In 1970, Thailand had an infant mortality rate of 68 per 1,000 live births, while today it is estimated at 13 per 1,000 live births. According to a 2008 study published in the medical journal Lancet, Thailand enjoyed the highest annual rate of reduction in child mortality among 30 low- and middle-income countries between 1990 and 2006. The maternal mortality ratio has also shown a similar decreasing trend. In addition, Thailand has been successful at curbing new HIV infection rates by 83 per cent since 1991, thanks to the arduous efforts made by governments and NGOs.
Such impressive health outcomes did not occur in isolation from its socio-economic development context. From 1969 to 2009, its gross national income (GNI) grew from US$210 to $3,760 in current figures, or 17 times over 40 years. During the 1970s and 1980s, Thailand invested heavily in highways that connect the isolated and impoverished Northeast and North to Bangkok; electrification throughout the country; as well as expansion of school enrollment for both boys and girls. As a result, the positive spillover effects also benefited the public health sector. As economic growth accelerated in the mid-1980s and 1990s, the country continued to finance infrastructure projects which brought greater connectivity, wider access to electricity and safe drinking water and clean sanitation, primary and secondary schools, and primary health centres in rural areas across the country.
Four decades ago when Thailand was still a low-income country, it invested early in health care infrastructure that has reached the most remote rural communities. Instead of concentrating resources to urban tertiary hospital development, public health leaders placed more financing to rural areas from 1982 onwards, which has encouraged greater and affordable access to healthcare at the most local levels. Such investments have paid off. In a study carried out by the London School of Hygiene and Tropical Medicine and released in Bangkok last month, Thailand featured as one of the countries to achieve “good health at low cost”. According to the World Health Organisation (WHO), its total health expenditures (THE) is estimated at 4.1 per cent of its GDP or $328 per capita, which is relatively low for the health outcomes achieved. The extensive network of primary healthcare facilities implemented through district health systems supplemented by some of the excellent research outfits undoubtedly played a crucial role in improving health outcomes especially for the rural population.
In addition, Thailand has been successful in training nurses and doctors for its health system, innovatively distributing human resources to rural areas by engaging new medical graduates to serve for three years in a rural hospital, and providing additional monetary incentives. In addition, health volunteers recruited from local communities also play important support, prevention and detection roles, thereby enhancing community involvement
Thailand’s health achievements are not limited to impressive indicators, but extend to attaining universal health coverage (UHC). Globally, the number of countries that have attained UHC is relatively small, and comprises mostly of OECD countries. Within Asean, Brunei, Malaysia, Singapore and Thailand have achieved UHC, with the Philippines, Vietnam, and Indonesia approaching full coverage as they embark on reforms. Yet, according to the International Labour Organisation (ILO), only 5 to 10 per cent of people are covered in sub-Saharan Africa and South Asia, while in middle-income countries, coverage rates vary between 20 to 60 per cent. Annually across the world, about 150 million people suffer financial catastrophe and 100 million are pushed below the poverty line due to regressive payment systems for healthcare and absence of UHC.
In 2002 when Thailand was still a lower-middle income country with a GDP/capita of $1,900, the country achieved UHC. This did not happen overnight but gradually since the 1970s through the creation of three health insurance schemes: the Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme (SSS) and subsequently the Universal Coverage (UC) Scheme – formerly referred to as the “Bt30” Scheme. Achieving a coverage rate of 99 per cent of the population is more than just meeting a national objective; it represents a source of inspiration to other low- and middle-income countries. As a matter of fact, officials from various health ministries and NGOs from Asia and Africa often request a visit to Thailand’s public health institutions such as the National Health Security Office, International Health and Policy Programme, Health Systems Research Institute and the Ministry of Public Health to “study how Thailand did it”.
As of now, 99 per cent of the Thai population is covered through a comprehensive healthcare package that ranges from health prevention and primary care, to hospitalisation due to traffic accidents to renal replacement therapy and access to ART treatment for HIV.
It has been shown that the UC Scheme has contributed significantly to reducing instances of catastrophic healthcare expenditures, especially in impoverished areas of the country. Based on the recent evaluation of the ten years of the Scheme, the number of impoverished households dropped from 3.4 per cent in 1996 to 0.8-1.3 per cent between 2006 and 2009, thus contributing to poverty reduction, building greater financial stability to vulnerable households and improved long-term livelihood security. In addition, it helps Thailand to attain the principle of the right to health for all. In a country with high income inequality as measured by the Gini Coefficient, access to affordable healthcare is a bridge that helps mitigate many of the socio-economic inequities that still plague this nation.
Thailand has demonstrated that UHC may not be an unattainable dream to be experienced by only the rich countries. Low-income countries such as Ghana and Rwanda have already made much progress towards UHC, and countries such as India and Bangladesh are working towards developing effective UHC systems. The biggest single determinant in this is political commitment. In a round-table conference in Bangkok in November, 2011, UN Secretary-General Ban Ki-moon declared that no countries rich or small would have “enough” resources to carry out UHC reform but the challenge for every country is how soon they can move into it. This was echoed at the recent Prince Mahidol Award Conference with the theme of UHC. Attended by participants from 68 countries, none said that UHC is impossible to achieve in their contexts. With the right policies – social, economic and political, it is possible for a low- or middle-income country to embark on the road towards UHC.
Although Thailand has achieved universal coverage, big challenges remain. These include: how to include foreign migrant workers into the healthcare system; how to merge the three schemes to reduce inequities in benefit packages; how to ensure sufficient and highly-trained human resources in health to meet current shortages; and how to manage Thailand’s transition into a “grey” society in the next decades, and what are the evolving financial mechanism that can be used to better serve the population?
UHC after all is not an endpoint in itself, but a journey that moves us closer to better health for all.
Mushtaque Chowdhury and Natalie Phaholyothin are based at the Rockefeller Foundation’s Asia Regional Office in Bangkok. The article reflects the views of the authors, which do not necessarily represent those of the Rockefeller Foundation.