Procedural fairness in benefit package design: inclusion of pre-exposure prophylaxis of HIV in Universal Coverage Scheme in Thailand.

Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.

COVID-19 Aftermath: Direction Towards Universal Health Coverage in Low-Income Countries Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective".

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Effective coverage of diabetes and hypertension: an analysis of Thailand's national insurance database 2016-2019.

OBJECTIVES: This study assesses effective coverage of diabetes and hypertension in Thailand during 2016-2019. DESIGN: Mixed method, analysis of National health insurance database 2016-2019 and in-depth interviews. SETTING: Beneficiaries of Universal Coverage Scheme residing outside Bangkok. PARTICIPANTS: Quantitative analysis was performed by acquiring individual patient data of diabetes and hypertension cases in the Universal Coverage Scheme residing outside bangkok in 2016-2019. Qualitative analysis was conducted by in-depth interview of 85 multi-stakeholder key informants to identify challenges. OUTCOMES: Estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases) were compared. Controlled diabetes was defined as haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mm Hg. RESULTS: Estimated cases were 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes, all indicators have shown slow improvement between 2016 and 2019 (67.4%, 69.9%, 71.9% and 74.7% for detected need; 38.7%, 43.1%, 45.1% and 49.8% for crude coverage and 8.1%, 10.5%, 11.8% and 11.7% for effective coverage). For hypertension, the performance was poorer for detection (48.9%, 50.3%, 51.8% and 53.3%) and crude coverage (22.3%, 24.7%, 26.5% and 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1% and 15.7%) than diabetes. Results were better for the women and older age groups in both diseases. Complex interplays between supply and demand side were a key challenge. Database challenges also hamper regular assessment of effective coverage. Sensitivity analysis when using at least three annual visits shows slight improvement of effective coverage. CONCLUSION: Effective coverage was low for both diseases, though improving in 2016-2019, especially among men and ัyounger populations. The increasing rate of effective coverage was significantly smaller than crude coverage. Health information systems limitation is a major barrier to comprehensive measurement. To maximise effective coverage, long-term actions should address primary prevention of non-communicable disease risk factors, while short-term actions focus on improving Chronic Care Model.

Universal access to comprehensive COVID-19 services for everyone in Thailand.

Despite Thailand having had universal health coverage (UHC) with comprehensive benefit packages since 2002, services are neither listed nor budget earmarked for COVID-19 responses. Policy decisions were made immediately after the first outbreak in 2020 to fully fund a comprehensive benefit package for COVID-19. The Cabinet approved significant additional budget to respond to the unfolding pandemic. The comprehensive benefit package includes laboratory tests, contact tracing, active case findings, 14-day quarantine measures (including tests, food and lodging), field hospitals, ambulance services for referral, clinical services both at hospitals and in home and community isolation, vaccines and vaccination cost, all without copayment by users. No-fault compensation for adverse events or deaths following vaccination is also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package applies to everyone living in Thailand including Thai citizens and migrant workers. A standardised and comprehensive COVID-19 benefit package for Thai and non-Thai population without copayment facilitates universal and equitable access to care irrespective of capacity to pay and social status and nationality, all while aiming to supporting pandemic containment. Making essential services available, notably laboratory tests, through the engagement of qualified both public and private sectors boost supply side capacity. These policies and implementations in this paper are useful lessons for other low-income and middle-income countries on how UHC reinforces pandemic containment.

Paths towards Universal Health Coverage: beyond political commitments.

The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.

Do efficiency gains really translate into more budget for health? An assessment framework and country applications.

Efficiency has historically been considered a key mechanism to increase the amount of available revenues to the health sector, enabling countries to expand services and benefits to progress towards universal health coverage (UHC). Country experience indicates, however, that efficiency gains do not automatically translate into greater budget for health, to additional revenues for the sector. This article proposes a framework to assess whether and how efficiency interventions are likely to increase budgetary space in health systems Based on a review of the literature and country experiences, we suggest three enabling conditions that must be met in order to transform efficiency gains into budgetary gains for health. First there must be well-defined efficiency interventions that target health system inputs, implemented over a medium-term time frame. Second, efficiency interventions must generate financial gains that are quantifiable either pre- or post-intervention. Third, public financial management systems must allow those gains to be kept within the health sector and repurposed towards priority health needs. When these conditions are not met, efficiency gains do not lead to more budgetary space for health. Rather, the gains may instead result in budget cuts that can be detrimental to health systems' outputs and ultimately disincentivize further attempts to improve efficiency in the sector. The framework, when applied, offers an opportunity for policymakers to reconcile efficiency and budget expansion goals in health.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand.

