318th Meeting - Tuesday, December 8, 2009

Universal Health Care in Thailand - A Presentation and Discussion of Dissertation Fieldwork

by

Joseph Harris

Present: Edward Rose, Caroline Ford, Bodil Blokker, Bruce Kennedy, Louis Gabaude, Helene Lepiray, Joel Akins, Patrice Victon, John Cadet, Edward van Tuyll. An audience of 10.

Background on Presenter:

This research was presented by Joseph Harris, a PhD candidate in Sociology from the University of Wisconsin-Madison.  Joseph has a background in public policy, having worked with the World Bank, UNDP, and Grameen Foundation and having received a Master's degree in Public Affairs from the Woodrow Wilson School of Public and International Affairs at Princeton University.

Research Puzzle:

A number of middle income countries, including Thailand, laid the foundations for universal health care in their constitutions or in enacting legislation right around the same time.  Given the pressures of neoliberalism and globalization, these expansive commitments by the state
were anything but expected.  What accounts for these shifting state obligations towards health care in newly industrial countries?  How have these commitments played out in practice?

Background:

Thailand has taken a gradualist approach to universal health care by enacting a number of government health insurance programs that have increasingly covered more and more of the population over the course of the last 40 years.  These include the Civil Servant Medical Benefit Scheme, the Low Income Health Card for indigent people, the Social Security program for workers in the formal sector (which includes five other benefits as well), and the Voluntary Health Card, which allowed low and middle income people to purchase coverage at a rate subsidized by the government.

In 2001, a new program called the "30 baht to cure all diseases" program consolidated two of the programs - the Low Income Health Card and the Voluntary Health Card - and extended coverage to an additional 30% of the population that had previously been excluded.  While my work was interested in the overall historical development of these programs, the major focus of my research explored the development and implementation of the major reform in 2001, which was also called the Universal Coverage (UC) program by technocrats within the Ministry of Public Health.

While the media and many scholars typically credit Thaksin Shinawatra's Thai Rak Thai with the reform, my work examined the role of other actors in the policy's development, including international organizations, local NGOs, and academics.  My historical research also examined fissures within the medical profession itself.

Preliminary Findings:

The ideas for universal health care in Thailand have a longer history than some conventional accounts and some sociological explanations would suggest.  My research emphasizes the work of a network of medical professionals with ties dating back over 30 years and locates the development of universal health care in the broader context of activism by NGOs and the AIDS movement.  I historically document how the original ideas of people within this network changed over time and were shaped by a number of domestic experiments and international experiences.  In this way, we come to understand how ideas that were initially inspired by the Health for All mantra of Primary Health Care were transformed into
Universal Health Care policy.

The second part of my research explores how Thailand's universal health care program works in practice.  A number of positive consequences are clear: Thailand's web of health care programs now covers 98% of the population.  In just two years, health-related catastrophic expenditures were cut in half.  Benefits of the UC program have grown to rival those of
the Social Security scheme and now include such high-tech treatments as HIV/AIDS medication, cancer drugs, dialysis, and methadone replacement therapy.  The reform also had major consequences in terms of strengthening the health care system as a whole.

However, the reform caused a number of tensions as well, among them consternation in the medical profession and long wait times at participating secondary and tertiary health care facilities.  The new scheme also brought attention to the fact that different kinds of benefits
are available among the different government health insurance programs as well as differences between public and private providers.

In terms of cost, the scheme's budget has more than doubled since it started in 2001.  Since it was under-budgeted initially, this has put its budget more in line with what some health economists thought to be a reasonable amount.  Currently, while some participating hospitals face problems balancing their books since the scheme's introduction, enough money exists in the system as a whole to prevent the system from collapsing.  Economists are continuing to make adjustments to the budget formulas to ensure appropriate levels of admissions and referrals at participating hospitals.  The reform is a work in progress.

In terms of sustainability, most health economists agree that the Civil Service Medical Benefit Scheme, not the UC program, is the biggest threat to the financial sustainability of the country's health care system today. At a budget of 60,000 million baht, that program covers less than 10% of the population.  The UC program, by contrast, covers nearly 80% of the
population but has a budget that is just under double the amount of the civil service program.  In many ways, the fee-for-service structure of the civil service program is similar to the structure of the private health insurance system in the U.S.  How Thailand addresses their problem may offer insights that could be useful in a reform in the U.S. (if that ever
proves politically feasible).

Concluding Points:

Conventional accounts of universal health care development in Thailand have underemphasized the role of professional networks and civil society. While indigenous Thai organizations should rightfully enjoy credit for the successes of the reform, international organizations have supported Thai efforts in ways that have been underappreciated and underreported.  This work serves as a corrective to those accounts and suggests that serious
historical work explore local social movements in other cases in which states in middle income countries recently made expansive commitments to health care.