Recently, Thailand prime minister, accompanied by a high-level delegation, visited India to enhance partnership between the two countries in the areas of trade, defence, security, education, science and technology and people-to-people contacts. Although not included in this list, healthcare is an area where India has much to learn from Thailand.
Thailand is a good example of how a middle-income country can provide healthcare cover to its entire population (almost!) in a relatively short period of time. Thailand achieved this in 2002, when its per-capita national income was almost the same as that of India today. It could extend healthcare coverage to its entire population also because of certain critical reforms, that preceded this achievement.
Two measures that Thailand initiated were: One, the establishment in 2001 of the National Health Security Act, which entitled the Thai population to health services of certain standard and efficiency as given in the Act, and; two, the creation of the National Health Security Office (NHSO), an autonomous state agency that administered healthcare fund received from the government and was responsible for registration of beneficiaries and healthcare providers and making payments as per the regulations.
This second reform led to a separation of the role of purchaser of care from provider of care, which was earlier vested with the same agency, that is, the Ministry of Public Health (MOPH) that allocated budget to healthcare providers based on facility size, staff numbers, and historical performance. Now, the NHSO contracts services from healthcare providers — the MOPH and its network of providers being the main contractor of the NHSO. This separation brought explicit focus on what the NHSO was getting for the money it was giving to the contractors. Further, the method adopted by the NHSO to pay healthcare providers — age adjusted per-capita payments (called “capitation based method”) for every registered person for out-patient care and case-based payment with a global budget ceiling for in-patient care — incentivised healthcare providers and hospitals to be efficient and cost conscious.
At the time of these reforms, Thailand already had a strong healthcare infrastructure even in rural areas, where two-third of its 70 million population live. The rural infrastructure was the result of a conscious decision taken in mid-1980s to shift public health investments away from secondary and tertiary care in urban areas to primary care infrastructure in rural areas. So, the public health delivery system was already available. As a result, high immunisation coverage and availability of essential drugs were already being observed, with a strong culture of public service among the health workforce. Further, determinants of health such as nutritional status of children, accessibility to clean water were addressed to a great extent.
One could argue that the two country contexts are very different. Thailand being much smaller in terms of geographical spread (equal to the size of Rajasthan and Orissa combined!), it is relatively easier to manage administratively. Being a unitary government, Thailand doesn’t face the Centre-state challenges observed in India. Besides, the Bangkok spends substantially more on healthcare than New Delhi.
Today, if Thailand’s health indicators are far better than India’s — average life expectancy at birth is 75 years in Thailand compared to 66 years in India and infant mortality rate is 11.3 compared to 41.4 in India — it is because Thailand has prioritised healthcare unlike most Indian states. Despite Thailand’s political instability, successive country leadership did not de-prioritise healthcare.
Surely, Indian states could try out the twin reforms of purchaser-provider split and performance-based payment system in districts that have decent health infrastructure and manpower. It will enable states to understand the possible impact of such reforms as well as what it would take to scale up.
(This article first appeared in the print edition under the headline ‘Eastern Promise’)