Universal health coverage: Hurdles and solutions

Countries must find their own path to universal health coverage. The Thai reform experience provides valuable lessons

The sustainable development goals (SDG) was committed to by all heads of state of the UN member states at the 2015 United Nations General Assembly in September. SDG has set much higher and more ambitious health-related goals and targets than did the millennium development goals (MDGs).
Evidence from countries and international development partners shows that the main challenge amongst MDG off-track countries is the failure to provide and sustain financial access to quality services by communities, especially the poor. Decent quality of health services are neither available, nor responsive to the health needs of the population. And where these are physically available, people, especially the poor, are not able to access them due to price barriers even in the government health services, where charging the users is common, formally or informally.
Universal health coverage (UHC), one of the SDG health targets adopted in September, is indispensable to achieving an improved level and distribution of health. UHC requires a significant increase in government investment in strengthening primary healthcare—the close-to-client service which can result in equitable access.
Given the trend of increased fiscal capacity in most developing countries, aiming at long-term progress towards UHC is financially feasible. It also needs political commitment and effective implementations.
In the ‘Good Health at Low Cost’ report, Thailand has outperformed many other countries in improving health outcomes at relatively low per capita health spending given the similar level of economic development. Interventions essential to child survival and maternal health, notably free antenatal care, skilled birth attendance, family planning and immunisation, reached universal coverage by the 1990s, and all health MDGs were achieved by the early 2000s.
Thailand was quoted by the World Bank and the World Health Organization as among the few success cases in achieving UHC; it has achieved UHC by 2002. A few lessons can be drawn on how it achieves UHC and its contributing factors.
First, government investment in health delivery systems. Four decades of health investment since 1970s led to extensive geographical coverage of health infrastructure; a health centre, manned by nurses and paramedics, provides primary health care services for a catchment population of 5,000 at sub-district level; a district hospital ranges from 30 to 120 beds in all 800 districts, provides primary and secondary health services for a catchment population of 50,000 people; tertiary care provincial hospital in all provinces and more than 30 regional hospitals provide backup referral patients.
Extensive geographical coverage of health services results in universal access to maternal and child health services, disease control and treatment of chronic non-communicable diseases. The pay-offs of investment are significant reduction of child mortality from 100 in 1970 to 12 per 1,000 live births in 2015. All other health indicators are above average compared with countries at the same level of economic development.
Data from World Development Indicators show that 99% of total 0.8 million births were attended by skilled health staff in 2000. Universal access to MCH services is achieved well before the achievement of UHC in 2002. Second, extension of financial risk protection since 1975. Policy targets of different population was applied, such as the free medical services for low-income families launched in 1975, which subsequently covers children under 12 years, the elderly and the disabled persons; the social health insurance launched in 1991, and voluntary public subsidized insurance scheme launched in 1984. Despite these efforts on extension of financial risk protection schemes, 30% of population was still uninsured by 2001. The government made a bold decision in 2001 and achieved UHC by 2002.
All 65 million Thais were covered by three health insurance schemes, ensuring them access to a comprehensive package of health services. The Universal Coverage Scheme (UCS) covered 47 million people, or 75% of the Thai population; 17% of the population were private-sector employees who were covered by the contributory Social Health Insurance; the remaining 8% was government employees, retirees and dependants, who were covered by the Civil Servant Medical Benefit Scheme (CSBMS).
Countries must find their own path to UHC. While no blueprint emerges from this work, the Thai reform experience provides valuable lessons, in particular the design of UCS systems. Three design elements are essential to achieving universal coverage—extension of access to services, cost containment and strategic purchasing. Financing reform must go hand in hand with ensuring physical access to services. There is no point giving people a theoretical entitlement to financial protection if they have no access to local services or if it is too costly to access services outside the community in which they live.
Cost containment mechanisms are critical because unless costs are controlled, it will be difficult to cover the whole of the population and to provide adequate services; such mechanisms ensure long-term financial sustainability.
Two such features of the UCS are the emphasis on primary health care (which was historically weak in Thailand) as the main first level of care, and the payment mechanisms, which use capitation and case-based payment within a global budget to fix the total cost. Strategic purchasing is necessary to manage the rationing of services and to direct the provision of care to those areas where need is greatest