Embargoed Until:
March 31, 2009
12:01 a.m. Eastern Time



Christopher Fleming

Thailand Has Achieved Near-Universal Coverage Under Its "30 Baht" Program

Researchers Say Thailand Has Avoided The Access Problems And Informal Payments That Have Plagued Coverage Expansions In Other Developing Countries

Bethesda, MD -- Through its 2001 health reforms, Thailand has achieved near-universal health coverage while avoiding the supply constraints and the informal under-the-table payments that have hampered efforts to expand coverage in other developing nations. The Thai reforms have greatly reduced the incidence of catastrophic out-of-pocket spending among the country's households, particularly among the poor.

These findings are contained in two papers published today on the Health Affairs Web site. In one paper, Kannika Damrongplasit and Glenn Melnick report that, through 2005, Thailand had added 13.6 million people to its insurance rolls since the 2001 enactment of its "30 baht" program. The program is named for its goal of ensuring that no individual is charged more than 30 baht (about 84 cents U.S.) for any inpatient or outpatient visit, including prescription drugs. In fact, the vast majority of individuals treated under the program owe no copayment whatsoever. By 2005, 95.6 percent of Thailand's population had health insurance under the 30 baht initiative and other public insurance programs.

Other developing nations that have attempted to expand health coverage have had to contend with the emergence of informal, under-the-table payments by patients to health care providers, say Damrongplasit, a postdoctoral research fellow at the University of California, Los Angeles, School of Public Health, and Melnick, a senior economist at RAND and the Blue Cross of California Chair of Health Care Finance at the University of Southern California in Los Angeles. These payments, although illegal and burdensome to many patients, have often been ignored by governments lacking the resources or the political support to fully fund universal coverage. Developing nations seeking to expand coverage have also been hindered by short-run shortages in the supply of health care services; these shortages have fostered reductions in access to care for both the newly insured and those already covered, as well as increases in informal payments as patients attempt to "jump the line."

Damrongplasit and Melnick conclude that Thailand appears to have avoided the twin hazards of informal payments and provider shortages. Analyzing data from Thailand's nationally representative Health and Welfare Survey, conducted by the Thai National Statistical Office, they find that the overall objectives of the 30 baht program "have been achieved: most of the previously uninsured have been added to the insurance system; rates of contact with health care for the previously uninsured have not gone down, while contact rates for the newly insured have gone up; and it appears that health care providers are not collecting more from patients than the amounts prescribed by government policy."

Damrongplasit and Melnick say more research is needed on the reasons for the 30 baht program's apparent success. One possibility is the program's targeted provider payment system, which offers capitated, per patient fees directly to the clinics and hospitals that sign up and serve patients. This approach ensures that the funding goes directly to facilities that have the most patients, providing incentives to sign up patients and the financial resources needed to add staff and other resources as needed, the authors suggest. Damrongplasit and Melnick also call for more research on questions about the 30 baht program that they did not address, such as whether the quality or mix of services provided has changed under the program.

The 30 Baht Program Has Reduced Catastrophic Out-Of-Pocket Health Spending

In a second paper published today by Health Affairs, Tewarit Somkotra and Leizel Lagrada find that the 30 baht program has made impressive strides in reducing catastrophic levels of out-of-pocket spending for health care by Thai households, particularly among the poor. The researchers defined catastrophic spending as spending exceeding 40 percent of a household's nonsubsistence spending.

According to Somkotra and Lagrada, the Thai households that remain at risk for catastrophic health spending are predominantly richer households, a marked contrast both to Thailand's past and to the experiences of other countries that have achieved universal coverage. What accounts for this seemingly paradoxical result? The researchers find the answer in choices by richer households to "opt out" of the public facilities where care is covered by the 30 baht program and other public insurance programs. Instead, richer households often seek care at private facilities, where care is perceived to be of higher quality, report Somkotra, a lecturer of dentistry at Chulalongkorn University in Thailand, and Lagrada, a researcher of health policy sciences at Tokyo Medical and Dental University in Japan.

While the 30 baht program has decreased the risk of catastrophic levels of health spending among poorer Thai households, some poorer households remain at greater risk for catastrophic spending than other such households. Based on January-June 2006 data from the Socioeconomic Survey (SES) and Health and Welfare Survey and other nationally representative surveys, Somkotra and Lagrada find an increased risk of catastrophic spending for households with higher proportions of members who are elderly or who have chronic illnesses or disabilities. The researchers note that public health insurance in Thailand still does not cover important services for the elderly such as long-term care, an important omission given that Thailand's population, like those of other nations, is aging, and Thailand is also experiencing shifts in family composition that may force more elderly Thais to live alone.

Somkotra and Lagrada also find an increased risk of catastrophic health spending for households that experienced a hospitalization, even when that hospitalization was at a public facility covered by public insurance. The culprit, they say, was uncovered spending associated with hospitalizations, such as transportation.

After the embargo lifts, you can read the paper by Damrongplasit and Melnick at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w457

You can read the paper by Somkotra and Lagrada at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w467


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.


©2009 Project HOPE–The People-to-People Health Foundation, Inc.