Thailand’s Universal Coverage Scheme came out of the manifesto of Thaksin Shinawatra’s Thai Rak Thai party for the 2001 general election. It brought him to power and contributes to his persistent popularity. At the time Shinawatra took over, the government’s tax revenue was just 13% of the Gross Domestic Product – much like in India today. Despite this, Thailand adopted its National Health Security Act in 2002, which created the National Health Security Organisation, an autonomous body under the health ministry that makes decisions on allocation of funds.
The Universal Coverage Scheme provides the budget for the district health systems based on the volume and type of healthcare provided. For outpatient care, funds are disbursed based on the number of people registered with a health centre in that district. The amount per capita is adjusted for the age of the population and the proportion of some chronic diseases being managed. For in-patient care, payment is based on the number of patients treated in any disease category. Unlike the usual insurance schemes, payments are not made case by case. Instead, a year’s budget allocation is computed based on the previous year’s treatment record. The rates are decided by a technical committee and is not subject to the capriciousness of a finance minister. In effect, funding for the scheme is based on requirement and the allocation to health facilities is flexible.
In India, public financing still follows rigid budgetary allocations, leading to inefficiencies. For example, different primary health centres may get the same budgetary allocation despite different numbers and types of patients treated or preventive services provided. The main financing lesson from Thailand’s Universal Coverage Scheme is not purchasing insurance from the private sector but instituting flexible financing of the public sector.
On the same basis as payments are made to the district health systems or to public hospitals, the National Health Security Organisation can purchase healthcare from private hospitals and networks of private providers. But in practice, over 95% of providers and provider networks under the scheme are public because there are slim profit margins under the government scheme. Significant private sector participation is only seen in the case of high-end procedures, and in urban Bangkok.
The Thai government has also built a system of healthcare provider accountability by instituting a robust grievance management and disputes settlement system. The government holds annual public hearings for members of the Universal Health Scheme. Thailand does not rely on consumer choice and competition leading to improvement of quality. It ensures quality by relying on a step-wise quality improvement process guided by a healthcare accreditation institute. This quality improvement is linked to financial incentives to the healthcare provider’s team. By 2012, almost all hospitals in Thailand were accredited or had quality assurance processes in place.
India has taken tiny steps in this direction. As of now, at least 67 public hospitals are accredited under the national quality assurance system – but there is little seriousness about pushing forward with this. The belief is still in markets and competition.
India’s National Health Protection Scheme is meant largely to buy insurance from the private sector and it can weaken the public sector. It covers only limited in-patient services and does not cover the entire population. It is being operationalised in a context where access to healthcare is not yet assured and unregulated private healthcare markets account for most services. Most importantly, it is being rolled out in a system where primary healthcare is weak and there are no linkages between primary care and other levels of care.
Thailand is not an example of new public management and market-based health sector reform. It is more an example of how understanding the political economy of healthcare helps organise services better, to have a more robust human resource strategy and a more flexible and responsive public financing of healthcare, despite changes in government and economic ups and downs.
This is the second part of a two-part series. The first part can be read here.