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil Servant Medical Benefit Scheme, Social Health Insurance and Universal Coverage Scheme. Each scheme is governed through individual laws. This study aimed to identify, analyse and compare the legislative provisions related to participatory and responsive governance within the three public health insurance schemes and draw lessons that can be useful for other low-income and middle-income countries in their legislative process for UHC. The legislative provisions in each policy document were analysed using a conceptual framework derived from key literature. The results found that overall the UHC legislative provisions promote citizen representation and involvement in UHC governance, implementation and management, support citizens' ability to voice concerns and improve UHC, protect citizens' access to information as well as ensure access to and provision of quality care. Participatory governance is legislated in 33 sections, of which 23 are in the Universal Coverage Scheme, 4 in the Social Health Insurance and none in the Civil Servant Medical Benefit Scheme. Responsive governance is legislated in 24 sections, of which 18 are in the Universal Coverage Scheme, 2 in the Social Health Insurance and 4 in the Civil Servant Medical Benefit Scheme. Therefore, while several legislative provisions on both participatory and responsive governance exist in the Thai UHC, not all schemes equally bolster citizen participation and government responsiveness. In addition, as legislations are merely enabling factors, adequate implementation capacity and commitment to the legislative provisions are equally important.

Primary health care and sustainable development goals.

We examine the potential and limitations of primary health care in contributing to the achievement of the health-related sustainable development goals (SDGs), and recommend policies to enable a functioning primary health-care system. Governments have recently reaffirmed their commitment to the SDGs through the 2018 Declaration of Astana, which redefines the three functions of primary health care as: service provision, multisectoral actions and the empowerment of citizens. In other words, the health-related SDGs cannot be achieved by the provision of health-care services alone. Some health issues are related to environment, necessitating joint efforts between local, national and international partners; other issues require public awareness (health literacy) of preventable illnesses. However, the provision of primary health care, and hence achievement of the SDGs, is hampered by several issues. First, inadequate government spending on health is exacerbated by the small proportions allocated to primary health care. Second, the shortage and maldistribution of the health workforce, and chronic absenteeism in some countries, has led to a situation in which staffing levels are inversely related to poverty and need. Third, the health workforce is not trained in multisectoral actions, and already experiences workloads of an overwhelming nature. Finally, health illiteracy is common among the population, even in developed countries. We recommend that governments increase spending on health and primary health care, implement interventions to retain the rural health workforce, and update the pre-service training curricula of personnel to include skills in multisectoral collaboration and enhanced community engagement.

Dans le présent document, nous étudions le potentiel et les limites des soins de santé primaires en matière de réalisation des objectifs de développement durable (ODD) liés à la santé. Nous formulons également des recommandations politiques pour l'instauration d'un système de soins de santé primaires efficace. Les gouvernements ont récemment réaffirmé leur engagement envers les ODD en 2018 par le biais de la Déclaration d'Astana, qui redéfinit les trois fonctions des soins de santé primaires comme suit: fourniture de services, actions multidisciplinaires et implication des citoyens. En d'autres termes, les ODD liés à la santé ne peuvent être atteints uniquement en proposant des services médicaux. Certains problèmes de santé sont inhérents à l'environnement et requièrent les efforts conjoints des partenaires locaux, nationaux et internationaux; d'autres nécessitent de sensibiliser le public (médecine préventive) aux maladies évitables. Cependant, la fourniture de soins de santé primaires, et par conséquent la réalisation des ODD, rencontre de nombreux obstacles. Tout d'abord, les dépenses inadéquates des gouvernements en matière de santé sont aggravées par le faible pourcentage octroyé aux soins de santé primaires. Ensuite, la pénurie et les inégalités de répartition des professionnels de la santé ainsi que l'absentéisme chronique dans certains pays ont débouché sur une situation où le niveau des effectifs est inversement proportionnel au niveau de pauvreté et aux besoins. Par ailleurs, le personnel soignant n'est pas formé aux actions multidisciplinaires et subit déjà une charge de travail écrasante. Et enfin, la méconnaissance des bases sanitaires est fréquente au sein de la population, même dans les pays développés. Nous conseillons aux gouvernements d'accroître leurs dépenses en soins de santé et soins de santé primaires, d'intervenir pour encourager les soignants à rester dans les régions rurales, et de mettre à jour les programmes de formation initiale du personnel pour y inclure des compétences en collaboration multidisciplinaire et en amélioration de l'engagement communautaire.

