selling drugs. The boundary between

public and private sectors is blurred and government health workers frequently ask for

informal payments or see patients privately. Many of these activities occur outside an

organised, regulated framework of health care provision. Potential users are much

more likely to live near a health facility or some kind of provider than 30 years ago,

but now they face major challenges in paying for care and finding competent

providers and effective and appropriate drugs.

PHC was designed to deal with prevention/health promotion and with infectious

diseases associated with poverty, poor sanitation and certain insect vectors. Although

these illnesses persist, there is growing pressure on health systems to address other

problems. People are also affected by other chronic conditions, associated with ageing

and lifestyle changes. This raises difficult questions about which treatments are

appropriate, who should pay for them and how health systems should be organised to

help people manage long-term conditions. Concern is growing about the potential

threat of epidemics of new diseases or organisms resistant to the available drugs.

Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza

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pandemic. Government responses rely heavily on convincing people to report

suspicious outbreaks and cooperate with public health measures they may perceive to

be against their short-term interest. This requires high levels of trust between the

population and their health system. More actors are involved in health systems than

thirty years ago, including a variety of private providers of health-related goods and

services, national and international NGOs, citizen advocacy groups and political

parties (where competitive electoral politics have been introduced). Governments are

seeking new ways to influence health systems with their powers to allocate money,

enact and enforce laws and publish information. This sometimes involves new types

of partnership for service delivery and regulation.

Finally, there have been dramatic developments of new technologies for diagnosis and

treatment of disease, which influence the design of health systems. In addition, the

rapid changes in information and communication technologies are having a big

impact. Providers and users of health services increasingly have access to the mass

media, mobile telephones and the internet. They carry health information produced by

governments, professions, citizen advocacy groups and private companies. In contrast

to 30 years ago, when health professionals were the major source of expert

knowledge, people have a variety of sources from which to find information. The

anniversary of the Alma Ata Declaration provides a good opportunity to reaffirm

national and international commitments to expand access to PHC. But, it is important

to understand the changed context when formulating strategies for achieving this.

Many innovations have emerged that involve quite different roles for governments,

markets, civil society and individuals than the drafters of the Alma Ata Declaration

envisaged. We need to find ways to involve all actors in an intensive process of

innovation and learning if the latest statements of good intentions are to be translated

into major improvements for poor people.

12. Health System Strengthening using Primary Health Care Approach

Thailand has achieved universal coverage of healthcare since 2002 by the

Implementation of Universal Healthcare Coverage (UC) Scheme. At present, three

main public health financing schemes cover the entire population. The Social Security

Scheme (SSS) covers formal sector employees while the Civil Servants Medical

Benefit Scheme (CSMBS) covers government employees and their dependences. The

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rest of population is covered by the UC Scheme. The main objectives for universal

coverage are as follows:

1. Equity: An equal sharing of health care expenditure and equity of access to the

same quality of health services.2. Efficiency: Efficient use of resources by good administrative and management

practices.

3. Choice: People have the right to choose their health services in order to reduce the

problem of an imperfectly competitive market.

4. Good health for all: Universal healthcare coverage aims not only to provide

curative care but also to provide disease prevention and health promotion where

appropriate.Thailands health financing system: Summary through PHCs

CSMBS SSS 30 BHAT SCEME

Population groups covered Government employees,

public sector workers and

dependents

Private employees Self-employed and the rest of the

population not covered by

CSMBS and SSS

Estimated population coverage

in 2004 (as a % of total

population of 65.1 millions)

10.0 % 11.2 % 78.8 %

Financing

Source of financing

Financing agent

provide payment method

health expenditure per capita

General tax

Ministry of Finance (MOF)

Fee for services and DRG

3,800 baht

4.5%

Social Security

Office

Capitation

1,830 baht

general tax and co-payment

national health security office

(NSHO), MOPH

Capitation.

of 1414 bhat

Notes: * Health and Welfare Survey (HWS) 2004, National Statistical Office (NSO)

** From 2004 on, the contribution rate has been adjusted from 3% with 1% each of the employee,

employer and government

*** Estimated by Simins, health expenditure per capita of the 30 Baht Scheme in 2004 is 1,614 baht

The Thailand Ministry of Public Health has been examining the possibility of this

idea for several years. Based on research, discussions and brainstorming sessions, the

ideal universal coverage health system should have the following characteristics:

Easy access and simplicity in order to benefit from this programme.

