The introduction of the universal coverage of health care in Thailand : policy responses

Doctoral thesis English OPEN
Pitayarangsarit, Siriwan

In 2001, Thailand introduced the Universal Coverage \ud of \ud Health \ud Care \ud Policy \ud (UC) \ud very \ud rapidly after the new government came \ud to \ud power. \ud The \ud policy \ud aims \ud to \ud entitle \ud all \ud citizens \ud to health care and includes health system reforms \ud to \ud achieve \ud equity, \ud efficiency, \ud and \ud accountability. The overall question this thesis \ud asks \ud is how \ud did this \ud policy \ud come \ud about, \ud and how likely is it that the policy will \ud achieve \ud its \ud goals? \ud Literature suggests that understanding the \ud policy process \ud is \ud as \ud important \ud as \ud assessing \ud the \ud content of particular policies when \ud judging \ud policy outcomes. \ud By \ud using \ud an analytical \ud framework to explore four elements: context, actors, process, \ud and content, \ud this thesis \ud aims to generate general understanding of \ud the \ud UC \ud policy \ud process, \ud and \ud to \ud use \ud this \ud analysis to assess implementation. It \ud starts \ud by \ud addressing \ud how \ud and why \ud universal \ud coverage, which had long been discussed in \ud Thailand, \ud got \ud on \ud to the \ud policy \ud agenda \ud in \ud 2001, and then explores how the policy was \ud formulated \ud nationally. \ud It \ud goes \ud on \ud to look \ud at \ud implementation in one province, examining \ud the inter-relationships \ud between \ud provincial, \ud district and community facilities. Data were \ud gathered \ud from key informant interviews, \ud document and media analysis, and group \ud discussion \ud with villagers. \ud The analysis suggests that Thailand's democratization, \ud created \ud new \ud actors \ud in health \ud policymaking processes which had long \ud been \ud under \ud control \ud of bureaucrats \ud and \ud professionals. The 1997 Constitution encouraged a more pluralistic \ud political \ud system. \ud Universal access to health was advocated \ud by \ud a group of non-government \ud organizations \ud who pushed to get UC through legislation and announced \ud their \ud campaign \ud a \ud few \ud months \ud before the 2001 election. NGO interest was paralleled \ud by \ud a \ud political \ud party \ud campaign, \ud announced in 2000 by the Thai-Rak Thai Party, \ud and \ud implemented \ud as \ud UC \ud when \ud the \ud Party \ud came to power. UC was picked up \ud because it \ud was seen as \ud legitimate, feasible \ud under \ud the \ud existing infrastructure and government \ud budget, \ud and \ud also \ud congruent \ud with \ud the \ud reform \ud intention of the political party. Once it became the \ud government \ud in 2001, \ud an \ud important \ud factor in early policy formulation was \ud the \ud extent \ud to \ud which national \ud research \ud provided \ud evidence to support the policy. \ud The \ud research community \ud was \ud tightly-knit \ud and \ud concentrated in medical-related professions. \ud One \ud member \ud of \ud this \ud policy \ud community \ud played an important role as a policy entrepreneur. \ud This \ud policy \ud community \ud continued \ud to \ud support evidence for debates in policy-making \ud during both \ud policy \ud formulation \ud and \ud implementation. The implementation process \ud was \ud a top-down \ud process; \ud however, there \ud were some spaces for street level bureaucrats to \ud adapt \ud decisions to fit their \ud context. \ud Implementation started through the extension \ud of \ud insurance \ud coverage \ud in four \ud phases \ud under the execution of the Ministry of \ud Public Health. Private \ud providers \ud were \ud only \ud minimally involved in these formulation and \ud implementation \ud phases. \ud The \ud UC \ud policy \ud in \ud 2001-2 was characterised by clear policy goals, \ud limited \ud participation, \ud strong \ud institutional \ud capacity, and very rapid implementation \ud - \ud all \ud factors \ud which anticipated \ud success \ud of \ud the \ud policy. However, the complex technical features \ud of \ud the \ud policy \ud and \ud the \ud big \ud change \ud in \ud system reform were a brake on success. \ud One \ud of \ud the implementation \ud problems \ud was \ud the \ud mobilization of human resources, especially where \ud bureaucrats \ud were \ud resistant \ud to \ud change. \ud It seems that the implementation of the \ud UC \ud policy \ud in \ud Thailand \ud reflected \ud both \ud managerial \ud as well as political problems. Given the findings \ud of \ud this \ud study, \ud policy \ud monitoring \ud should \ud pay attention to political as well as technical assessment.
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