Se analizan las posibilidades y las limitaciones de la atención primaria de salud para contribuir al logro de los objetivos de desarrollo sostenible (los ODS) relacionados con la salud, y se recomiendan políticas que permitan el funcionamiento del sistema de atención primaria de salud. Recientemente, los gobiernos reiteraron su compromiso con los ODS en la Declaración de Astaná de 2018, en la que se redefinen las tres funciones de la atención primaria de salud, a saber: la prestación de servicios, las medidas multisectoriales y una mayor participación de los ciudadanos. Es decir, los ODS relacionados con la salud no se pueden cumplir tan solo con la prestación de servicios de atención de la salud. Algunos temas de salud están relacionados con el medio ambiente, lo que requiere esfuerzos conjuntos entre los asociados locales, nacionales e internacionales; otros temas requieren la concienciación del público (conocimientos sobre la salud) acerca de las enfermedades que se pueden evitar. Sin embargo, la prestación de atención primaria de salud, y por consiguiente el logro de los ODS, presenta diversas dificultades. En primer lugar, el gasto público inadecuado en salud empeora debido a los porcentajes tan reducidos que se asignan a la atención primaria de salud. En segundo lugar, la escasez y la mala distribución del personal sanitario, así como el absentismo crónico en algunos países, han creado una situación en la que los niveles de personal están relacionados de manera inversa con la pobreza y la necesidad. En tercer lugar, el personal sanitario no está capacitado para emprender medidas multisectoriales, además de que ya tiene una carga de trabajo abrumadora. Por último, la falta de conocimientos sobre salud es común entre la población, incluso en los países desarrollados. Se recomienda a los gobiernos que aumenten el gasto en salud y en atención primaria de la salud, que implementen intervenciones para fidelizar al personal sanitario de las zonas rurales y que actualicen los programas de capacitación del personal previa a la prestación de servicios para integrar las habilidades en la colaboración multisectorial y el aumento de la participación de la comunidad.

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings.

BACKGROUND: Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS). OBJECTIVE: This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement. METHOD: In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings. RESULTS: The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency. CONCLUSIONS: Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner.

Children and Women's Health in South East Asia: Gap Analysis and Solutions.

In response to the Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) commitment, eight selected countries in the South East Asia region have made a remarkable reduction in infant and child mortality, while a few have achieved an SDG 3.2 target of 25 and 12 for child and neonatal mortality rate, respectively, well before 2030. Across these eight countries, there is a large variation in the achievement of the nine dimensions of maternal, neonatal, and child health service coverage. The poorest wealth quintiles who reside in rural areas are the most vulnerable and left behind from access to service. The rich rural residents are better off than the poor counterparts as they have financial means for travel and access to health services in urban town. The recent 2019 global Universal Health Coverage (UHC) monitoring produced a UHC service coverage index and an incidence of catastrophic health spending, which classified countries into four quadrants using global average. Countries belonging to a high coverage index and a low incidence of catastrophic spending are good performers. Countries having high coverage but also a high incidence of catastrophic spending need to improve their financial risk protection. Countries having low coverage and a high incidence of catastrophic spending need to boost service provision capacity, as well as expand financial protection. Countries having low coverage and a low incidence of catastrophic spending are the poor performers where both coverage and financial protection need significant improvement. In these countries, poor households who cannot afford to pay for health services may forego required care and instead choose to die at home. This paper recommended countries to spend adequately in the health sector, strengthen primary health care (PHC) and safeguard the poor, mothers and children as a priority in pathways towards UHC.

Defining the Benefit Package of Thailand Universal Coverage Scheme: From Pragmatism to Sophistication.

