The history of Thailand’s Universal Healthcare Coverage, and its uncertain future

With Covid-19, Thailand’s universal healthcare coverage (UHC) scheme is under immense pressure. But the politicization of UHC has obscured much of the benefits, and complexities it has brought to Thailand’s healthcare system – questions that are now more important than ever.

The UHC scheme was initially introduced as “30 baht cures all diseases,” part the package of policies that swept Thaksin Shinawatra to power in 2001. 

“The basis is that every Thai citizen is entitled to the 30-baht scheme, but if that citizen is already covered in another way, the other coverage will be used first,” explains Atipong Pathanasethpong, a doctor at Khon Kaen University hospital. The 30-baht scheme insures approximately 48 million of the total 69 million population, while the remaining population is insured through employers or the civil servants medical benefit scheme. 

With Thaksin as the face of the “30 baht” scheme, public opinion on UHC seemed to organize along partisan lines. The scheme was replaced once by the Democrat-led government in 2009 under the slogan “free treatment for 48 million people.” It was subsequently resurrected in 2012 with the “30 baht” moniker under the Pheu Thai government. 

But UHC had been championed by public health officials long before Thaksin. The Rural Medical Doctors Network, chaired by Dr. Sanguan Nitayarumphong, had worked on a UHC proposal since the 1980s. Dr. Sanguan worked in Rasi Salai, one of the poorest districts in Thailand, and saw firsthand how inaccessible the medical system was for those in remote villages and communities.

He marketed the scheme to multiple parties standing in the 2001 elections – it was Thaksin’s Thai Rak Thai that took it up seriously. 

“I hated it at first,” Atipong admits. “Economically speaking, Thailand is very neo-liberal, and in the neo-liberal mindset giving free things to people is a bad idea. The primary assumption is that people are going to exploit it opportunistically.”  

Studies have shown, however, that utilization of UHC among beneficiaries in Thailand is only at 40%. Those who can afford it continue to seek out of network care. Usage among low-income, older and female groups is much higher – indicating that UHC has in some ways lived up to its pro-poor and pro-vulnerable agenda. 

How the neoliberal funding system behind UHC failed 

The Thai neo-liberal faith in free markets culminated in the 1997 financial crisis. Thailand has long taken its cues from the United States, given the special relationship that developed during the Vietnam War and the Cold War more broadly, and 1980s Reaganomics sparked a wave of liberalization, deregulation and privatization throughout the 1990s. 

According to scholars like Kevin Hewison, the Thaksin era was marked by its intense opposition to neo-liberalism. ’30-baht healthcare’ is touted as the prime example of the turn to the welfare state. 

But this misunderstands the “dual track” system that 30-baht healthcare was a part of – one that optimistically relied on unregulated private markets to fund a social security program. 

“The dual track mechanism was a holistic approach toward healthcare policies. The two tracks were meant to go together – 30-baht healthcare, and a program to promote Thailand as a hub for medical tourism,” said Wirun Limsawat, a researcher at the Ministry of Public Health who completed his PhD in Medical Anthropology at Harvard on Thailand’s universal healthcare system.  

“The thinking was, the medical hub program would bring income into the country, which we be used to help fund 30-baht healthcare.”

It didn’t turn out that way. According to a research report produced by Krungsri Bank, the private healthcare industry has enjoyed double digit growth rates, projected to continue at 10-13 per cent from 2019 to 2021 (although this will likely change after Covid-19). But very little of this has gone to funding universal healthcare. 77 per cent of funding for UHC comes from the public sector, while already limited contributions from the private sector are declining year-on-year. 

What’s more, Wirun points out, “The growth of private hospitals actually pulled doctors from government hospitals where there already weren’t enough medical professionals.”  This ‘internal brain drain’ between private and public sectors has always been a problem but was less visible in the 1990s when the private sector’s share of hospitals was 10 per cent. It has reached extreme proportions as the share of private sector hospitals has increased to 54 per cent as of 2019, with doctors drawn away from district hospitals by incentives like higher pay and greater social mobility. 

As a result, public sector hospitals have had to adapt by cutting costs even more. They thus have to use cheaper medicine and keep wages for medical staff low – only increasing the gap between public and private. “It’s one reason why doctors move or work part time in private hospitals.”