People should be the part of the ownership, overseeing, access and cost sharing of

health services.

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The universal healthcare coverage should reduce the problem of overlap and

inequity of healthcare schemes.

It should be a transparent system. The providers, consumers and third parties/

payers/ purchasers must be able to check easily the effectiveness, and theadministrative power should be balanced among the three partners.

There should be efficiency and equity of budgeting, planning, and development of

the health services based on evidence and information.

It should have appropriate methods of co-payment

It should institute a reasonable role for insurers in order to pool the risks.

Lastly, it should be a accountable, reliable and accepted scheme.

From the above, the Universal Coverage Committee has suggested the three possible

alternatives toward universal health care coverage, as follows:

1. Expansion of existing systems

Now a days, there are several health insurance/welfare schemes in Thailand, for

example, Voluntary Healthcare Card Scheme, Civil Servants Medical Benefit/Welfare

Scheme (CSMBS), Social Security Scheme (SSS; compulsory scheme for formal

sector) and Health Welfare for the low income group, the elderly, children under 12

and other underprivileged groups. Although these schemes have covered various

population groups, they have not yet covered 100% of the total 60 million Thai

populations. Besides, there are still some weaknesses in terms of efficiency and

equity.. If we expanded the previous schemes to become universal health coverage,

the study would need to:

Set the universal standard regulation for health for all.

Change their philosophy to offer health schemes of greater similarity.

Readjust the legislation related to health insurance, especially private health

insurance.

Adapt a registration information system.

Organize the payment mechanism and reimbursement standard to operate in the

same direction.

Set a more appropriate accreditation system and consumer protective system.

The expansion of the previous health schemes would be cost saving from the

adaptation in the initial stage and would not greatly affect the structure of government

services. Furthermore, another strong point is the comparability between health

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schemes. However, these advantages cannot be used for adaptation because of their

existing limitations, for instance, the basis of their capitation and their philosophy.

There are several weaknesses of the expansion concept. Firstly, there is inequity in

health care access and financing systems between the differing health schemes.

Secondly, there are differences in health cover efficiency because each scheme is an

individual independent system administered by different Ministries. Some schemes

are mandatory, other are not. Still many people are not eligible for insurance. Yet,

some people may belong to more than one health scheme to provide necessary gap

coverage because of practical difficulties on both consumer and provider sides.

Lastly, some commercial groups may oppose and try to block the legislation to make

possible the necessary changes seen as blocking their benefits.

2. Single-payer system

The philosophy of this system is a national health insurance, which is managed by

government. This system is suitable for starting when there are no existing health

insurance schemes. In this system, the government can organize health legislation so

all people can access the same basic health services, with pooling of risks for

providers and vertical equity of health financing. The difficulty in a country which

already has health insurance schemes is in the transition stage and the question of how

to integrate all existing health insurance schemes together, since each scheme has

their own funding, concept, package and payment methods.

The strength and weakness of the single-payer system should be analyzed in three

parts, namely equity, efficiency and choice/quality of system. The strong point lies

with equity, in that all people can access in the same basic of health services. With

respect to efficiency, such a system can reduce the adverse selection problem, reduce

the overlap/gaps between previous health schemes and introduce a standard to

administration and to information systems. Lastly, with respect to choice and quality

of care, it offers a way to stimulate the providers to compete with each other in order

to increase the quality of services. A weakness is that, if the administration of the

legislation is not adequate, it will lead to equitably poor care. This system would

possibly fail if the administration were not appropriate since it is based on a

centralized funding system. Moreover, there is no competitive pressure to help

maintain adequate quality or contain the budget.

