Wednesday, May 9, 2012

[EQ] Thailand's Universal Coverage Scheme: Achievements and Challenges

Thailand’s Universal Coverage Scheme: Achievements and Challenges

An independent assessment of the first 10 years (2001-2010)

This study was funded by the Health Systems Research Institute, the Prince Mahidol
-Award Conference, the World Health Organization Regional Office for South-EastAsia and the National Health Security Office.

May 2012 - Health Insurance System Research Office

Available online PDF [120p.] at:

“…..The assessment shows there were some extraordinary achievements in the first 10 years of the UCS. However, the UCS is an ongoing, long-term reform and further work is needed to address a number of challenges. Based on the insights gained through the assessment, two sets of policy recommendations — one set related to the unfinished agenda and one to the future agenda — are offered with a view to sustaining and improving the UCS over the next 10 years…..”

Policy implications for the rest of the world

Many factors contributed to the successful implementation of the UCS policy, including political and financial commitments, a strong civil service acting in the public interest, active civil society organizations, technical capacity to generate and use research evidence, economic growth, and policies to increase fiscal space. While some countries may find this list daunting it is important to realize that all these elements can be developed over time. Countries must find their own path to universal coverage — while no blueprint emerges from this work, the Thai reform experience provides valuable lessons.

Managing the process

As important as it is to bring different stakeholders together to listen, consult, negotiate and compromise, it is essential that the leaders of the reform have

the power to resolve conflicts and to drive through the necessary changes.

Otherwise countries risk getting stuck in the design stage, stalled by interest groups that feel threatened and are resisting change. Countries need a concrete plan to manage the reform process. It is also important to build capacity, not just to design a universal coverage scheme, but also to manage its implementation, including capacity for learning from the experience and tweaking the scheme as it is implemented.

Designing the system

Three design elements are essential to achieve universal coverage: extension of access to services, cost containment and strategic purchasing. Financing reform must go hand in hand with ensuring physical access to services. There is no point giving people a theoretical entitlement to financial protection if they have no access to local services or if it is too costly to access services outside the community in which they live. Thailand was in a good position to implement the UCS policy because for decades the government had invested in building local health infrastructure.

Cost containment mechanisms are critical because unless costs are controlled it will be difficult to cover the whole of the population and to provide adequate services; such mechanisms ensure long-term financial sustainability. Two such features of the UCS are the emphasis on primary health care (which was historically weak in Thailand) as the main first level of care, and the payment mechanisms, which use capitation and case-based payment within a global budget to fix the total cost. The third design element, strategic purchasing, is necessary to manage the rationing of services and to direct the provision of care to those areas where need is greatest………..”



Executive Summary

Chapter 1. Introduction

Chapter 2. Setting the scene: background to the Universal Coverage Scheme UCS reform

Chapter 3. Why the Universal Coverage Scheme UCS was launched in 2001:
                  the convergence of political commitment, civil society mobilization and technical know-how

Chapter 4. The Universal Coverage Scheme UCS policy: a brief overview

• Goal and strategic objectives

• Tax-financed scheme free at the point of service

• Comprehensive benefits package with a primary care focus

• A fixed annual budget and a cap on provider payment

• Not poor health care for poor people

Chapter 5. New institutions and new ways of working

Chapter 6. Implementing the Universal Coverage Scheme UCS: institutional conflicts and resistance to change
            • Purchaser-provider split: anything but cut and dry

• Redefining institutional roles and relations: muddy and murky waters

• Health workforce: more difficult to redistribute according to need than anticipated

• Harmonization of public health insurance schemes
• High levels of satisfaction among Universal Coverage Scheme UCS members and providers

Chapter 7. Governance: good, but room for improvement

• Participation, transparency, consensus and rule of law

• Responsiveness and accountability

• Effectiveness and efficiency

• Other accountability concerns

• Overall governance of the NHSB and its subcommittees

Chapter 8. Significant positive impacts in the first 10 years

• Increased utilization and low levels of unmet need demonstrate improved access

• Decreasing catastrophic expenditures and household impoverishment

• Difficult to measure but important impact indicators

• Spill-over effects on the health system

• Macroeconomic impacts of the Universal Coverage Scheme UCS

Chapter 9. Universal Coverage Scheme UCS in the next 10 years: the challenges ahead

• Continuing towards full implementation of the UCS

• Managing the growth of the UCS

Chapter 10. Recommendations and lessons

• Policy recommendations for Thailand

• Policy implications for the rest of the world

• Concluding remarks


Annex: Framework for assessing the Thai Universal Coverage Scheme



International experts: Timothy G. Evans, BRAC University; A. Mushtaque R. Chowdhury, Rockefeller Foundation; David B. Evans, World Health Organization; Armin H. Fidler and Magnus Lindelow, World Bank; Anne Mills, London School of Hygiene & Tropical Medicine; Xenia Scheil-Adlung, International Labour Organization.

Thai secretariat team: Viroj Tangcharoensathien and Walaiporn Patcharanarumol, International Health Policy Program; Pongpisut Jongudomsuk, Health Systems Research Institute; Samrit Srithamrongsawat, Aungsumalee Pholpark, Patchanee Thamwanna and Nutnitima Changprajuck, Health Insurance System Research Office.



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