FINANCING STRATEGIES TO IMPROVE PRIMARY HEALTHCARE SERVICES AND POLICES IN

THAILAND
Nenavath Sreenu, PhD Scholar, School Of Management Studies, University Of Hyderabad, A.P, INDIA,
500046, E-mail, ID : sri_cbm@yahoo.com , mobile no: +919966483998.
Dr. Somsaowanuch chamusri, associate dean, community nursing faculity of nursing, mahasarkham university
Thailand. Mail ID: chamusri10@yahoo.com mobile no: 6643754356.
ABSTRACT
Purpose: The purpose of this study is to assess the financing stragies to improve primary healthcare
services and policies in Thailand.
Design/methodology/approach: This study has been developed based on literature review of
research in primary healthcare management. To improve the performance healthcare delivery
services process and major step find the problems identification and formation the universal
healthcare coverage policy
Findings: The study finds problems of the healthcare delivery services in Thailand 1) Problem of
primary healthcare delivery system efficiency 2) Improved the delivery of quality healthcare services,
accessibility and affordability.
Research limitations/implications: This study is based on literature review, examining current
problems in Thailand. Healthcare financing Contribution to research on primary healthcare delivery
by the development of a comprehensive instrument of provider-perceived healthcare delivery system
in Thailand. And lack of healthcare financing within the new decentralized system
Practical implications: The proposed model can be implemented in primary healthcare centre
services in order to improve primary healthcare performance. It may also be applied to other services.
Provides a practical framework for stakeholders to develop an healthcare services performance
measurement system to rationalize resource allocation process that enhances continuous primary
healthcare financing stragies improvement.
Originality/value: The study suggests the adoption of an approach of management practices in
dealing with Thailand healthcare services system problems and provides the quality healthcare
service at primary healthcare level.
Key Words: financing, primary, healthcare, management, efficiency, delivery, services and health
system.
FINANCING STRATEGIES TO IMPROVE PRIMARY HEALTHCARE SERVICES AND POLICES IN
THAILAND

1. Introduction: Thailand has a long history of primary health care (PHC) development which started
before the Declaration of Alma Ata in 1978. The National PHC programme was implemented nation-
wide as part of the Fourth National Health Development Plan (1977–1981) focusing on the PHC
management of village health communicators and village health volunteers. Since then PHC has
evolved through many innovative health activities: community organization, community self-financing
and management, the restructuring of the health system and multi-sectoral co-ordination. PHC has
been successful in Thailand because of community involvement in health, collaboration between
government and non-government organizations, the integration of the PHC programme, new
paradigm of National Health Service development focusing on improving healthcare equity had been
experimented in Thailand for decades. Community involvements in healthcare in various forms were
implemented. Based on the experiences gained and the global movement on primary healthcare
financing (PHC). Thailand PHC program started with the new district hospitals and health centre and
the creation of community health workers i.e. village health communicators and village health
volunteers to offset the main problem of health professional shortage. During the 5th National Health
Development plan (1982-1987), many initiatives were implemented. To strengthen and sustain
community self-reliance, village health revolving funds were set up. Selected community leaders were
trained in planning and management and assigned to manage the so-called “Self-managed PHC
Villages” and their skill and knowledge were transferred to other villages under the “Technical
Cooperating among Developing Village” (TCDV) Program. To increase inter-sectoral collaboration for
PHC to be an integral part of the comprehensive national socioeconomic development strategies,
“Health for All” agenda was shifted to “Quality of Life’ (QOL). The “Basic Minimum Needs” (BMN)
indicators were developed and placed under the shared responsibilities of all social Ministries.
Healthcare policies typically focus on improving the population’s health and preventing diseases and
health hazards so that their entire population can aspire to a Healthy and happy life and thus
productively contributing to the prosperous development of the country and its economy. The
achievement of national health objectives is eventually achieved through the selection of an adequate
and efficient combination of method of financing, organizational delivery structure for health services
and payment approach for health providers. The main methods of financing for health care include the
national health insurance system, general revenue, private insurance, community-based insurance
and out-of-pocket payments. The choice of method will impact on who bears the financial burden, the
amount of resources available and who manages the allocation of resources. This study focuses on
the current primary healthcare financing method in Thailand priority in the field of health policies – the
achievement of universal health coverage – and discusses various approaches towards this priority,
that are designed in a coherent manner for each population group through pluralistic methods of
financing and delivery systems while ensuring an efficient use of national resources and sufficient
solidarity across population groups. The government of Thai Health Promotion Fund has become an
autonomous organization. The major development in this period is the launch of the universal health
coverage scheme, so called ‘30 Baht ’ scheme aiming at universal coverage (UC) for the entire
population by 2002. Although the PHC movement in Thailand encountered the time of ups and downs
during these 30 years of development, the nationwide network of village health volunteers is
sustained and found to be an extremely valuable health resources.