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3. Dual health insurance system for formal and informal sectors

In this system, there is a parallel between the formal sector, (e.g. civil servant and

state enterprise officers health insurance) and the informal sector (e.g. farmers, self-

employed, elderly, monks children health insurance). For the formalsector health

insurance, the methodology is the same as previously, but it should expand to include

spouses and children less than 18 years in the Social Security Scheme. The system of

Civil Servant and State Enterprise Medical Benefit Scheme should change to the same

direction as the Social Security Scheme with respect to part contribution to funding.

The informal-sector health insurance should be managed under the universal health

fund with support of government, locality organization and resident co-payment.

Poor groups may need to be exempted from co-payment.

A strong point of this system is that, by reducing the weakness of the single payer

system, for example, it can be compared with each existing health schemes and

adjusted accordingly to save costs and to improve the system. However, even though

this system seems to be appropriate, it still has some weaknesses. Thus, it might

encompass some of the inequity and inequality in benefits and budget present in the

existing health schemes. Secondly, the lack of administrative experience in the

informal sector funding may lead in the initial stages to overlap of benefits to the

families of formal sector health insurance recipients. Lastly, it is very difficult in the

political and administrative sense to bring each system of funding together. In

summary, the study has suggested that the appropriate way to move towards universal

health care coverage is to start from the dual health insurance system for formal and

informal sectors before leading to the single-payer or national health insurance in the

future.

The government launched the 30 Baht health policy. The first phase was established

in six pilot provinces - Nakhonsawan, Phayao, Patum Thanee, Samut Sakhon,

Yasothron and Yala in 2001. The insured are all of the people who were not in any

health scheme and whose names are in the house registrations in those provinces.

These people would receive the universal health card or the gold card. This card must

show consistency with the individuals identification card every time they access the

health services, which are the government health services or the private sector health

services registered with this project. The accessing health service has to follow the

referral system from the primary health center or the nearby hospital, which are

registered under the project. For emergencies and accidents, the insured can access

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any government health services. To access needy health services, the insured must

contribute a co-pay of 30 Baht per episode. Under this 30 Baht Universal Coverage

Policy, the insured will receive the same quality health services as offered by other

health schemes. At present, the service package includes most health services except

cosmetic care, obstetric delivery beyond two pregnancies, drug addiction treatment,

hem dialysis, organ transplantation, infertility treatment, and other high cost

interventions. However, with more resources and disease priorities, the inclusion can

expand further over time. From the government side, the funding of the system is paid

by capitation. The total payment per capita paid from tax revenue is 1404 Baht per

year, parts of which are paid to the health care facilities, according to the number of

local residents who are registered with them, hence to be served. This capitation

includes the costs for the curative, preventive, promotional care as well as the

administration. It can be divided into

574 Baht for out-patient care

303 Baht for in-patient care

175 Baht for prevention and control of diseases.

32 Baht for high cost care. This amount of money will accumulate in the central

office of budget. In the case of high cost care, such as neurosurgery, cardiac

surgery, chemotherapy, radiotherapy, etc, the reimbursement can be done by

following the price schedule.

25 Baht for emergency and accident care. The system is the same as for high cost

care.

88 Baht for structural investment. This money will accumulate at the central level

and will be distributed to the healthcare facilities in the appropriate way.

10% of the total package for central and regional administration, developing the

information system and quality assurance.

10% of the out-patient and in-patient services budget for contingency funds. There

are some criticisms from experts, which can be summarized as:

Loss and bankruptcy of services. In the next 5 years, some hospitals would face

the bankruptcy problem and will have to shut down. This problem may occur due

to inadequate hospital management of the budget. Moreover, this problem may

occur from adverse patient distribution, for example, some hospitals have a high

percentage of chronic patients, which is costly.

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Quality of services. Quality of care is still a questionable problem for many

experts. As in the past, there are still some criticisms of the health care quality in

some health schemes, such as the low-income card or Social Security Scheme. At

this point, the government is attempting to compel all hospitals to participate in

the Hospital Accreditation Programme to provide assurance of the quality of care.