Atipong recognizes the sheer inequity between the systems. “If I were in a private hospital, I would get paid at least three to four times as much, if not more – that’s a huge gap.” He points out that, for him, “getting a doctor’s pay in the public sector isn’t bad regardless.”  

The failure of the dual-track system led some in the Ministry of Public Health to question the sustainability of financing UHC. From 2006 to 2018, figures from the Thailand Development Research Institute (TDRI) showed that spending on public healthcare increased by 12 per cent on average, with UHC accounting for 40 per cent of the costs. 

Following the 2014 coup d’état, the Medical Council recommended a 30-50 per cent patient ‘co-pay’ to bring healthcare costs in line with hospital capacity. The recommendation was never taken on.

Public healthcare under pressure

The costs of UHC are due to rise given Thailand’s aging population – and there is as yet no plan to make funding it any easier. Toon Bodyslam’s viral 2019 Run for Hospitals campaign only served to highlight the intensifying decay of the public health system. 

The mismatch between the government’s intention to treat all patients and lack of support in shouldering the costs is exacerbated under Covid-19. 

Prayudh Chan-Ocha has promised to reimburse Covid-19 treatment for all hospitals. “But they are using a similar tactic,” Wirun reveals, “no matter how high your costs, they will reimburse you the same amount. For private hospitals where costs go into the hundreds of thousands, the government won’t pay enough to cover it.”

Wirun attributes this systematic failure to a military government that has never made public health a priority. “Every year, we at the Ministry of Public Health are given less budget. We have enough budget to buy weapons but not enough for healthcare.” In the 2020 budget, the Ministry of Public Health once again saw budget cuts. 

But for Wirun and Atipong, the fact that UHC must continue to exist is not a question.

“It is a sustainable model – it is sustained by its own morals,” says Wirun. He acknowledges the challenge of rising costs, not just from an aging population but from new diseases, and the expensive technologies and medicines that have been developed to deal with them. But he maintains that getting rid of the system would be unethical. 

“If we didn’t have UHC, this current Covid-19 situation would be terrifying. With UHC, everyone is confident that they can get healthcare. Hopefully, Covid-19 forces us to rethink the system.” 

“UHC is a very normal thing in continental Europe,” Atipong points out, “part of making sure everybody has access to basic enabling rights, or positive rights, so a person can compete in the open market.” He believes that if more people embraced notions of positive rights, “they will come to see universal healthcare in a new way” – as a necessity that the government must take responsibility for funding. 

There is no silver bullet for funding a vast, yet critical, apparatus of social care. But perhaps rethinking the neo-liberal flaws in the original ‘dual track’ program may provide a first step towards an answer. Profits from private hospitals will accrue to shareholders without government intervention. Therefore, a ‘universal healthcare’ tax could be imposed on private hospitals, many of which currently receive corporate income tax exemptions

Earmarked taxes that redistribute income from one sector to another have been used to finance public health spending, as in Australia. In New York State, subsidies to public hospitals and to reimburse services for the uninsured come from a pool of funds including cigarette taxes, private hospital surcharges and taxes on insurance policies. 

The arguments in favor of imposing earmarked taxes on the private hospital sector are threefold. First, given the income profile of users in the public (low-income) vs. private (middle to upper income) healthcare system, it functions as another form of progressive taxation in a country ridden with deep income inequality. Second, it may limit the growth of medical staff salaries in the private sector, and thus also limit the internal brain drain that is emptying the public sector of the medical staff it needs to survive. Finally, and most importantly, it will rightfully treat private hospitals as the businesses that they are – not some sacrosanct sector of the economy, but businesses that are profitable enough to engage in M&A activity, regional expansion and horizontal expansion into related industries

Given the double digit growth rates of the private hospital sector projected by financial analysts, this will help provide a steady stream of revenue to subsidize the UHC system. It would also begin the much-needed process of redistributing income from the one per cent. 

Such a program would require significant political will, and a government that believes in the positive rights Atipong alludes to. Perhaps this is not that government – after all, there is nothing more neoliberal than asking billionaires for help in a public health crisis. But the moral imperative of sustaining an accessible public health system will not disappear, not under this government or the next. Public funding must adapt to meet that imperative. 


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