Benefit package is crucial for implementing universal health coverage (UHC). This editorial analyses how the benefit package of the Thai Universal Coverage Scheme (UC Scheme) evolved from an implicit comprehensive package which covered all conditions and interventions (with a few exceptions), to additional explicit positive lists. In 2002 when the Thai UC Scheme was launched; the comprehensive benefit package, including medicines in the national essential list of medicines, formerly offered by the previous schemes were pragmatically adopted. Later, when capacities of producing evidence on health technology assessment (HTA) increased, rigorous assessment of cost effectiveness is mandatorily required for inclusion of new interventions into the Thai UC Scheme benefit package. This contributed to evidence-informed policy decisions. To prevent emptied promises, whichever policy choices are made about the benefit package, either using a negative or a positive list, developing country governments need to make quality health services available and accessible by the entire population. Political decision on benefit package should be informed by evidence on cost effectiveness, equity dimension and health system capacity to deliver equitable services. Low- and middle-income countries need to strengthen HTA capacity to generate evidence and inform policies.

Legislating for public accountability in universal health coverage, Thailand.

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand's universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand's position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens' rights and government accountability has been implemented. Thailand's constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens' voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens' ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens' trust.

Maintenir la couverture sanitaire universelle exige une forte participation publique à l'élaboration des politiques et à la gouvernance. En Thaïlande, le régime de couverture universelle a été mis en œuvre dans tout le pays en 2002, permettant de couvrir l'ensemble de la population grâce à trois régimes publics d'assurance maladie et d'améliorer les résultats de santé. Bien que la position de la Thaïlande concernant les Indicateurs de gouvernance mondiaux de la Banque mondiale se soit détériorée depuis 1996, des dispositions en matière d'expression et de reddition de comptes ont été intégrées à la législation et à la structure du régime de couverture universelle. Nous discutons ici de la mise en œuvre de la législation relative aux droits des citoyens et à la reddition de comptes du gouvernement. En vertu de la constitution de la Thaïlande, les citoyens ont pu soumettre un projet de loi dont les dispositions en matière d'expression et de reddition de comptes ont été intégrées aux textes législatifs et transposées dans la loi. La législation rend obligatoire l'enregistrement des bénéficiaires, une assistance téléphonique 24h/24 et 7 j/7, des auditions publiques annuelles et une aide financière systématique pour les patients qui ont été victimes d'événements indésirables. Pour garantir le droit à des services de santé, permettre aux citoyens de faire entendre leur voix et s'assurer que des mesures soient prises, les institutions doivent être en mesure d'appliquer la législation. Par exemple, la Thaïlande devait pouvoir enregistrer 47 millions de personnes et les rattacher au réseau de prestataires de soins du district où elles vivaient, et réenregistrer les personnes qui changeaient de district. Les auditions publiques annuelles doivent faire participer les citoyens, les prestataires de soins, les organisations de la société civile et les parties prenantes telles que les collectivités locales et les groupes de patients. Les réponses qui en découlent au point de vue des politiques et de la gestion sont importantes pour instaurer la confiance dans le processus et permettre aux citoyens de se l'approprier. Les rapports annuels publics sur les résultats du régime de couverture permettent d'accroître la transparence et de renforcer la confiance des citoyens.

Para mantener la cobertura sanitaria universal se requiere una sólida participación activa del público en la formulación de políticas y la gobernanza. El plan de cobertura universal de Tailandia se implementó en todo el país en 2002, lo que permitió a Tailandia lograr una cobertura completa de la población a través de tres planes de seguro médico público y demostrar mejores resultados en materia de salud. Aunque la posición de Tailandia respecto de los Indicadores mundiales de gobernanza del Banco Mundial ha disminuido desde 1996, las disposiciones relativas a la voz y la rendición de cuentas estaban incorporadas en la legislación y en el diseño del plan de cobertura universal. Se discute cómo se ha implementado la legislación relacionada con los derechos de los ciudadanos y la rendición de cuentas del gobierno. La Constitución de Tailandia permitía a los ciudadanos presentar un proyecto de ley en el que las disposiciones sobre la voz y la rendición de cuentas se incorporaban con éxito en los textos legislativos y se aprobaban como ley. La legislación exige el registro de los beneficiarios, una línea telefónica de ayuda 24 horas al día los 7 días de la semana, audiencias públicas anuales y asistencia financiera gratuita para los pacientes que han sufrido eventos adversos. Para garantizar el derecho a los servicios de salud y que se escuche la voz de los ciudadanos y se adopten medidas, es necesario contar con la capacidad institucional para aplicar la legislación. Por ejemplo, Tailandia necesitaba la capacidad de inscribir a 47 millones de personas y ponerlas en contacto con la red de proveedores de servicios de salud del distrito en el que viven, y de volver a inscribir a los miembros que se trasladan fuera de sus distritos. Las audiencias públicas anuales deben incluir a los ciudadanos, los proveedores de servicios de salud, las organizaciones de la sociedad civil y las partes interesadas, como los gobiernos locales y los grupos de pacientes. Las respuestas políticas y de gestión subsiguientes son importantes para generar confianza en el proceso y en la apropiación del plan por parte de los ciudadanos. El informe público anual sobre los resultados y el rendimiento del plan fomenta la transparencia y aumenta la confianza de los ciudadanos.

