The equity impact of the universal coverage policy: Lessons from Thailand

Abstract

Objective: This paper assesses the health equity achievements of the Thai health system before and after the introduction of Universal Coverage (UC). It examines five dimensions of equity: equity in financial contributions, the incidence of catastrophic health expenditure, the degree of impoverishment as a result of household out-of-pocket payment for health, equity in health service use and the incidence of public subsidies for health. Methodology: The standard methods proposed by O’Donnell et al. (2008b) were used to measuring equity in financial contribution, healthcare utilization and public subsidies, and in assessing the incidence of catastrophic health expenditure and impoverishment. Two major national representative household survey datasets were used: Socio-Economic Surveys and Health and Welfare Surveys. Findings: General tax was the most progressive source of finance. Because this source dominates total financing, the overall outcome was progressive, with the rich contributing a greater share of their income than the poor. The low incidence of catastrophic health expenditure and impoverishment prior to UC was further reduced after UC. Use of healthcare and the distribution of government subsidies were both pro-poor: in particular the functioning primary health care at the district level serves as a “pro-poor hub” in translating policy into practice and equity outcomes. Policy implications: The Thai health financing reforms have been accompanied by nationwide extension of primary health care coverage, mandatory rural health service by new graduates, and systems redesign, especially the introduction of a contracting model and closed-ended provider payment methods. Together, these changes have led to a more equitable and more efficient health system. Institutional capacity to generate evidence and to translate it into policy decisions, effective implementation, and comprehensive monitoring and evaluation are essential to successful system-level reforms.