Learning from Thailand's health reforms

doi:10.1136/bmj.328.7431.103

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Adrian Towse, director (atowse@ohe.org)1,
Anne Mills, professor2,
Viroj Tangcharoensathien, researcher3

¹Office of Health Economics, London SW1A 2DY
²London School of Hygiene and Tropical Medicine, London WC1E 7HT
³International Health Policy Programme, Thailand, Bangkok

Correspondence to: A Towse

Accepted 20 November 2003

Providing all of Thailand's population with subsidised health care required radical changes in the health system

Thailand took a “big bang” approach to introducing universal access to subsidised health care. In 2001, after years of debate1^–3 and slow progress,4 5 it extended coverage to 18.5 million people who were previously uninsured (out of a population of 62 million). This move was combined with a radical shift in funding away from major urban hospitals in order to build up primary care. Such an approach has merits but also risks. We discuss the implementation and some of the problems.

Formulating the change

Prime Minister Shinawatra obtained a landslide victory for his Thai-Rak-Thai (Thais love Thais) Party in 2001 on a platform including the “30 baht treat all” scheme for universal access to subsidised health care. Under the scheme, people pay 30 baht (£0.50, €0.7, $0.86) for each visit or admission.

Thailand previously had four public risk protection schemes (box 1) with widely differing benefits and contribution levels. These schemes protected a total 43.5 million people, leaving 18.5 million paying fees for care from public or private providers.

The initial plan was to merge resources from the four schemes into one universal coverage scheme to remove overlaps in coverage and improve equity. This met resistance from government departments running the other schemes and from civil servants and trades unionists benefiting from the two employment based schemes. The government therefore decided to fund the 30 baht scheme by pooling the Ministry of Public Health budgets for public hospitals, other health facilities, and the low income and voluntary health card schemes and providing some additional money. This could be done without legislation, enabling progress to be made while legislation was prepared and debated.

The National Health Security Act was passed by parliament in November …