How access was integrated into health system reforms:

Thailand’s progress in improving primary health care (PHC) has been incremental, with a series of reforms over the last few decades intended to improve both geographic and financial access to PHC.

Geographic:

Starting in the 1970s, in order to address the emigration of Thai-trained physicians, Thailand instituted a three-year mandatory service in the public sector for providers trained in public institutions. Additionally, the country deployed doctors to rural areas, offering them financial incentives and providing increased educational support and opportunities. In addition to the increased supply of doctors in rural areas, Thailand also introduced a new cadre of health workers - community health volunteers (CHVs) – who were responsible for health promotion, basic care, and control of communicable disease and who worked directly in communities.1 

Thailand coupled these interventions with the establishment of multidisciplinary teams. These teams - called contracting units for primary care (CUP) -  included a doctor, nurse, pharmacists, dentist, community health worker, and family caregiver and were established to care for entire families to increase efficiency of delivering person-centered care. In order to be considered a CUP, providers were required to show up for 75% of their scheduled working time, and, as a group, services are required to be provided for at least 56 hours a week with laboratory and transportation systems present. Because these robust teams may not be efficient or feasible in rural settings with a small catchment area, health centers in these areas are required to be associated with a hospital in order to quality as a CUP.2 

What are the important considerations for ensuring geographic access?

There are three important components of geogrpahic access: access to human resources, access to nearby facilities, and access to transportation. Some strategies to address these challenges include strategic deployment of providers across the country, community-based care, voucher programs, and electronic health.

In addition to these efforts to bolster human resources, Thailand has also committed to improving geographic access through strengthened facility infrastructure. Between 1982 and 1986, the Thai government redirected funds intended for hospitals to establish 9,762 PHC centers spread amongst all sub-districts in the country.13

Financial:

Although Thailand had implemented a series of policies and programs that improved financial access to care for specific segments of the population starting in the 1970s, at the turn of the century, approximately 30% of the population still lacked insurance.4 In particular, informal sector workers and the near poor generally did not quality for existing programs and lacked financially accessible care. In conjunction with the reforms discussed above that strove to create a more equitable distribution of providers, in 2002 the National Health Security Act (NHSA) instituted a risk protection scheme called the Universal Health Coverage Scheme/30 Baht program (UCS) to build upon the pre-existing Civil Servant Medical Benefit Scheme and the Social Security Scheme. UCS expanded financial access by providing health insurance to the poor and informal sector workers.5 Under this scheme, beneficiaries payed a 30 Baht (less than $1) copayment for service, and many groups received exemptions from this reduced fee. The copayment was eliminated a few years later but then reinstated in 2012 for largely political reasons.1

Outcomes & Impact:

As a result of Thailand’s significant investment in increasing access to rural primary care, each rural village now has at least one PHC center, and the percent of total outpatient visits occurring in rural areas increased from 29.4% to 41.1% between 1977 and 2006. There has also been a reduction in catastrophic health spending and impoverishment from health payments since the start of the UCS.(5)

The maternal mortality ratio in Thailand has decreased from 37 to 13 deaths per 100,000 live births between 1990 and 2013, and Thailand performs strongly compared to neighboring countries on contraceptive prevalence, measles immunization, and antenatal care coverage.(1) Additionally, among those who were previously uninsured, increased utilization of health care under the UCS resulted in a reduction in infant mortality.(5)

References:

  1. Thailand: Improved geographic and financial access to care strengthens primary care. Primary Health Care Performance Initiative.
  2. Kidd M, editor. The contribution of family medicine to improving health systems. 2nd ed. London: Radcliffe Publishing Ltd; 2013.
  3. Kitreerawutiwong K, Sriruecha C, Laohasiriwong W. Development of the competency scale for primary care managers in Thailand: Scale development. BMC Fam Pract. 2015 Dec;16:174.
  4. Report S. Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years (2001-2010). Nonthaburi, Thailad; 2012.
  5. Hanvoravongchai P. Health financing reform in Thailand: toward universal coverage under fiscal constraints. World Bank [Internet]. 2013;(20):1–36. Available from: http://documents.worldbank.org/curated/en/2013/01/17208145/thailand-health-financing-reform-thailand-toward-universal-coverage-under-fiscal-constraints