The introduction of the universal coverage of health care in Thailand : policy responses

In 2001, Thailand introduced the Universal Coverage of Health Care Policy (UC) very rapidly after the new government came to power. The policy aims to entitle all citizens to health care and includes health system reforms to achieve equity, efficiency, and accountability. The overall question this thesis asks is how did this policy come about, and how likely is it that the policy will achieve its goals? Literature suggests that understanding the policy process is as important as assessing the content of particular policies when judging policy outcomes. By using an analytical framework to explore four elements: context, actors, process, and content, this thesis aims to generate general understanding of the UC policy process, and to use this analysis to assess implementation. It starts by addressing how and why universal coverage, which had long been discussed in Thailand, got on to the policy agenda in 2001, and then explores how the policy was formulated nationally. It goes on to look at implementation in one province, examining the inter-relationships between provincial, district and community facilities. Data were gathered from key informant interviews, document and media analysis, and group discussion with villagers. The analysis suggests that Thailand's democratization, created new actors in health policymaking processes which had long been under control of bureaucrats and professionals. The 1997 Constitution encouraged a more pluralistic political system. Universal access to health was advocated by a group of non-government organizations who pushed to get UC through legislation and announced their campaign a few months before the 2001 election. NGO interest was paralleled by a political party campaign, announced in 2000 by the Thai-Rak Thai Party, and implemented as UC when the Party came to power. UC was picked up because it was seen as legitimate, feasible under the existing infrastructure and government budget, and also congruent with the reform intention of the political party. Once it became the government in 2001, an important factor in early policy formulation was the extent to which national research provided evidence to support the policy. The research community was tightly-knit and concentrated in medical-related professions. One member of this policy community played an important role as a policy entrepreneur. This policy community continued to support evidence for debates in policy-making during both policy formulation and implementation. The implementation process was a top-down process; however, there were some spaces for street level bureaucrats to adapt decisions to fit their context. Implementation started through the extension of insurance coverage in four phases under the execution of the Ministry of Public Health. Private providers were only minimally involved in these formulation and implementation phases. The UC policy in 2001-2 was characterised by clear policy goals, limited participation, strong institutional capacity, and very rapid implementation - all factors which anticipated success of the policy. However, the complex technical features of the policy and the big change in system reform were a brake on success. One of the implementation problems was the mobilization of human resources, especially where bureaucrats were resistant to change. It seems that the implementation of the UC policy in Thailand reflected both managerial as well as political problems. Given the findings of this study, policy monitoring should pay attention to political as well as technical assessment.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Stakeholder’s Assessment of the Awareness and Effectiveness of Smoke-free Law in Thailand

Background This study reports stakeholders’ ratings, and perceived gaps in World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Article 8 implementation in Thailand viewed against WHO’s Guidelines for Article 8 and to inform action in preparing the 2017 Tobacco Product Control Act. Methods Stakeholder ratings of Guideline provisions of Article 8 on a three-tiered scale of implementation from understanding to effectiveness and efficiency were used to identify gaps in enforcement and compliance important to success in meeting Article 8 goals. This stakeholder assessment occurred through a stakeholder meeting of 55 stakeholders in Bangkok, Thailand in June 2016. Results The average of all assessment ratings by stakeholders on an ascending 0-3 scale had a mean score of 1.67, which means the level of implementation for Article 8 in Thailand was rated less than effective for enforcement. The assessment shows that the public understanding of smoke-free principles is also poor at a mean of 1.28, that there is incomplete effectiveness of smoke-free measures with a mean of 1.75, and only a general effectiveness that smoke-free protections are adequately covering most places with a mean of 1.98. More needs to be done to make all places compliant through enforcement efforts rated with a mean of only 1, and that more is necessary for protection from tobacco-smoke exposure in other public places and in private vehicles with mean ratings of 1.71 and 1.14. Conclusion This stakeholder approach using a three-tiered rating scale found that the implementation of Article 8 in Thailand is still lacking. With this approach, stakeholders identified critical issues needing improvement and informed changes in the then-proposed Tobacco Product Control Act which later was adopted in 2017

Stakeholder’s Assessment of the Awareness and Effectiveness of Smoke-free Law in Thailand