2.0 LITRATURE REVIEW

2.1 Conceptual Model of the Primary Healthcare in Thailand: Public policies specific government
programs may be formulated analyzed and evaluated without necessarily taking into account the
actual organization. Interest group further strengthening of the basic health infrastructure to support
PHC. A system of ‘family health facilities’ which will be the ‘facility for each family’ and work with the
community and family to improve health related risks and addressing all new diseases. Ups, this
analytical framework is based on two conceptual models of the implementation process (voradej
chandarasorn 2002), The model hypothesizes that success of an implementation depends upon the
capacity of responsible implementing organizations the ability to implement policies, therefore, may be
hindered by the factors like inappropriate design of organization and work systems, inadequate and
poorly trained staff, the agency’s inability to deploy the personnel to their appropriate place and under
utilization of resources as well as the utilization of resources in the wrong direction. Apart from the
afore mentioned model and theories, this study also benefits from review of related literature in
particular the primary healthcare development for rural villages require a new management approach.
The approach stipulated that the basic healthcare services could be delivered most cost-effectively if
integrated; demand for medical care services could be met, to a great extent, by up grading existing
healthcare personnel to be clinically competent Para physicians and also the need for healthcare
promotion and disease prevention services could be more broadly and effectively met through
community participation. The approach proved to be a successful one. Under its guidance primary
healthcare development and personnel development a number of innovations and modifications of the
existing healthcare system which constituted. Reorganization and strengthening of the primary
healthcare services Infrastructure by integrated curative, disease prevention, and healthcare services
by coordinating and administration them a single primary healthcare administration, Establishing a
department of community healthcare within the primary healthcare hospital and Improving
management and supervisory practices in part by developing a practical management healthcare
system. Development of community healthcare from existing healthcare services personnel, to be
deployed to every district hospital and sub- district healthcare centre, Development of community
healthcare volunteers in every village including training of a village healthcare volunteers in every
village, and Stimulating other community and private sector involvement by establishing healthcare
committees in every village and at every administrative level, and by eliciting the interest and support
of other private sector group.

2.2 Strategies for Implementing Primary Health Care: In 1998 twenty years after the conference in
alma-ata, WHO sponsored a follow up meeting in almaty, Kazakhstan to explore new strategies to
achieve health for all in the 21 century. Participants described sustainable healthcare gains resulting
from the implementation of primary healthcare in many regions, but inadequate progress in other
areas where there had been deterioration in health statues. They concluded that the PHCs approach
had resulted in considerable improvements in health outcomes. They recognized inconsistent
implementation as a key challenges, and identified the following prerequisites (WHO 2000b) for
effective primary healthcare
1. supportive national healthcare policies with long term commitments, decentralized
responsibility, accountability and acceptable conditions for health worker
 2. financing to assure access for the poor, continuous efforts to improve quality, community
empowerment and participation and sustainable partnerships
These elements when combined in a continuous cycle of planning implementation and monitoring.
Can be used to steer a health system towards better performance. A variety of additional strategies
will enhance the delivery of primary healthcare. They include community oriented primary healthcare
and improving collaboration among stakeholders. Community oriented primary healthcare is a
systematic approach to improving primary healthcare services through integrating clinical medicine
with public health at the community level (kark 1998, Abramson 1998) this involves sequence of
related activities that include (1)defining a community by geographical, demographic or other
characteristics,(2) determining the health needs of the community in systematic manager(3)
identifying and prioritizing healthcare problems;(4) developing programme to address priorities within
the context of primary healthcare(5) assessing outcomes, Uniting Stake holder’s through Partnership,
Primary healthcare is also enhanced by sector wide approaches that unite key players. Such as
development banks, donor organizations and government agencies, around shared goals and
collective responsibilities. The assumption underlying this approach ins that better use of available
funds is likely to occur when healthcare services delivery policies are developed jointly among
involved parties and when those policies are then reflected in consistent resource allocations and
institutional framework (cassels 2000).
