The Political Economy of UHC Reform in Thailand: Lessons for Low- and Middle-Income Countries

Abstract

Thailand achieved full population coverage of financial protection for health care in 2002 with successful implementation of the Universal Coverage Scheme (UCS). The three public health insurance schemes covered 98.5% of the population by 2015. Current evidence shows a high level of service coverage and financial risk protection and low level of unmet healthcare need, but the path toward UHC was not straightforward. Applying the Political Economy of UHC Reform Framework and the concept of path dependency, this study reviews how these factors influenced the evolution of the UHC reform in Thailand. We highlight how path dependency both set the groundwork for future insurance expansion and contributed to the persistence of a fragmented insurance pool even as the reform team was able to overcome certain path inefficient institutions and adopt more evidence-based payment schemes in the UCS. We then highlight two critical political economy challenges that can hamper reform, if not managed well, regarding the budgeting processes, which minimized the discretionary power previously exerted by Bureau of Budget, and the purchaser-provider split that created long-term tensions between the Ministry of Public Health and the National Health Security Office. Though resisted, these two changes were key to generating adequate resources to, and good governance of, the UCS. We conclude that although path dependence played a significant role in exerting pressure to resist change, the reform team's capacity to generate and effectively utilize evidence to guide policy decision-making process enabled the reform to be placed on a "good path" that overcame opposition.

Understanding the problem of access to public health insurance schemes among cross-border migrants in Thailand through systems thinking

“…Furthermore, the linkage between HICS and public health security can be observed as an accelerator to the likelihood of the HICS selling. The concern over spreading certain infectious diseases from migrants to the wider Thai public (such as tuberculosis, HIV, syphilis and malaria) that could cause public health threats is a major factor which encourages providers to sell the HICS [30][31][32][33][34][35]. As a result, the relationship in access to the HICS and public health security is positive as shown in R2 in the CLD.…”

Financial risk protection of Thailand’s universal health coverage: results from series of national household surveys between 1996 and 2015

“…The achievement of UHC in Thailand is remarkable, in terms of health-utilisation outcomes and economic merit [ 5 ]. The UCS resulted in a reduction of the probability that an ill person would not receive formal treatment and an increased probability of the use of both outpatient (OP) and inpatient (IP) services at public hospitals; the increases in OP utilisation were greatest amongst the poorest part of the population [ 6 ].…”

Financial risk protection of Thailand’s Universal Health Coverage: results from series of national household surveys between 1996 and 2015

“…Key characteristics of these three main schemes are described in Table 1. Source: Tangcharoensathien et al [14] The achievement of UHC in Thailand is remarkable, in terms of health-utilization outcomes and economic merit [4]. The UCS resulted in a reduction of the probability that an ill person would not receive formal treatment and an increased probability of the use of both outpatient (OP) and inpatient (IP) services at public hospitals; the increases in OP utilization were greatest amongst the poorest part of the population [5].…”