Political economy of Thailand's tax-financed universal coverage scheme.

PROBLEM: The challenge of implementing contributory health insurance among populations in the informal sector was a barrier to achieving universal health coverage (UHC) in Thailand. APPROACH: UHC was a political manifesto of the 2001 election campaign. A contributory system was not a feasible option to honour the political commitment. Given Thailand's fiscal capacity and the moderate amount of additional resources required, the government legislated to use general taxation as the sole source of financing for the universal coverage scheme. LOCAL SETTING: Before 2001, four public health insurance schemes covered only 70% (44.5 million) of the 63.5 million population. The health ministry received the budget and provided medical welfare services for low-income households and publicly subsidized voluntary insurance for the informal sector. The budgets for supply-side financing of these schemes were based on historical figures which were inadequate to respond to health needs. The finance ministry used its discretionary power in budget allocation decisions. RELEVANT CHANGES: Tax became the sole source of financing the universal coverage scheme. Transparency, multistakeholder engagement and use of evidence informed budgetary negotiations. Adequate funding for UHC was achieved, providing access to services and financial protection for vulnerable populations. Out-of-pocket expenditure, medical impoverishment and catastrophic health spending among households decreased between 2000 and 2015. LESSONS LEARNT: Domestic government health expenditure, strong political commitment and historical precedence of the tax-financed medical welfare scheme were key to achieving UHC in Thailand. Using evidence secures adequate resources, promotes transparency and limits discretionary decision-making in budget allocation.

The Political Economy of UHC Reform in Thailand: Lessons for Low- and Middle-Income Countries.

Thailand achieved full population coverage of financial protection for health care in 2002 with successful implementation of the Universal Coverage Scheme (UCS). The three public health insurance schemes covered 98.5% of the population by 2015. Current evidence shows a high level of service coverage and financial risk protection and low level of unmet healthcare need, but the path toward UHC was not straightforward. Applying the Political Economy of UHC Reform Framework and the concept of path dependency, this study reviews how these factors influenced the evolution of the UHC reform in Thailand. We highlight how path dependency both set the groundwork for future insurance expansion and contributed to the persistence of a fragmented insurance pool even as the reform team was able to overcome certain path inefficient institutions and adopt more evidence-based payment schemes in the UCS. We then highlight two critical political economy challenges that can hamper reform, if not managed well, regarding the budgeting processes, which minimized the discretionary power previously exerted by Bureau of Budget, and the purchaser-provider split that created long-term tensions between the Ministry of Public Health and the National Health Security Office. Though resisted, these two changes were key to generating adequate resources to, and good governance of, the UCS. We conclude that although path dependence played a significant role in exerting pressure to resist change, the reform team's capacity to generate and effectively utilize evidence to guide policy decision-making process enabled the reform to be placed on a "good path" that overcame opposition.

Strategic Purchasing: The Neglected Health Financing Function for Pursuing Universal Health Coverage in Low-and Middle-Income Countries Comment on "What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review".

Sanderson et al's realist review of strategic purchasing identifies insights from two strands of theory: the economics of organisation and inter-organisational relationships. Our findings from a programme of research conducted by the RESYST (Resilient and Responsive Health Systems) consortium in seven countries echo these results, and add to them the crucial area of organisational capacity to implement complex reforms. We identify key areas for policy development. These are the need for: (1) a policy design with clearly delineated responsibilities; (2) a task network of organisations to engage in the broad set of functions needed; (3) more effective means of engaging with populations; (4) a range of technical and management capacities; and (5) an awareness of the multiple agency relationships that are created by the broader financing environment and the provider incentives generated by multiple financing flows.

Lessons from the Thai Health Promotion Foundation.