3. O Primary Healthcare financing Services in Thailand: The implementation of government
healthcare policies and health initiatives will only succeed when health care systems are rationally
funded to achieve priority objectives. Apriority goal of primary healthcare is to provide easy access to
essential healthcare services for all with as few financial barriers as possible. A limited number of
physician payment options exist in any country or healthcare system. They include fee for services.
Salaries, capitation payments, integrated capitation and combination payment systems. While the
advantage and disadvantages of each option may vary depending on social and cultural
considerations particular to given country. Some generalizations about the main system of payment
can be made. In healthcare system financed by free-for service payments, patients are usually not
registered with specification primary healthcare. In addition free-for-services payments may be
associated with relatively higher payments for diagnostic studies and medical procedures but
relatively lower reimbursement for cognitive services such as counseling and education which
characterize the practices of family doctors, healthcare system that principally use fee-for- services
payment have experienced spiraling costs resulting from the unrestrained incentive to pay for any
services provided. Strategies to Improve Primary Healthcare Services (1)provide sufficient funding to
support a strong primary healthcare infrastructure(2) minimize financial barriers to essential
healthcare services(3) provide financial and other incentives to attract family doctors to increases of
greatest need (4) use a combination of payment methods to support and reward high quality
comprehensive, equitable primary healthcare services(5) measure performance and provide incentive
for targeted services such as prevention,
3.1 Health Care Financing: The health care system reflects the entrepreneurial, market-driven
nature of its economy. It is a cross- over system of public-sector and private-sector interfacing in both
healthcare financing and provision. Recently, the overall resources allocated to health care increased
markedly. The total health expenditure did rise steadily, at a higher rate than the growth of the gross
domestic product (GDP). In 2003, the total health expenditure equalled 3.3% of the GDP, of which a
higher proportion (61.6%) was covered by the public sector than by the private sector (38.4%). The
achievement of national health objectives is eventually achieved through the selection of an adequate
method of financing as well as through the choice of an effective and efficient organizational delivery
structure for health services and payment approach for health providers. The method of financing
consists of the way in which financial resources are mobilized and how they are utilized. It is multi-
faceted as it relates to different factors including: (1) The approach to mobilize financial resources;
the institutional organization delivery structure; and the allocation of resources; (2) The remuneration
and incentive method for health providers; and others. The approaches to mobilize resources
typically include a mixture of general taxation and contributions to public health systems and private
health insurance schemes. The main methods of financing for health care include the national health
insurance system, general revenue, private insurance, community-based insurance and out-of-pocket
payments.
3.2 Financing Policies to Achieve Universal Health Care: The national objective for health care
during the period 2006 to 2010, as set by the WHO is: “To renovate and improve quality of people’s
health protection and care to meet the requirement in the human development strategy”. The
document also specified tasks related to health financing, emphasizing increases in Government
budgets for the grass-roots-level health-care system and preventive health care as well as support for
access to health services by social policy beneficiaries, the poor and low-income groups. In parallel,
with revision of the user-fee policy in the principle of identifying full costs of health care, the
Government would support user fees for the poor and social policy beneficiaries, Public Health Care
and Protection Strategy in the 2001-2010 In order to achieve the objective of universal health-care
provision, the following resolution on health financing was introduced in the Strategy for the People's
Health care Protection.(1) State investment for the health-care service shall take the lead in revenues
for the health sector. Efforts will be made to allow higher regular expenditures for health service from
the total State budget. Priority shall be given to poor, mountainous and remote areas, focusing on
preventive services, traditional health services, maternal and child health care and primary health
care in local medical units, providing health services to the poor and priority targets. (2) Hospital fees
shall be adapted in accordance with costs incurred, level of investment and affordability of the public.
4.0 Universal Health Care Coverage Policy (30-baht Policy): The fragmented funding and
provision of health care made it difficult to provide equitable services, and contributed to inefficiencies
and variable levels of quality of care. The implications of reform of the Thai health care system were
taken into consideration by the government in 2001, with regard to financing, delivery of services, and
consumer rights. The main objectives and characteristics of the Universal Health Care Policy are:
universal coverage, single standard, and sustainable system. To ensure the effectiveness of the
system, strong emphasis has been placed on both resource and technology efficiencies, underpinned
by adequate and stable budget allocation to secure the system’s financial affordability. Legislation
was initiated so as to ensure policy sustainability. The government drafted a pertinent law, the
National Health Security Act, which was duly enacted in November 2002, to ensure sustainability in
terms of policy, financing, and institutional support.
