Thailand: Improved geographic and financial access to care strengthens primary care
Melissa May/Courtesy of Photoshare
Over the last four decades, Thailand has focused substantial investment and planning into strengthening its primary health care (PHC) system to attain universal health coverage. To achieve this goal, Thailand recognized the need to reduce the high levels of inequalities between income groups and between rural and urban populations. Thailand’s reforms prioritized strengthening a district health system with a strong pro-rural and pro-poor focus [1-4]. Many of Thailand’s reform initiatives were directed towards two major goals: 1) expanding the geographic accessibility of effective primary health care and 2) protecting the poor from unaffordable health costs and improving financial accessibility of primary health care.
Expanding Geographic Access
Infrastructure: Throughout the 1970s and 1980s, Thailand implemented reforms designed to increase geographic access to primary healthcare services by increasing and improving rural health infrastructure and increasing the supply of primary health care providers outside of large urban centers. From 1982 to 1986, the government of Thailand halted new investments in urban hospitals and invested the money earmarked for these facilities into building rural district hospitals and health centers . The Thai government built at least one primary care health center in all sub-districts in the country (9762 in total) and community hospitals in over 90 percent of districts, doubling the number of these hospitals by the mid-1990s [6-8].
Human Resources: From 1960-1975, it is estimated that 25 percent of physicians trained in Thailand emigrated out of the country, primarily to the United States and United Kingdom . This emigration created a shortage of doctors throughout Thailand, with the largest gaps in rural areas. Beginning in 1972, Thailand required graduates of public medical schools to work for three years in the public sector in Thailand or pay a significant penalty fee. [8-10]. In the wake of the Alma Ata Declaration and the new international focus on Health for All, Thailand began specifically deploying doctors to rural areas resulting in a fourfold increase in the number of rural doctors from 300 to 1162 by the mid-1990s . To supplement and further incentivize physicians to work in rural locations, the Collaborative Project to Increase Rural Doctors (CPIRD) began in 1974, which provided increased medical education opportunities for those with a rural background; students were recruited from rural regions, trained, and returned to their town to practice [8, 10]. The CPIRD program has been successful with an incidence rate of 14.9 percent of physicians leaving rural areas over an 11-year period compared to 17.6 percent of physicians not in the CPIRD program . However, long-term success has still been challenging. By the fourth year of recommended Ministry of Health rural service, only 51 percent of CPIRD physicians and 44 percent of non-enrolled physicians remained .
The unequal distribution of physicians between rural and urban areas has fluctuated since the 1970s, influenced by the rise of the private sector, which was primarily urban and serving the wealthier populations. Although never reaching the inequity seen in the 1960s and 1970s, by 2007, doctor density in Bangkok was 10 times higher than that in the most rural areas of the country . In response, to incentivize physicians to work in rural hospitals, the government created a financial scheme that supplemented physician income with a monthly allowance, and in 2008, physicians in rural areas received 10-15 percent more per month compared to new physicians in urban, non-private hospitals .
Irene Laxmi Fernandez Garcia/Courtesy of Photoshare
To further expand the primary health care workforce in rural areas, Thailand introduced community health volunteers (CHV) in the 1960s . CHV responsibilities include promoting primary health care across the country, helping control communicable diseases, and providing basic care services to the local villages . The CHVs engage in home visits to provide follow-up care and serve as a link between clinical care and community resources . At these home visits, CHVs might take the patient’s blood pressure, provide emotional and mental support through family counseling and informal conversations, and cook meals and provide information on healthy eating. Other activities include helping with community projects and connecting residents with traditional medicine resources . The community health volunteers are from the local community, which helps ensure that they fully understand the cultural context of their community’s health care needs and can provide appropriate physical and emotional support to individuals and families.
By 2010, there were more than 800,000 trained volunteers that served 12 million households throughout Thailand ; today, that number is estimated to be at 1 million .
Thailand's community health volunteers were so effective in contributing to successes such as HIV prevention and control, avian flu surveillance, and oral health in children that the World Health Organization identified the program as a global model for community-based public health ."
Another innovative feature of Thai PHC community health volunteers is its Health Promotion Temple project, which began in 2003 as a result of the Healthy Thailand agenda [12, 13]. Historically, temples have been viewed as community hubs and centers for community activities. When PHC first began in Thailand, monks were often considered “bare-headed doctors” and were trained in a range of basic healthcare interventions and traditions . The Health Promotion Temple project came in the wake of a modern, transitioning healthcare system: once residents started seeking care in hospitals instead of with traditional healers, monks had to redefine their traditional healthcare roles to continue to help the community. In this context, monks shifted their focus to health promotion and disease prevention with an emphasis on mental and physical wellbeing . Similar to CHVs, monks bring primary health care back to the community level and provide residents with a care provider that is more easily accessible and who is familiar with the community and cultural norms.