To facilitate the policy response to noncommunicable diseases in Thailand, parliament adopted the Health Promotion Foundation Act in 2001. This Act led to the establishment of an autonomous government body, the Thai Health Promotion Foundation, called ThaiHealth. The foundation receives its revenue from a 2% surcharge of excise taxes on tobacco and alcohol. The fund supports evidence generation, campaigns and social mobilization to address noncommunicable disease risk factors, such as tobacco-use, harmful use of alcohol and sedentary behaviour. On average, its annual revenue is 120 million United States dollars (US$). Some notable ThaiHealth-supported public campaigns are for schools free of sweetened carbonated beverages; alcohol abstinence during three-month Buddhist lent; and nationwide physical activity. The percentage of people using tobacco decreased from 22.5% in 2001 to 18.2% in 2014. The annual per capita alcohol consumption decreased from 8.1 litres pure alcohol in 2005 to 6.9 litres in 2014. The percentage of the adult population doing at least 150 minutes of moderate-intensity or 75 minutes high-intensity aerobic exercise per week, increased from 66.3% in 2012 to 72.9% in 2017. A dedicated funding mechanism, a transparent and accountable organization, and the engagement of civil society organizations and other government agencies have enabled ThaiHealth to run these campaigns.

Afin de soutenir l'action politique concernant les maladies non transmissibles en Thaïlande, le Parlement a adopté une loi sur la Fondation pour la promotion de la santé en 2001. Cette loi a conduit à l'établissement d'un organisme gouvernemental autonome, la Fondation thaïlandaise pour la promotion de la santé, appelé « ThaiHealth ¼. Cette fondation tire ses revenus d'une majoration de 2% des taxes d'accise sur le tabac et l'alcool. Ces fonds soutiennent la production de données, l'organisation de campagnes et la mobilisation sociale pour agir sur les facteurs de risque de maladie non transmissible, tels que la consommation de tabac, la consommation nocive d'alcool et le comportement sédentaire. Le revenu annuel moyen de ThaiHealth s'élève à 120 millions de dollars des États-Unis. Certaines campagnes publiques importantes financées par ThaiHealth prônent l'élimination des boissons gazeuses sucrées dans les écoles, la privation d'alcool pendant les trois mois de la retraite de la saison des pluies, et l'activité physique dans tout le pays. Le pourcentage des fumeurs de tabac est passé de 22,5% en 2001 à 18,2% en 2014. La consommation annuelle d'alcool par habitant est passée de 8,1 litres d'alcool pur en 2005 à 6,9 litres en 2014. Le pourcentage de la population adulte faisant au moins 150 minutes d'exercices aérobiques modérément intenses ou 75 minutes d'exercices aérobiques très intenses par semaine est passé de 66,3% en 2012 à 72,9% en 2017. Un mécanisme de financement spécial, une organisation transparente et responsable, et l'engagement d'organisations de la société civile et d'autres agences gouvernementales ont permis à ThaiHealth de mener ces campagnes.

Para facilitar la respuesta política a las enfermedades no contagiosas en Tailandia, el Parlamento aprobó en 2001 la Ley de la Fundación para la promoción de la salud. Esta ley dio lugar a la creación del organismo gubernamental autónomo, la Fundación tailandesa para la promoción de la salud, denominada ThaiHealth. La fundación recibe ingresos de un recargo del 2 % de los impuestos especiales sobre el tabaco y el alcohol. El fondo apoya la generación de pruebas, las campañas y la movilización social para hacer frente a los factores de riesgo de las enfermedades no contagiosas, como el consumo de tabaco, el consumo nocivo de alcohol y los hábitos sedentarios. De media, sus ingresos anuales ascienden a 120 millones de dólares estadounidenses. Algunas de las campañas públicas que apoya ThaiHealth van dirigidas a sacar de las escuelas las bebidas con gas azucaradas, a la abstinencia del alcohol durante la cuaresma budista de tres meses y a fomentar la actividad física en todo el país. El porcentaje de personas que consumen tabaco disminuyó del 22,5 % en 2001 al 18,2 % en 2014. El consumo anual de alcohol per cápita disminuyó de 8,1 litros de alcohol puro en 2005 a 6,9 litros en 2014. El porcentaje de población adulta que hace al menos 150 minutos de ejercicio aeróbico de intensidad moderada o 75 minutos de ejercicio aeróbico de alta intensidad por semana aumentó del 66,3 % en 2012 al 72,9 % en 2017. Un mecanismo de financiación específico, una organización transparente y responsable, así como la participación de organizaciones de la sociedad civil y otros organismos gubernamentales han permitido a ThaiHealth llevar a cabo estas campañas.