Getting to universal coverage – Learning from experience: A conversation with Dr. Suwit Wibulpolprasert

Lessons from Thailand’s journey towards universal health coverage

Dr. Suwit Wibulpolprasert, Senior Adviser on Disease Control Ministry of Public Health, Board member of the Thai Health Promotion Foundation, the Mahidol University Council, and the National Science and Technology Board, sat down with Gina Lagomarsino, Managing Director at Results for Development Institute, prior to the 2012 Prince Mahidol Awards Conference (PMAC) in Bangkok, Thailand.

Conference organizers led by the Royal Thai Government, the Prince Mahidol Award Foundation, and other global partners including the World Health Organization, the Rockefeller Foundation, Results for Development Institute, and the World Bank – chose Universal Health Coverage (UHC) as this year’s theme to shed light on the experiences of low, middle and high-income countries that are trying to design equitable, efficient and sustainable health financing to ensure access to and utilization of essential health services without financial barriers.

Lagomarsino: This year’s PMAC theme is “universal health coverage.” Why was this theme chosen at this moment in time?

Suwit: The theme for this year’s conference was chosen two years ago when WHO published the WHR 2010. The primary reason, for us in Thailand, was to celebrate the ten year anniversary of Thailand’s Universal Health Scheme (UHS). We also thought this would be a good opportunity for us to learn from people all over the world and use that knowledge to improve UHS. At the same time, we wanted to invite other countries from around the world to learn about the program we have been implementing for ten years.

Lagomarsino: Thailand is noted for having achieved UHC earlier than many of its’ peers. What are some of the underlying reasons that Thailand has been so successful?

Suwit: Multiple factors have contributed to our success. First, is democracy. The long march to UHC was started, covering only the poor, in 1975 by the elected democratic government, after Military regime. When the government comes from the people, they have a stake in pleasing the people. Our democratic government committed to providing not only free medical care, but also education, and bus riding. In 1975, they also changed the allocations of some of the budget to distribute money directly to villages to avoid the bureaucracy of the government. If you look at our incremental increases in UHC coverage, it all happened in the period of an elected democratic government.

Second, is economic growth. When you implement UHC you need additional money. Before we began providing health services for the poor in 1975, our health budget was mere 2.5 percent of overall government spending. It immediately rose to more than 3 percent after the ‘free health services for indigent’. Furthermore, when we implemented a policy to build new rural hospitals and health centers all over the country the health budget increased to 4 percent of overall government spending. When you have economic growth, the budget to serve the public becomes proportionally less. With rapid economic growth from mid 1980s to mid 1990s, Thailand was able to achieve a up to 20 percent increase in fiscal space due to reduction in proportion of debt servicing budget.

Third, you need peace or your security budget will consume any excess funds. Since Thailand achieved internal peace in 1985, the proportion of our budget spent on security decreased from 25 to 12 percent in 1997. This resulted in an additional 13 percent fiscal space which could then be spent elsewhere. Combined with economic growth, this provided an additional 20-30 percent of fiscal space in our overall budget over the years.

Last, you also need a strong civic movement. The first draft of the National Health Security bill was drafted, signed, and submitted to the parliament by 50,000 Thai citizens. Our 1997 constitution allows 20,000 citizens to propose a bill to the parliament. When the people’s bill was proposed, the government and the opposition had to act. This allow the representatives of these active citizens to play active roles in the special commission to look into the detail of the draft bill and also put themselves into the members of the National Health Security Board.

Some of these factors are specific to Thailand. It is important to remember that socio-political context cannot be transferred across countries, but can be considered applied appropriately.

Lagomarsino: Are there specific policy decisions that have been particularly important to what Thailand has achieved?

Suwit: I think there were two very important decisions. First is the decision to lay down a basic health infrastructure with a focus on primary health care, from 1982 onwards. At that time, we were very poor. We were facing a serious economic crisis and entered into our first contract with the International Monetary Fund (IMF). In spite of that economic downturn, the government decided to invest in developing rural health care infrastructure. We established health centers and hospitals in rural areas and trained tens of thousands of health workers. Where did we get the money? It was a very difficult decision. For five years, the government decided to freeze all new capital investments of urban health facilities for 5 consecutive years and shift the budget to build up rural facilities including extensive production of community health workers. This was not easy, but because of the leadership of the Prime Minister and the Health Minister – both of whom worked in rural areas for many years – this is the first very important decision.

The second was to move from 75 percent coverage of UHC to 100 percent coverage in 2001. The people that were not covered at that time were largely informal workers that did not fall under a special category such as poor, elderly, women, children, disables, veterans, religious personnel, and health volunteer.

Lagomarsino: Were there any other policy decisions that contributed to Thailand’s success?

Suwit: Yes, but they were around implementation, specifically related to managing the budget. There was a fight about whether to use capitation or fee for service as payment mechanism. Ultimately, capitation won which has allowed us to effectively control the budget. We also made the decision to include the salaries of public sector health workers in the capitation. Prior to that, health facilities and human resources were unfairly distributed based on political power. There was a much greater density of doctors in urban central areas as compare to the poor rural Northeast. By including salary money as a part of the capitation, it stimulates shifting hospital staff toward rural areas because urban hospitals had an incentive to hire fewer staff.

Lagomarsino: Thailand has many impressive achievements. What are some of the remaining priorities for improvement?

Suwit: UHC faces huge challenges in the coming years due to the aging population and explosion of chronic disease. These will be big challenges for our system and others. I do not believe that medical technology is the answer. Social and community measures must be taken to address these issues. We have tried to convince the government, and it seems to be working, that we need more primary care and each household needs to have a family caregiver. This does not necessarily have to be a doctor, but someone that knows about health--a community health worker or a nurse--so that when people need health services, they don’t have to think where to go. This system has more or less existed in the rural areas for years, but is still a big challenge in urban areas like Bangkok.

Lagomarsino: What are you hoping countries will take away from the PMAC conference?

Suwit: We expect them to go home with three things. First, they are confident that they do not have to wait until they are rich to start and achieve universal health coverage. Even the richest countries do not have universal coverage.

Second, they should develop their systems based on their own socio-political and cultural contexts.

And third, they need to build their own capacity to generate evidences to support the formulation and implementation of their systems. At the end of the day, it is their own capacity that will sustain their systems.

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