(1)  active finding of the target group,
(2) expanding eligibility criteria to the handicapped, the elderly, farmers without their own land, and temporary residents living below basic minimal needs,
(3)  dissemination of information,
(4)  facilitating the process of application.

There are practical difficulties in assessing the income level of those working in an informal sector, workers with irregular employment, and those engaged in farming.  Most village committees used MOPH guideline together with their conversant criteria, e.g. temporary home, landless even for house building, poor health status, chronic diseases.  (Oumkrua A, 1989)

The problems on coverage of the Low Income Card are:

(1)  appropriateness and adequacy of the eligibility criteria,
(2)  application of eligibility criteria during card issuance,
(3)  shifting of target population to other competing scheme.

10.1 Social Security Scheme and Workmen Compensation Scheme

During the first 2 years of implementation, the Social Security Scheme covered those enterprises with 20 employees upward.  In 1993, the scheme extends to cover the enterprise with 10-19 employees.  In 1995, the scheme included voluntary health insurance.  The populations covered were 2.93%, 3.87% and 4.62% and the end of calendar year 1991, 1992 and 1993 respectively.  However, because of the high rate of turn over of the workers, the actual number of workers covered by the Social Security Scheme at any time was only 70-75% of the above figure (social Security Office, 1993).

There was an abrupt rise in the number of workers registered with the Workmen Compensation Fund from 1.8 millions in 1990 to 2.75 million of the workers under Social Security Scheme was one reason for a higher coverage of the Workmen Compensation Fund.

10.2 Health Card Scheme

The coverage of Health Card Scheme gradually declined after reaching the peak in 1987.  After changing to be a health insurance scheme with greater political commitment and the Agriculture and Cooperative Bank (ACB) has been approach to be a partner of the scheme to collect money from the village level, it seems that the coverage is rising up again.  Unfortunately, the information system in the Health Insurance Office is lack of the number of card members; only number of cards sold is collected.  Estimation of 1.1 million households or 4-5 million people, i.e. 8% of the population, was members of Health Insurance Card in 1994.  However, the figure from ACB which is considered to be the most reliable was 3.3% of the population.

Even though the eligibility criteria was not changed according to the economic growth, the percentage of people receiving Low Income Card were nearly the same in 1984 and 1990 issuance, i.e. 20.2% and 19.2% of the total population respectively.  The coverage was intentionally dropped to 14.5% in 1987 due to the promotion of the Health Card Project.

The Rural Health Division and Mahidol University (1988) found that the scheme covered only 28% of the eligible poor and 20% of the cards were distributed to the ineligible people.  The percent coverage might be underestimated because the poor defined by this study were as high as 62.4% of the sample population.  The NSO socioeconomic survey (SES) in the same year showed that households that have monthly income lower than 2000 Baht in the rural area was only 43.8%.  The correct coverage in that study should be 17.5% of the total population or 39.9% of the eligible poor.

Mongkolsmai D.  (1993) noticed that means test for the “single poor” is almost 4 times the poverty line.  It should cover at least all of those under the poverty line or 23.7% of the population in 1988/89.  However, single person account for less than 10% of the population.The means test for an average household of 3.9 persons ( 2,000 Baht / household / month or 6,154 Baht/person/year) was 1.5 times of the poverty line for the rural population or nearly the same level as the poverty line for the urban population.

Monkolsmai D (1993) compared the percentage of LIC holders in each region with percentage of poor population determined by means test and poverty line.  In 1987, the LIC holders accounted for 14.5% of total population, 28.3% of the low income people determined by means test, and 49.2% of the poor determined by poverty line.  The percentage of LIC holder compared with those below the poverty line rise to 81.0% in the 1990 issuance.

In table 3-5, the author used monthly household income from SES 1988 and 1990 to determine the percentage of eligible household, i.e. household income below 2,000 Baht.  The percentage of LIC holders was then compare with the percentage of eligible households.  It was found that the percent of eligible households dropped from 35.3% in 1987 to 25.2% in 1990 because the income level for eligibility was the same.  The number of LIC holders increased from 7.6 millions to 10.7 millions.  Thus, the coverage of LIC for the eligible households increases from 41.1% in 1987 to 76.2% in 1990.  The leakage of LIC to the non-eligible might lower these figures.

