Abstract
In responses to Norheim’s editorial, this commentary offers reflections from Thailand, how the five unacceptable trade-offs were applied to the universal health coverage (UHC) reforms between 1975 and 2002 when the whole 64 million people were covered by one of the three public health insurance systems. This commentary aims to generate global discussions on how best UHC can be gradually achieved. Not only the proposed five discrete trade-offs within each dimension, there are also trade-offs between the three dimensions of UHC such as population coverage, service coverage and cost coverage. Findings from Thai UHC show that equity is applied for the population coverage extension, when the low income households and the informal sector were the priority population groups for coverage extension by different prepayment schemes in 1975 and 1984, respectively. With an exception of public sector employees who were historically covered as part of fringe benefits were covered well before the poor. The private sector employees were covered last in 1990. Historically, Thailand applied a comprehensive benefit package where a few items are excluded using the negative list; until there was improved capacities on technology assessment that cost-effectiveness are used for the inclusion of new interventions into the benefit package. Not only cost-effectiveness, but long term budget impact, equity and ethical considerations are taken into account. Cost coverage is mostly determined by the fiscal capacities. Close ended budget with mix of provider payment methods are used as a tool for trade-off service coverage and financial risk protection. Introducing copayment in the context of fee-for-service can be harmful to beneficiaries due to supplier induced demands, inefficiency and unpredictable out of pocket payment by households. UHC achieves favorable outcomes as it was implemented when there was a full geographical coverage of primary healthcare coverage in all districts and sub-districts after three decade of health infrastructure investment and health workforce development since 1980s. The legacy of targeting population group by different prepayment mechanisms, leading to fragmentation, discrepancies and inequity across schemes, can be rectified by harmonization at the early phase when these schemes were introduced. Robust public accountability and participation mechanisms are recommended when deciding the UHC strategy.
Highlights
Article History: Itrnadrees-pooffnCssweosemrteomaNpeponlrihetediomton’st“hedeNiutoanrviivaielg,rsatahtliishnecgaolmtBhmecoetnvwetareraeygeno(fUSfeHtrseCar)elftrleehfcotAriomdnssvbforeotcwmaeceTynh1aa9inl7a5ndda,Unhdno2wc0o0t2nhewscfhiiveoenuuthsneaDcwcohepogtlmeab6la4etism: RATecchceeipevteedd:: ePublished: 31 July 2016 global discussions on how best Universal Health Coverage (UHC) can be gradually achieved
The X axis is the population coverage, the Y axis is the cost coverage measured by level of out of pocket cost sharing by members, and the Z axis is the service coverage, how comprehensive the benefit package would cover? There are trade-offs between these three dimensions such as should the country cover more services to certain groups, or same service for the whole population?
Private sector employment are growing especially in middle-income context, that payroll tax financed social health insurance (SHI) systems should be introduced as soon as possible, in order to minimize the regressive out of pocket payment, with a caveat that payroll tax finance must be designed as a progressive source, where the higher income employees pay higher contribution than the lower income counterparts
Summary
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