Presently, a Clinical Practice Guideline is now being developed to assure the same

quality of services.

Lastly, this system is criticized in regard to the role of the locality in

administrative decision-making. In this context the government still has not set up

tangible methodology.

13. Financing Policies to Achieve Universal Health Care

The national objective for health care during the period 2006 to 2010, as set by the

WHO is: To renovate and improve quality of peoples health protection and care to

meet the requirement in the human development strategy. The document also

specified tasks related to health financing, emphasizing increases in Government

budgets for the grass-roots-level health-care system and preventive health care as well

as support for access to health services by social policy beneficiaries, the poor and

low-income groups. In parallel, with revision of the user-fee policy in the principle of

identifying full costs of health care, the Government would support user fees for the

poor and social policy beneficiaries,

13.1 Public Health Care and Protection Strategy in the 2001-2010

In order to achieve the objective of universal health-care provision, the following

resolution on health financing was introduced in the Strategy for the People's Health

care Protection.

1. State investment for the health-care service shall take the lead in revenues for

the health sector. Efforts will be made to allow higher regular expenditures for

health service from the total State budget. Priority shall be given to poor,

mountainous and remote areas, focusing on preventive services, traditional

health services, maternal and child health care and primary health care in local

medical units, providing health services to the poor and priority targets.

2. Hospital fees shall be adapted in accordance with costs incurred, level of

investment and affordability of the public.

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13.2 Universal Health Care Coverage Policy (30-baht Policy)

The fragmented funding and provision of health care made it difficult to provide

equitable services, and contributed to inefficiencies and variable levels of quality of

care. The implications of reform of the Thai health care system were taken into

consideration by the government in 2001, with regard to financing, delivery of

services, and consumer rights. The main objectives and characteristics of the

Universal Health Care Policy are: universal coverage, single standard, and sustainable

system. To ensure the effectiveness of the system, strong emphasis has been placed on

both resource and technology efficiencies, underpinned by adequate and stable budget

allocation to secure the systems financial affordability. Legislation was initiated so as

to ensure policy sustainability. The government drafted a pertinent law, the National

Health Security Act, which was duly enacted in November 2002, to ensure

sustainability in terms of policy, financing, and institutional support.

13.3 Implementation of the Universal Health Care Policy

In its start-up phase, beginning in April 2001, the 30-baht Universal Health Care

Policy covered six provinces. Coverage was expanded to include 21 provinces, as of

June 2001, followed by its expansion, in October 2001, to all but one province.

Finally, the province with the capital city of Bangkok was included, in January 2002.

As of December, 2005, a total of 47 million people were covered by this scheme. The

remainders comprise eight million people who include civil servants and their

dependents (spouses, parents, and children) and eight million workers covered under

the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Health

Insurance Scheme (SSS), respectively. The above three schemes differ with regard to

eligible population segment, services provided, and financing as well as payment

systems. As funding mechanism, a capitation grant was chosen to finance the UC

scheme. A capitation grant based on a rate of 1,202 baht per registered capita per year

was prepaid to the health care facility to cover the benefit package during the first two

years. The budget under the Universal Coverage Policy was allocated to provinces

according to the registered population. The payment mechanism was applied to both

public-sector and private-sector facilities. Highest priority was given to channeling

allocations to the primary care units based on the registered population. Secondary

and tertiary hospitals were funded from the budget of and through primary care units

for inpatient care, commensurate with their services as determined by the number and

type of referred cases. The capitation grant rate was increased to 1,396.30 baht for the

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fiscal year 2004/2005, owing to study findings that showed a capitation grant rate of

1,510 baht as adequate. After the third year of implementation, household surveys

revealed that the 30 baht Universal Health Care Policy was strongly supported by

the beneficiaries, regardless of their socio-economic status.

13.4 Challenges for 30-baht Policy

Thailand might be one of only few countries whose governments have made headway

towards accomplishing any

resaerch report

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