Lessons from Thailand: For universal health coverage, invest in public systems and human resources

Finance Minister Arun Jailtley’s Budget speech this year and the subsequent media coverage projected insurance coverage as being almost synonymous with universal health coverage. Nothing could be further from the truth. Health insurance is only a small part of ensuring universal health coverage. Besides, to get health insurance right, it has be designed differently from publicly-funded health insurance programmes of India. A study of health insurance in Thailand helps understand why.

Thailand is the developing world’s beacon when it comes to universal health coverage, which is simply defined as “all people having access to quality healthcare to meet their healthcare needs without financial hardship”. Not only does Thailand have better health outcomes, it also offers almost complete financial protection to its citizens, and is responsive to the entire range of healthcare needs – from common cold to organ transplantation. There are few expressly stated exclusions such as cosmetic surgery. Furthermore, Thailand’s public health expenditure is only about 3% of its Gross Domestic Product. Brazil and Cuba have also achieved universal health coverage but spend close to 8% of their GDP on health. All developed nations spend even more for universal health coverage. Thailand’s level of public health expenditure is one that India can easily afford and so its healthcare model is one for India to emulate.

Thailand’s success has been attributed to what is called the Universal Coverage Scheme, once also called the 30 baht scheme after its popular slogan, “30 baht pays for everything”, referring to the country’s currency. Thailand has three government-run insurance programmes. Like India’s Central Government Health Scheme, Thailand has a comprehensive insurance scheme for civil servants. Like India’s Employees’ State Insurance, Thailand has a social insurance cover for its organised sector employees. The Universal Coverage Scheme covers the rest and is very different from the existing and proposed publicly-funded insurance programmes in India.

People in place

One crucial difference is that when the Universal Coverage Scheme was launched in 2002, the infrastructure and human resource requirements of the public health system had been largely met. The Thai public health system like India’s is built around district health systems, but with important differences. A district in Thailand has a population of about 50,000 to 70,000, which is smaller than an administrative block or tehsil in a district in India. A Thai district is served by a district hospital and several health centres. Each of these centres serves 3,000 to 5,000 people and is staffed by three to five non-medical care providers, either nurses or trained paramedics.

In terms of the population served, the Thai health centre is much like India’s health sub-centre, only India’s have just two staff and provide select services – largely antenatal care, immunisation and access to contraceptives. A Thai health center provides the entire range of primary healthcare needs, including care for all infectious diseases, as well as regular medication and care for hypertension, diabetes, asthma and respiratory diseases, mental illnesses, arthritis and most such chronic illnesses.

In India, this wider range of services is expected only of primary health centres, each of which caters to 20,000 to 30,000 people. A primary health centre relies on the presence of a doctor. In practice, even in a well-performing state health system, only the block or district hospital provides such a range of services. Most primary health centres, in practice, provide only limited services that represent less than 10% of all morbidities. If and when India’s health centres are upgraded to 1.5 lakh Health and Wellness Centres as envisioned in the National Health Policy, it will be a system equivalent to Thailand’s. However, even though the Indian government’s health budgets have reinforced the idea of Health and Wellness Centres, they have failed to provide adequate funds for them.

The Thai district hospital system is also much stronger than India’s. Each of Thailand’s district hospitals serves about 50,000 people and can have between 30 and 100 beds. Even a 30-bed district hospital in Thailand is staffed by three to four general practitioners, 30 nurses, two to three pharmacists, one to two dentists, and more than 20 paramedics and other administrative staff. Larger district hospitals often have specialist doctors in addition to regular medical staff. A district hospital in India, on the other hand, serves between 10 lakh and 20 lakh people. India has 30-bed community centres but they provide services more along the lines of primary health centres, providing pregnancy care and care under national disease control programmes, and not district hospitals. Curiously, community health centres and district hospitals in India have far more doctors than district hospitals in Thailand, but far fewer nurses and paramedics.

The biggest difference is that all healthcare, including drugs and diagnostics, in the Thai public health system is free. All it asks for is a voluntary payment of 30 baht, or Rs 60, from those who can afford it. For comparison, the daily minimum wage in the country is 300 baht.

Thailand’s Universal Coverage Scheme can purchase care from the private system as well, like any insurance system. However, the government has fixed reasonable rates for care from the private system while consciously promoting the public district health system, which is managed by the Ministry of Public Health, or MOPH. Most secondary and tertiary care under the Universal Coverage Scheme is provided at provincial and regional government hospitals. A recent report on the Thai health system in the journal Lancet states:

“In 2014, 67% of the country’s 1,61,000 hospital beds were in MOPH facilities, 14% of beds were in other public non-MOPH facilities, and 19% of beds were in private hospitals. The private sector generally has a small role in health delivery: in 2015, it contributed 14% of total outpatient visits (9% at private clinics and 5% at private hospitals) and 11.3% of total admissions.”  

Thailand vs India

One of India’s big problems in building a strong public health system is attracting and retaining human resources in rural and remote areas and within public services. This is how Thailand addresses this challenge.

• In Thailand, all posts are regular appointments under the MOPH with salaries paid by the department. There are no individual performance-based monetary incentives. India fails to sanction adequate healthcare posts and when it does, the government prefers to extend only contractual employment.
• In Thailand, all doctors, dentists and pharmacists, have a three-year mandatory rural health service placement that like in India is poorly enforced and enforceable. However, Thailand also has a provision for generous financial incentives for those working in rural areas. A doctor in a rural area can be paid be more than twice that of his or her urban counterpart and gets free housing. These incentives have made a huge difference to eliminating vacancies in the rural healthcare system. 
• Thailand has a special track to recruit high-school students from rural and underserved areas into medical and nursing courses on the condition that they work in their home districts after graduating. This special track has contributed to 20% of total annual national medical student enrolment in the past decade, and though entrance scores of candidates are lower, they show no difference  in grades compared to regular medical candidates while passing out. Moreover, in the last three years of their medical posting, their clinical training is in public hospitals located in their home districts. Between 2000 and 2014, 5,927 medical graduates from the special track programme added substantially to the provision of rural services.  This has been suggested in India, but never picked up, though there is evidence from all over the world that measure works effectively. 
• The MOPH established nine public health schools to train paramedical personnel, mostly through two-year diploma courses. These more than 25,000 public health officers provide almost all care in levels below district hospitals as well as in the national health programmes. These graduates filled the human resource gaps during Thailand’s rapid expansion of its district health systems. The diploma courses have now been replaced by bachelor’s courses to improve quality and standards.
• In addition to all this, Thailand has a workforce of close to 14 lakh community health volunteers, each paid about 600 baht, equal to Rs 1,200, per month. The country has one community health worker for every 20 households. In comparison, India has 9 lakh Accredited Social Health Activists, one for about 200 households.

This is the first part of a two-part series. The second part will explain how Thailand has managed to finance its universal healthcare programme without relying on private health insurance.