Abstract Background: This study reports stakeholders’ ratings, and perceived gaps in World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Article 8 implementation in Thailand viewed against WHO’s Guidelines for Article 8 and to inform action in preparing the 2017 Tobacco Product Control Act. Methods: Stakeholder ratings of Guideline provisions of Article 8 on a three-tiered scale of implementation from understanding to effectiveness and efficiency were used to identify gaps in enforcement and compliance important to success in meeting Article 8 goals. This stakeholder assessment occurred through a stakeholder meeting of 55 stakeholders in Bangkok, Thailand in June 2016. Results: The average of all assessment ratings by stakeholders on an ascending 0-3 scale had a mean score of 1.67, which means the level of implementation for Article 8 in Thailand was rated less than effective for enforcement. The assessment shows that the public understanding of smoke-free principles is also poor at a mean of 1.28, that there is incomplete effectiveness of smoke-free measures with a mean of 1.75, and only a general effectiveness that smoke-free protections are adequately covering most places with a mean of 1.98. More needs to be done to make all places compliant through enforcement efforts rated with a mean of only 1, and that more is necessary for protection from tobacco-smoke exposure in other public places and in private vehicles with mean ratings of 1.71 and 1.14. Conclusion: This stakeholder approach using a three-tiered rating scale found that the implementation of Article 8 in Thailand is still lacking. With this approach, stakeholders identified critical issues needing improvement and informed changes in the then-proposed Tobacco Product Control Act which later was adopted in 201

Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity.

BACKGROUND: Empirical evidence demonstrates that the Thai Universal Coverage Scheme (UCS) has improved equity of health financing and provided a relatively high level of financial risk protection. Several UCS design features contribute to these outcomes: a tax-financed scheme, a comprehensive benefit package and gradual extension of coverage to illnesses that can lead to catastrophic household costs, and capacity of the National Health Security Office (NHSO) to mobilise adequate resources. This study assesses the policy processes related to making decisions on these features. METHODS: The study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources. RESULTS: Continued political and financial commitments to the UCS, despite political rivalry, played a key role. The Thai Rak Thai (TRT)-led coalition government introduced UCS; staying in power 8 of the 11 years between 2001 and 2011 was long enough to nurture and strengthen the UCS and overcome resistance from various opponents. Prime Minister Surayud's government, replacing the ousted TRT government, introduced universal renal replacement therapy, which deepened financial risk protection.Commitment to their manifesto and fiscal capacity pushed the TRT to adopt a general tax-financed universal scheme; collecting premiums from people engaged in the informal sector was neither politically palatable nor technically feasible. The relatively stable tenure of NHSO Secretary Generals and the chairs of the Financing and the Benefit Package subcommittees provided a platform for continued deepening of financial risk protection. NHSO exerted monopsonistic purchasing power to control prices, resulting in greater patient access and better systems efficiency than might have been the case with a different design.The approach of proposing an annual per capita budget changed the conventional line-item programme budgeting system by basing negotiations between the Bureau of Budget, the NHSO and other stakeholders on evidence of service utilization and unit costs. CONCLUSIONS: Future success of Thai UCS requires coverage of effective interventions that address primary and secondary prevention of non-communicable diseases and long-term care policies in view of epidemiologic and demographic transitions. Lessons for other countries include the importance of continued political support, evidence informed decisions, and a capable purchaser organization

Developing health systems research capacities through north-south partnership: An evaluation of collaboration with South Africa and Thailand

BACKGROUND: Over the past ten years, calls to strengthen health systems research capacities in low and middle income countries have increased. One mechanism for capacity development is the partnering of northern and southern institutions. However, detailed case-studies of north-south partnerships, at least in the domain of health systems research, remain limited.This study aims to evaluate the partnerships developed between the Health Economics and Financing Programme of the London School of Hygiene and Tropical Medicine and three research partners in South Africa and Thailand to strengthen health economics-related research capacity. METHODS: Data from programme documents were collected over five years to measure quantitative indicators of capacity development. Qualitative data were obtained from 25 in-depth interviews with programme staff from South Africa, Thailand and London. RESULTS AND DISCUSSION: Five years of formal partnership resulted in substantial strengthening of individual research skills and moderate instituonalised strengthening in southern partner institutions. Activities included joint proposals, research and articles, staff exchange and post-graduate training. In Thailand, individual capacities were built through post-graduate training and the partner institution developed this as part of a package aimed at retaining young researchers at the institution. In South Africa, local post-graduate teaching programs were strengthened, regular staff visits/exchanges initiated and maintained and funding secured for several large-scale, multi-partner projects. These activities could not have been achieved without good personal relationships between members of the partner institutions, built on trust developed over twenty years. In South Africa, a critical factor was the joint appointment of a London staff member on long-term secondment to one of the partner institutions. CONCLUSION: As partnerships mature the needs of partners change and new challenges emerge. Partners' differing research priorities (national v international; policy-led v academic-led) need to be balanced and equitable funding mechanisms developed recognising the needs and constraints faced by both southern and northern partners. Institutionalising partnerships (through long-term development of trust, engagement of a broad range of staff in joint activities and joint appointment of staff), and developing responsive mechanisms for governing these partnerships (through regular joint negotiation of research priorities and funding issues), can address these challenges in mutually acceptable ways. Indeed, by late 2005 the partnership under scrutiny in this paper had evolved into a wider consortium involving additional partners, more explicit mechanisms for managing institutional relationships and some core funding for partners. Most importantly, this study has shown that it is possible for long-term north-south partnership commitments to yield fruit and to strengthen the capacities of public health research and training institutions in less developed countries