There is a problem of double counting in the group of children under 12 years.  The Ministry of Education is responsible for setting the target of primary school students to be covered.  Even though the figure are students in school under  supervision of the Office of National Primary School only, the summation of children under all health benefit schemes in this age group are more than the total number of children in this age group.

Kiranandana T (1993) did a forecasting the coverage of 8 schemes up to the year 2000 based on the projection of demographic and economic data.  The poverty line for the Low Income Scheme was a previous one, i.e. 2,000 baht/month for households and 1,500 Baht /month for individuals.  Thus the percentage of those who will be covered by the Low Income scheme was underestimated.

Comparing the 4 sources of information (table 3-4), there is a gradual decline of the uncovered groups.  The reliability should be checked across various sources of information, including a national survey.  The coverage figure in 1995 was the last estimation.  The only unreliable data is for the Health Card Scheme.  In the worst case, i.e. the Health Card cover only 3.3%, then the uncovered people should rise to 37.3%.  However, it is still difficult to determine effective coverage, especially for the Medical Welfare Scheme for the Low Income.

The following graph shows numbers of beneficiaries in each scheme from reported data.  There are gradual expansion of CSMBS,SSS, and WCF.  The drop in coverage of Free Medical Care for the Low Income coincided with the promotion and rising of Health Card in 1987.  There was shrinkage of Health Card Scheme during after it reached the peak in 1987.  With political support, it expands again in 1994.  The elderly and children under 12 are not included in this graph.

Since 1991, there have been a number of changes on health benefit schemes. The first was the Social Security Scheme started in 1991 and now covers about 7% of the total population, from working establishment of 10 workers and higher.  The second scheme is the Road Traffic Accident Liability Scheme enforced since 1993.  It is supposed to be the first compulsory universal health insurance coverage against road traffic accident, but failed in its administration because it let the private insurance companies to set up requirements that prevent easy reimbursement.  The third is the strengthening of the public welfare schemes to cover the aged (7% of the population), children under 12 years old (24%) and public subsidy to voluntary health card purchaser (15%) (Pannarunothai S, 1995)

Tangcharoensathien V & Supachutikul A (1993) categorized health benefits schemes into 4 groups and using data from report of the responsible organizations to analyze health benefit coverage.  It was found that 44.4% of the population was not covered by any health benefit scheme, two-thirds of the NSO’s figure.  This was because the Social Security Scheme was not started until June 1991, the Free Medical Care for the Elderly was not started until 1992, and the health welfare scheme for primary school children was not reported during the survey.

1) To promote services for maternal and child health, family planning; other health promotion, prevention and curative services.
2) To change the role of the population and health personnel so that communities could initiate and participate in the management and health personnel would support and provide the necessary services.
3) To improve the potential of the communities in financial management and to improve the quality and effectiveness of health care personnel.
4) To reduce the number of out-patient visits at provincial hospitals and use the saved resources for more efficient activities.

The fundamental philosophy of the HCP has much to do with primary health care development at the village and tambon levels, and improvement of back-up referral facilities.  The communities through the Health Card Funds were expected to manage the premium collected; a certain percentage of funds are earmarked for village PHC and other development activities.  (Hongvivatana T et al., 1986)

The German Agency for Technical Cooperation (GTZ) supported this project in a pilot area of Chiangmai from 1984 to 1988.  After a program evaluation, the second phase started in 1990 to support 5 project provinces in implementation a new model of Health Care Scheme.  The project province considered multiple objectives of the scheme, community development and health insurance, as a failure factor.  The objective of community development succeeds in not many places, so the only objective in tee new model was voluntary health insurance.  After testing the new model in 1991-1992 and the results were report in August 1993, the GTZ terminated support to the project (Supachutikul A & Sirinirund T, 1993).  The MOPH adopted the new model of HCP at national level in 1994 under its new name, “the Health Insurance Card”, and with subsidization from the government. It was hope that the scheme will make universal coverage of the country possible.  However, some lessons and suggestions from the report of model testing were not considered seriously.