Expanding Financial Access
Through the expansion of rural workforce and infrastructure, Thailand significantly reduced geographic barriers to accessing care. However, financial burdens still prevented many in rural and urban areas from accessing primary care services. To address this financial barrier, the National Health Security Act (NHSA) was enacted in 2002. The NHSA preserved two primary previously existing public risk protection schemes (Civil Servant Medical Benefit Scheme (CSMBS) and the Social Security Scheme (SSS)) while adding a third that targeted uninsured, low socioeconomic groups, the Universal Health Coverage Scheme/30 Baht program (UCS) [4, 14, 15].
The CSMBS began in the 1980s to insure primary health public servants and their dependents, and most of its providers are public hospitals and clinics . Ten years later, the SSS was started to provide PHC coverage for employees in the formal sector through a mix of public and private hospitals contracted to the Social Security office . However by 2000, only 71% of the population was covered by an insurance scheme [3, 5, 16]. With governmental elections that year, parties promised to close the 29% gap, a promise that was kept and achieved through the introduction of Thailand’s UCS. The UCS was a reform consisting of budget allocation and payment methods designed to strengthen primary health care access and use . The UCS targeted economically marginalized populations many of whom were previously uninsured [3, 15]. The insurance scheme is an important mechanism to increase equitable, high-quality services on a continuous basis by removing financial barriers and protecting Thai citizens from catastrophic health expenses [2, 5, 14, 16]. Patients are able to avoid unaffordable healthcare costs through utilizing contracted public and private primary health care providers as a first point of contact for primary care services and as a gatekeeper for any necessary referrals .
Today, 98 precent of health care units are registered with the UCS, making them readily accessible to participants in that scheme for use as the first point of contact in the healthcare system ."
Initially, residents enrolled in UCS only had to pay a small 30 Baht copay (approximately USD 0.84) for each visit . This fee was eliminated in 2006, but then reinstated in 2012 with some exceptions (i.e. emergency care, prevention activities, visits to health facilities below the community hospital level) [14, 15]. Reasons for eliminating the fee in 2006 related to a new government that year, which pushed to extend the benefits of UCS and move away from the notion that “30 baht treats all diseases” . The copay, also motivated by political considerations, was later restored in 2012 on the belief that Thailand was encouraging “moral hazard” as citizens were overusing services, thus decreasing system efficiency .
Building strong primary care teams
In order for primary care units to be funded (referred to as contracting units for primary care (CUP)), they must have sufficient human resource capacities. Each CUP must have a doctor who works with a nurse, community health worker, and a family member who acts as a caregiver; these individuals function at various levels in the health care system, comprising a matrix team. Vertical links are created when each individual is responsible for caring for the patient at a particular system level. For example, at the district hospital level, the family doctor is primarily given the responsibility of care, and at the village level, this responsibility falls on the community health worker. The CUP teams are responsible for caring for entire families, not just individuals, and highlight the importance of team-based care.
Significant improvements in health coverage and outcomes
Improved geographic and financial accessibility of primary health care services has contributed to substantial increases in effective service coverage in Thailand. By 2002, the UCS covered 99 percent of the population in Thailand, only missing migrants in the informal workforce. This coverage level has continued through today [5, 18] with significant gains:
- Between 1977 and 2006, the percent of outpatient visits occurring in rural health centers increased from 29.4 percent  to 41.1 percent ,
- The percent of outpatient visits occurring in urban provincial hospitals fell from 46.2 percent to 18.2 percent .
- Skilled birth attendance rose from 66% in 1987 to 99% in 2007 —placing Thailand significantly above the average for the Southeast Asian WHO region.
- Thailand also outperforms its neighbors in contraceptive prevalence, measles immunization, and antenatal care coverage . However, this increase in accessibility has put a significant strain on the health workforce of the country as they struggle to meet the rapidly increasing demand for care .
Thailand’s health outcomes have also improved dramatically:
- The under-five mortality rate in Thailand decreased from 37 deaths per 1000 live births in 1990 to 13 deaths per 1000 live births in 2013 [18, 19], putting Thailand on track to meet Millennium Development Goal 4.
- The maternal mortality rate has also declined, from 42 deaths per 100,000 live births in 1990 to 26 per 100,000 live births in 2013 . In addition, the average yearly reduction in mortality was 8.5%, making it a top performer in this area when compared to other low- and middle-income countries .
Importantly, Thailand has also made significant strides towards reducing some geographic inequities in health outcomes. Taking a pro-rural stance, each rural village has at least one PHC center . Also, the CPIRD program brought physicians to rural communities that previously lacked trained healthcare providers . Between 1990 and 2000, the excess risk for U5MR between the poorest and richest quintiles was reduced by 55% .
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