4.1 Beneficiaries of the UC Scheme: The Medical Welfare Scheme was the public health financing
scheme for the poor, the UC Scheme has relatively higher proportion of the poor more than two
schemes. Beneficiaries in income quintile 1 and 2 in the UC Scheme are more than half while in the
SSS and the CSMBS account for 6.9% and 16.1% respectively. Success of the UC Scheme and
harmonization of the UC Scheme with the others would strongly affect equity improvement for the
poor.(1) Improving access to healthcare From 2002-2007, utilization rate of ambulatory service
increased 4.2% annually, while hospital admission rate increased 2.2% annually. Health service
utilization has changed to focus more on primary healthcare. When rural healthcare infrastructures
were extensively developed. Share of health service utilization at district hospital increased(2)
Prevention of medical impoverishment The UC Scheme could reduce household expenditure on
health including catastrophic healthcare expenditure. It was fond that incidence of catastrophic
expenditure (health expenditure more than 10% of household expenditure) reduced from 5.4% in
2000 to 3.3-2.8% in 2002-2004. As a result of this, it was estimated that the poverty headcounts due
to out of pocket payments dropped from 2.1% in 2000 to 0.8-0.5% in 2002-2004.(3) Promoting equity
in health Many features of the UC Scheme promote equity in health. For its source of healthcare
finance,
4.2 Challenges and strategies Universal coverage for health care: Aligning pluralistic public
health protection system although there was consensus among every stek holders that Thailand
should have Universal coverage for health care.(1) Appropriate payment mechanism Experience in
Thailand clearly that public health care providers are also response to different payment mechanism
in similar way with private ones.(2) Long-term financial sustainability The UCS now depends on
general revenue financing through annual budgeting process, (3) Improve equity, quality and
efficiency Thailand still retains a fragmented health insurance system and single fund management is
not politically feasible at the moment.
5. ANALYSIS: (1) PHC has been successful in Thailand because of community involvement in health,
collaboration between government and non-government organizations, the integration of the PHC
programme, the decentralization of planning and management, inter-sectors collaboration at
operational levels, resource allocation in favour of PHC, the management and continuous supervision
of the PHC programme from the national down to the district level, .(2) To strengthen and sustain
community self-reliance, village health revolving funds were set up. Selected community leaders were
trained in planning and management and assigned to manage the villages the need for healthcare
promotion and disease prevention services could be more broadly and effectively met through
community participation. Under its guidance primary healthcare development and personnel
development a number of innovations and modifications of the existing healthcare system (3) the
effectiveness and equity of healthcare system correlated with their orientation towards primary
healthcare. This correlation was demonstrated in a study that measured the healthcare out comes of
the industrialized nation in relation to the characteristics of their healthcare system policies and
practices that reflect primary healthcare.(4) The main methods of financing for health care include the
national health insurance system, general revenue, private insurance, community-based insurance
and out-of-pocket payments. The choice of method will impact on who bears the financial burden, the
amount of resources available and who manages the allocation of resources.(5) The budget under the
Universal Coverage Policy was allocated to provinces according to the registered population. The
payment mechanism was applied to both public-sector and private-sector facilities. Highest priority
was given to channeling allocations to the primary care units based on the registered population.
Secondary and tertiary hospitals were funded from the budget of and through primary care units for
inpatient care.
6. Conclusion: (1) Thailand has implemented the UC Scheme for six years with some successes
especially in improving access to healthcare for the poor and financial protection for catastrophic
illness. These successes happen as a result of well-designed systems based on knowledge learnt
from health system development in the past. (2) Health service provision based on primary care and
district health system, and a tax based financing system. Universal approach and a tax based
financing system share a common characteristic of administrative simplicity and, therefore, can be
easily implemented in developing countries where administrative capacity is limited.(3) It should be
noted that vertical equity of a tax based financing system depends on a country specific tax structure
and higher share of income tax would result in more vertical equity. Health service provision based on
primary care would ensure access to healthcare for the poor and improvement of system efficiency.
(4) PHCs are the well designed organizational structure and management system. The establishment
of a coordinating mechanism for primary healthcare evaluation. at district level the strength is the
structure of the district coordinating committee (5) The implementation of government healthcare
policies and health initiatives will only succeed when health care systems are rationally funded to
achieve priority objectives. Apriority goal of primary healthcare is to provide easy access to essential
healthcare services for all with as few financial barriers as possible.(6) Further strengthening of the
basic health infrastructure to support PHC. A system of ‘family health facilities’ which will be the
‘facility for each family’ and work with the community and family to improve health related risks and
addressing all new diseases.
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