In Thailand in 2001, before the Universal Coverage Scheme (UCS), nearly one in four people were uninsured.^source Others were covered by insurance that offered only partial protection. The result: over 17,000 Thia children under five died each year, two-thirds from easily preventable infectious diseases, and out-of-pocket health spending tipped one in five of the poorest Thai households below the national poverty line.^source

Achieving universal access to healthcare has been a goal of most high-income countries since the postwar era. Recently, the introduction of universal health coverage, a system whereby all people can obtain health services without suffering financing hardship, has gained momentum in low- and middle-income countries. Advocates and researchers highlight the enormous potential of universal health coverage to promote health and human rights.^source

In Thailand, UCS followed a long string of efforts to improve equity in health. In 1975, the government had made health services available to the poor free of charge. Recognizing the problem of a lack of health centers in rural areas, the government froze all new capital investment in urban hospitals between 1982 and 1986. It reallocated those resources to rural district hospitals and health centers, trained and employed doctors and community health workers, and recruited and trained village volunteers to strengthen primary care. 

Despite progress, about 25 percent of Thai people were still without insurance in 2001. Coverage was inequitably distributed and medical indicators reflected this imbalance. Where large proportions were enrolled in the Medical Welfare Scheme—which covered people living poverty, the elderly, children, veterans, monks and priests—rates of infant mortality were higher than in other areas.^source The 1997 Asian financial crisis exacerbated the effects of inequitable health coverage, weakening the Thai economy along with its health system.

In 1999, government and civil society proponents of universal health coverage saw an opportunity to push forward a radical change in how Thais accessed healthcare. At the heart of the movement was the populist Thai Rak Thai party, along with reformers in the Ministry of Public Health and Dr. Sanguan Nitayaramphong, who would later oversee the UCS rollout. Leading up to the 2001 elections, they all worked tirelessly to persuade politicians and the public to embrace universal coverage.^source In its campaign, Thai Rak Thai promised that the proposed new scheme would protect Thais without insurance coverage. Its slogan was “thirty Baht treats all diseases”.

Civil society was a crucial part of the policymaking process, too. Senator Jon Ungphakorn brought together local NGOs to support UCS. The group led a campaign advocating greater equality in coverage, increased participation of the people in health management, and better financial risk protection. Civil society held five seats on the parliamentary commission to review drafts of the UCS legislation, giving these representatives genuine influence over policy design.^source 

Thai Rak Thai's landslide win in January 2001 opened the path for change.^source The government proceeded with rapid implementation, despite the recommendation of World Bank and WHO advisors to pursue a gradual introduction.^source Although Thai leaders were cautious, they believed a quick rollout would build confidence in their leadership.

To prevent overlap and inequity, the government planned to merge resources from four existing health coverage schemes—the Medical Welfare Scheme (MWS), the Health Card Scheme (HCS), the Social Security Scheme (SSS), and the Civil Servants Medical Benefits Scheme (CSMBS). However, they met resistance from the departments responsible for each.^source To avoid losing momentum, the government compromised and only pooled the budgets for the MWS and HCS—schemes for the poor and near-poor. 

The compromise allowed for the passage of the National Health Security Act in 2002, and the UCS was ready to take flight.^source Rollout was swift: starting with six provinces in mid-2001, the scheme was extended to nearly all Thialand's 75 provinces by the end of the year.^source As the UCS reached an additional 18 million people by combining existing pools form the MWS and the HCS, the group of uninsured Thais shrunk dramatically. By 2001, the UCS was covering 48 million members and their families, leaving less than 2 percent of the Thai population without health insurance coverage.^source

One of the scheme's central administrative features was that the provider and the purchaser of health services were two discrete entities. The Ministry of Public Health was responsible for providing health services, and a new independent entity, the National Health Security Office (NHSO), managed and operated the UCS.

All citizens were eligible for the UCS. To enroll, people registered with a contracting unit (usually a district healthcare provider network), and received a gold card. The card entitled enrollees to free care at health centers in their home district and contracted hospitals, plus referrals to provincial or tertiary care hospitals in urban areas.^source  Members were entitled to a comprehensive benefits package, which provided similar coverage to the pre-existing health insurance schemes, and later extended to cover more expensive services.

The scheme was primarily financed by general income taxes, so it was proportionately more heavily funded by the rich than the poor.^source Initially, users paid a co-payment of BHT30 (US$0.70) per visit. However, collection of the co-payments ultimately cost more than the revenue it generated. Following a military coup in 2006, eliminating the co-payment also helped the incoming public health minister' show his party’s dedication to the UCS. ^source

In the decade after its launch, the UCS increased access to health care—particularly among babies and women aged 20 to 30 years old—and its members have gotten healthier. When the financial barriers to health services were lowered, previously uninsured Thais, especially those with the lowest income, increased their use of health services. The poorest women of reproductive age and their infants benefitted the most. Indeed, the association between poverty and infant mortality disappeared, suggesting that the UCS succeeded in erasing the equity gap in infant health.^source

One year after the UCS launched, people were less likely to report that illness had prevented them from going to work than before—an improvement that researchers attributed to the UCS. The effect was far larger for workers over the age of 65.^source By keeping Thailand’s ageing workers healthy, it is conceivable that the UCS improved labor productivity.

