Thailand UHC in Action: Universal Access to Comprehensive COVID-19 Services by Thai and Non-Thai Population

Keywords

Universal Health Coverage; COVID-19 outbreak; Comprehensive benefit package of COVID-19; Equitable access; Health financing; Thailand

Universal Health Coverage Context

Thailand achieved Universal Health Coverage (UHC) in 2002 through three main public health insurance schemes; the tax-financed Civil Servant Medical Benefit Scheme (CSMBS) covers public sector employees and dependants (7.1% of total population), payroll-tax financed Social Health Insurance (SHI) Scheme covers private sector employees (17.2%), and the tax-financed Universal Coverage Scheme (UCS) covers the remaining majority (75.7%) [1,2].

Registered migrant workers are covered by the SHI while voluntary premium-contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers undocumented migrants and their dependants. Hence, many unregistered migrant workers and their family members are not covered by any financial risk protection systems; services are paid for out-of-pocket [3].

Extensive geographical coverage of district health systems facilitates adequate and equitable access [4] with low levels of unmet needs [5]. The comprehensive benefit package [2] and free-at-point of services result in low and continually decreasing prevalence of catastrophic health spending [6] (6.7% in 1994 to 2.2% in 2017 [7]) and incidence of impoverishment (1.4% in 1996 to 0.4% in 2015 (using international poverty line of US$ 3.1 per capita per day)) [8].

This perspective analyses how Thailand has responded to the COVID-19 pandemic through the UHC lens, covering all Thai and non-Thai populations, including migrant workers, with a comprehensive set of COVID-19-related services for everyone--a key contributing factor to pandemic containment.

COVID-19 Situation in Thailand during 2020-2021

Thailand has faced three waves of COVID-19 beginning in March 2020. The nation responded effectively to the first wave of COVID-19. The second wave was triggered by a large number of undocumented migrant workers who spread the virus in factories and a large wholesales seafood market in Samut Sakhon province. This wave subsided in March 2021 through effective containment and trace-and-test implementations [9]. However, Thailand has confronted more challenges in the third wave starting in April 2021; virus infections have been spreading widely in communities, notably in crowded Thai and migrant communities in Bangkok, factories and prisons, affecting mostly vulnerable populations [10]. As of 21 November 2021, there were a cumulative 2.06 million COVID-19 cases, 20,360 deaths [11], and 87,271 current active cases under treatment [12] resulting in greatly strained healthcare facilities.

Policy Response

Making services available

A robust health infrastructure with hospital beds, intensive care units, and ventilators in all provinces were insufficient for a pandemic. RT-PCR tests, key entry points of case identification for immediate public health and social measure implementation, were not sufficiently available to test all individuals suspected with COVID-19. As such, RT-PCR capacity was immediately strengthened. From April 2020 to June 2021, 39 certified RT-PCR laboratories in Bangkok and 41 outside Bangkok [13] were up-scaled to 317 RT-PCR laboratories nationwide (124 in Bangkok and 193 in the remaining 76 provinces) [14]. Personal protective equipment (PPE) such as surgical masks, polypropylene and alcohol-based hand sanitizers were made available to population through scaled-up local production [15,16]. Field hospitals, supported by local government, Ministry of Higher Education, Science, Research and Innovation, Ministry of Defence, private sector, community, and individual donations, were rapidly built within days in heavily affected provinces, especially during the second and third waves.

Adequate financial resources for Thai and non-Thai populations

In addition to the regular budget for health services by each of the three public health insurance schemes, an additional budget of 6,352.5 million Baht (US$ 206.4 million) was approved in the first half of fiscal year 2021 for COVID-19 screening and vaccines. Also, the Cabinet approved an additional budget of 10,569.8 million Baht (US$ 343.2 million) in the second half of 2021 to finance COVID-19 health services [17] and financially compensate individuals who suffer from adverse events following COVID-19 vaccination as public vaccination roll-out started in May 2021.

An additional budget for non-Thais was also earmarked directly to the MOPH to manage payment of services at the same rate as for a Thai citizen. The Cabinet approved two additional tranches of 99.9 million and 959.3 million Baht for all migrant workers not insured by any scheme [18], ensuring everyone can access COVID-19 services. Furthermore, a new budget was allocated to the Ministry of Defence to finance international travellers, mostly non-Thai citizens for the 14-day mandatory state quarantine.

Comprehensive benefit packages for Thai and non-Thai population

The Royal Gazette published on 2 April 2020 [19] defines a comprehensive benefit package to include the whole range of COVID-19 services. For inpatient services, members are covered by their respective public health insurance schemes. Additional payment for out-of-routine services such as lab tests, active case findings, home and community isolation, field hospitals and hospitel care and ambulance referral services was applied using a standard fee schedule covered by NHSO including non-clinical services such as food and lodging where there is no co-payment by patients as the fee schedule reflects cost of production by healthcare facilities. Co-payment can hamper access to care for those unable to afford it. The same benefit packages, payment rates, and fee schedules are applied to all patients, Thai or non-Thai.

Lessons: UHC for Every People

First, in a public health emergency, the evidence reconfirms that no one is safe until everyone is safe; the major clusters among migrant workers in seafood markets during the second wave, and construction workers and slum residents during the third wave reaffirms that effective pandemic control requires universal access to essential COVID-19 interventions by all. Vaccine provision to migrant workers confirms the Government statement “universal vaccination to all target groups who live in Thailand on a voluntary basis” [20].

Second, the same benefit package for all Thais across three insurance schemes and non-Thais; the same payment rates to public and private healthcare facilities; and the adequate rates to recover the cost-of-service provision are key contributing factors for access to services by all.

Third, the prerequisite to universal access to services is the extensive availability of qualified RT-PCR tests, steady supplies of laboratory reagents, and timely report of results within 24 hours. The availability of essential services is equally important.

Declaration

Acknowledgements: We acknowledge the contributions by all policy actors in the government and the three public health insurance schemes for a comprehensive benefit package, harmonized fee schedules for everyone living in Thailand who are affected by COVID-19 without prejudice. Universal access to COVID-19 related services contributes to effective containment of pandemic.

Funding: Institutional core funding from International Health Policy Program supported the synthesis of this paper.

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