The health Insurance Card is purely voluntary health insurance scheme.  However, there are other 2 varieties of Health Insurance Cards designed to accommodate the need of providing medical coverage to those who work for the government at village level, i.e. community leaders and village health volunteers.  The card for these two groups are issued free of prepaid premium to provide coverage to them and their family members, hence these variants are a kind of fringe benefits to the government employees.  However, the government policy on health benefits for community leader was not stable.

The first private health insurance company was established in 1978.  The introduction of the health insurance concept later induced other life insurance companies to offer an additional health insurance services in their life insurance marketing plan.

Insurance business in Thailand has been legally categorized into 2 groups: life and non-life insurance.  Health insurance.  Health insurance is classified as a subset of non-life insurance, not as a subset of life insurance as in other countries.  However, life insurance companies may offer health insurance as optional plans attached to the main life insurance policy, e.g. accident and injury plan, health care plan, cancer and other severe diseases plan, permanent completely disability plan.

In 1993, there were 17 companies offering life insurance service and 67 companies offering non-life insurance service.  There are 18 health insurance firms.  Only six of them offer only health insurance.  (kiranandana T, 1993)

In 1972, a workmen compensation system for work related illness and injuries was incorporated into the Labors Act and the Workmen Compensation Fund was set up in 1874.

In 1990, while the economy of the country was expanding, the parliament passed the new Social Security Act that covers 7 benefits for workers in the formal private sectors, i.e.

(a) medical benefits for non-work related illness or injuries,
(b) maternity benefits,
(c) invalidity benefits,
(d) death benefits,
(e) old age benefits,
(f) unemployment benefits, and
(g) children allowance benefits.

The first four benefits were implemented immediately within 6 month (June 1991).  From this act, the Social Security Office (SSO) was set up in the Ministry of Interior, and was later integrated with other departments to form the Ministry of Labour and Social Welfare.  The SSO also looks after the Workmen Compensation Fund.  During the first two years of implementation.  Social Security Scheme covered enterprises with 20 or more workers.  In September 1993, it began to cover enterprises with 10-19 workers.  In 1994, the scheme allows workers who terminate their eligibility due to unemployment to become voluntary insurers.

Social security system can be achieved through 3 basic approaches, i.e. (a) public assistance to the indigent, (b) social service or public service to all citizen and, (c) social insurance by pooling resources and risks between members in a society.  Health security in Thailand is based on a mixture of the first and the third approach and the existing health insurance and health welfare schemes in Thailand it may be categorized into 4 main groups:

1) public assistance to the indigence (the poor, the elderly, children).
2)  health benefits for government employees.
3) compulsory health insurance for formal sector employee.
4) voluntary health insurance.

The following table summarizes all important events about health insurance and welfare schemes chronologically.

3.2 Public Assistance to the Indigence

The government policy to provide free medical care for the low income was initiated by the Social Action Party in 1975, together with other free public services such as public transportation, with an objective to reduce inequity in access to public service.  While free public transportation failed to be implemented, the Free Medical Care for the Low Income Scheme has been continuing until nowadays and covers people more than any other schemes.

At the beginning, it was determined that a person with income below 1,000 Baht per month would be eligible for welfare benefit.  During 1976=1980 there was no identification card to those eligible.  The decision to provide free care was at discretion of staffs of public health facilities.  The first issuance of the Low Income Card was done in 1981 and resistance every 3 years.

In 1994, the name of the scheme was changed to “Medical Welfare Scheme” for the Low Income.  Apart from adjusting the income level for eligibility, no other significant change was made.
In practice, MOPH hospitals have 3 categories of assistance:

(1) Type A assistance for those who have Low Income Card or nowadays Medical Welfare Card.
(2) Type B assistance for those who have no card but are unable to pay for medical expenditure.  Social workers in hospitals will interview and determine to what extent the hospitals will exempt for them.
(3) Type C assistance for monks, village leaders, veteran, members of local councils, etc.  The degrees of assistance in this group vary from free service to some deduction.