The government’s overall expenditure on health increased from BHT84.5 billion (US$2.6 billion) in 2001 to BHT1116.3 billion (US$3.6 billion) in 2002, and continued to increase steadily to BHT247.7 billion (US$7.6 billion) in 2008.^source The UCS is entirely funded by the government of Thailand, mostly through revenue from general taxes.

The UCS budget, determined by the number of beneficiaries multiplied by a standard per-person rate, also increased in absolute and per capita terms. In 2002, the government allocated roughly BHT1,200 (US$35) per beneficiary, and increased this to about BHT2,700 (US$80) by 2012.^source  Meanwhile, government expenditure on other schemes, such as the SSS, remained flat. Thailand has achieved near universal coverage at slightly lower cost to the government relative to the country's GDP ^source than other upper-middle-income countries such as Colombia and South Africa.^source

A stable and dedicated leadership sustained the UCS. The Thai Rak Thai party integrated the scheme into its 2001 election promises, and the leaders who had pushed for reforms continued to do so once elected. Dr. Nitayaramphong, secretary-general of the NHSO, worked hard to get politicians and citizens to accept the UCS. His successor and long-time deputy, Dr. Winai Sawasdivorn retained that momentum.^source Tangible benefits made the Thai Rak Thai party popular and sustained its power, which allowed it to nurture and strengthen the program.^source

Thai reformers were quick to learn from international experience, existing Thai health coverage schemes, and initial stages of the UCS rollout. In particular, the implementation of the SSS informed the decision to separate the healthcare purchasing and healthcare provision. The government also procured medicines and devices at the central level, leveraging the sheer size of UCS coverage to negotiate lower prices. UCS architects’ ability to craft a strategy based on past experiences ultimately improved the scheme's efficiency.

The UCS also gave hospitals a boost. Their BHT1,200 (US$35) per-patient budgets greatly exceeded the roughly BHT250 (US$8) reimbursements that MWS members had previously received.^source More money meant that public facilities could provide more and better health services. 

Another important factor in the program's success was the country’s judicious approach to determining which health services and technologies the program would cover. These decisions are made through an evidence-based, systematic process conducted by the Health Intervention and Technology Assessment Program (HITAP), an autonomous public arm of the Ministry of Public Health.

This coverage scheme has been justly praised, but it has some critics. Some charge that, despite increased budgets, UCS-contracted hospitals provide a lower quality of care than those available to CSMBS and SSS enrollees. The government is taking steps to address these concerns and improve the equity of quality care.^source

Many countries have pursued quality healthcare for all.^source  Some have found success, such as Colombia and Turkey; others, such as the Philippines, have seen reforms stall.^source  In comparison, Thailand's UCS was rolled out rapidly, showing that a lower-middle income country can achieve universal health coverage under the right circumstances. Sustained political commitment, sound public financing and oversight policies, and civil society engagement helped make it possible.

Thailand is a leader in the use of evidence to inform health policy decision making. HITAP is one of the few agencies in a low- and middle-income countries to systematically assess whether health technologies will be eligible for coverage.^source To make policy development participatory, a diverse panel of health professionals, academics, patient groups, and civil society organizations oversee the prioritization of health interventions. This process is attractive due to its built-in accountability and cost-saving advantages, and the Thai government is working to share its experience with others.

There are many ways to finance universal health coverage. Thailand's experience adds to a growing body of evidence that health-financing systems do not have to rely on fees from health-system users. The majority of Thais receive health coverage without fees, their benefits financed by tax revenues. Some Thais—private company and temporary public employees—contribute directly to universal health coverage.^source

The growing UCS budget casts some doubt on its sustainability. To address this concern, researchers have suggested that the UCS devote more of its budget to preventive and health-promotion services, which currently account for just under 20 percent of the budget.^source  They also recommended health planners continue to carefully analyze new and available interventions based on cost-effectiveness evidence and their implications for the budget.^source Other countries will watch carefully to see how Thailand tackles the sustainability challenge.

Expanding health coverage can improve health by expanding access and by providing financial protection.^source Experience shows that free healthcare alone does not guarantee better health; other elements are needed to improve health outcomes. By providing free and cost-effective services while at the same time strengthening its health system, Thailand managed to keep workers healthy and save young lives. While challenges remain, Thailand's UCS is working. It can provide a model and inspiration for other countries on the path to universal health coverage.