International service trade and its implications for human resources for health: a case study of Thailand

This study aims at analysing the impact of international service trade on the health care system, particularly in terms of human resources for health (HRH), using Thailand as a case study. Information was gathered through a literature review and interviews of relevant experts, as well as a brainstorming session. It was found that international service trade has greatly affected the Thai health care system and its HRH. From 1965 to 1975 there was massive emigration of physicians from Thailand in response to increasing demand in the United States of America. The country lost about 1,500 physicians, 20% of its total number, during that period. External migration of health professionals occurred without relation to agreements on trade in services. It was also found that free trade in service sectors other than health could seriously affect the health care system and HRH. Free trade in financial services with free flow of low-interest foreign loans, which started in 1993 in Thailand, resulted in the mushrooming of urban private hospitals between 1994 and 1997. This was followed by intensive internal migration of health professionals from rural public to urban private hospitals. After the economic crisis in 1997, with the resulting downturn of the private health sector, reverse brain drain was evident. At the same time, foreign investors started to invest in the bankrupt private hospitals. Since 2001, the return of economic growth and the influx of foreign patients have started another round of internal brain drain

The introduction of the universal coverage of health care in Thailand : policy responses

In 2001, Thailand introduced the Universal Coverage of Health Care Policy (UC) very rapidly after the new government came to power. The policy aims to entitle all citizens to health care and includes health system reforms to achieve equity, efficiency, and accountability. The overall question this thesis asks is how did this policy come about, and how likely is it that the policy will achieve its goals? Literature suggests that understanding the policy process is as important as assessing the content of particular policies when judging policy outcomes. By using an analytical framework to explore four elements: context, actors, process, and content, this thesis aims to generate general understanding of the UC policy process, and to use this analysis to assess implementation. It starts by addressing how and why universal coverage, which had long been discussed in Thailand, got on to the policy agenda in 2001, and then explores how the policy was formulated nationally. It goes on to look at implementation in one province, examining the inter-relationships between provincial, district and community facilities. Data were gathered from key informant interviews, document and media analysis, and group discussion with villagers. The analysis suggests that Thailand's democratization, created new actors in health policymaking processes which had long been under control of bureaucrats and professionals. The 1997 Constitution encouraged a more pluralistic political system. Universal access to health was advocated by a group of non-government organizations who pushed to get UC through legislation and announced their campaign a few months before the 2001 election. NGO interest was paralleled by a political party campaign, announced in 2000 by the Thai-Rak Thai Party, and implemented as UC when the Party came to power. UC was picked up because it was seen as legitimate, feasible under the existing infrastructure and government budget, and also congruent with the reform intention of the political party. Once it became the government in 2001, an important factor in early policy formulation was the extent to which national research provided evidence to support the policy. The research community was tightly-knit and concentrated in medical-related professions. One member of this policy community played an important role as a policy entrepreneur. This policy community continued to support evidence for debates in policy-making during both policy formulation and implementation. The implementation process was a top-down process; however, there were some spaces for street level bureaucrats to adapt decisions to fit their context. Implementation started through the extension of insurance coverage in four phases under the execution of the Ministry of Public Health. Private providers were only minimally involved in these formulation and implementation phases. The UC policy in 2001-2 was characterised by clear policy goals, limited participation, strong institutional capacity, and very rapid implementation - all factors which anticipated success of the policy. However, the complex technical features of the policy and the big change in system reform were a brake on success. One of the implementation problems was the mobilization of human resources, especially where bureaucrats were resistant to change. It seems that the implementation of the UC policy in Thailand reflected both managerial as well as political problems. Given the findings of this study, policy monitoring should pay attention to political as well as technical assessment