Apart from assisting the low income group, the government also has policies to assist various groups of people, i.e. the elderly, children 0-12 years old. The disables.

3.3 Health Benefits for Government Employees

Health benefits have long been included as fringe benefits and privilege for civil servants.  It was only during the last 5 years that civil servants were suffered as “the new poor” and health benefits were considered to be compensation for low salaries.

At first there were rules and regulations for medical allowance reimbursement for civil servants and permanent workers of the government.  In 1978, the first Royal Decree for Civil Servant Medical Benefits Scheme was enacted, and 2 years later it was replaced with the present one, of which underwent series of adjustment.

Each state enterprise will have its own rules and regulations for medical benefits of its employees, of which similar to the Royal Decree for CAMBS.  Only choice of health service and rate of reimbursement that differ.

In 1995, the parliament approved the amendment of the constitution.  Article 41 of the constitution states that ‘people have right to get access to standard health care and the poor can get free medical care’.  The implementation is going on with drafting relevant laws.

Criticism

Health insurance and welfare schemes vary widely in the target population, benefits package, and fund managers, source of funding, payment mechanism and government subsidy.  Hsiao W (1993) criticized that Thailand has a three-tiered health care system.  The bottom tier for the poor, of which services are rationed by limiting supply.  The middle tier for middle income people.  And the top tier for upper income persons who pay directly and freely choose their services.

Though the classification of these tiers are not fully correct, it stimulates us to look closely at what are we doing in our system and to what direction it will be.  Hsiao W further questioned on the cost-effectiveness of resource used comparing with its peer nations.

As equity, efficiency and quality of care seem to be the universal goals for every developed countries, one may question how far Thailand being from these goals.

Objectives

The objectives of this paper are:

(1) to review the extent of existing health insurance schemes on     population coverage, benefits package given, mode of health service delivery, mode of financing, quality of care and health service utilization.
(2) to assess the strengths and weakness of existing schemes in term of, efficiency and equity including moral hazards and adverse selection.
(3) to explore future development to achieve equity, efficiency and quality of health insurance system in Thailand.

Thailand has experienced a lot of transformation during the last 3 decades.  The country is moving from a subsistence agricultural society to a rapidly growing industrialized sector.  Economic growth in Thailand continue steadily even during the time of world crisis.  Unfortunately, the country does not use this advantage to create mechanism for a fair distribution to all the citizen, thus results in widening of income gap between the richest and the poorest population.

Export economy boosts manufacturing but shrinks agricultural sector.  There is an increasing trend of diseases related to behavior, occupation, environment and social pathology.  Communication and information technology has been advanced, promoting information and education, but it is also used to promote consumerism and exploit consumers.  Thailand is experiencing epidemiological transition whereby poverty related diseases such as communicable diseases and nutritional problems dramatically decreased but still present in some groups of population, Lifestyle related diseases such as cardiovascular diseases, cancer, traffic accidents are increasing causes of death.  HIV problems, a reflection of social and political problem, are growing rapidly.

Health Care Systems in Thailand

Thailand’s health care system reflects the entrepreneurial market-driven nature of its economy.  It has a pluralistic public/private mix in both financing and delivery of health care.  While the government organizes health care financing for some segment of its population, it adopts largely a laissez-faire policy toward private providers and private insurers.

The public health infrastructure, hospitals and health centers, have been well developed but not functioning properly due to limited technical support, poor management and confusing roles.  The private sector is growing rapidly both in Bangkok and nearly in every province the health system is quite chaotic because patients can seek care from anywhere they wish.  Popularity of ambulatory care in a large and famous hospital results in expensive and fragmented system.  The Thai medical care system is characterized by over-specialization, negligence of comprehensive and continuity of care, negligence of health promotion and disease prevention, over-mechanization, inefficient and costly.