Universal, but not equal: Thailand’s public health disparities persist

The latest in-depth investigation into the Thai public health system shows much higher figures for maternal deaths and infant mortality than previously documented, revealing inequality in public health services despite the universal healthcare system.

On Tuesday afternoon, 25 August 2015, the Thailand Development Research Institute (TDRI), a Thai public policy think tank, held a press briefing on a report of Thailand’s public health policies.

The research collected data between 2007-2011 from the Thai Public Health Ministry and health establishments throughout the country using maternal deaths, infant mortality, and health coverage of the elderly under the government official healthcare scheme and the universal scheme as indicators of quality and justice in the country’s health policies.   

According to Worawan Chandoevwit, the head of the research project, although Thailand’s healthcare system is ahead of many other developing countries, there are still many problems in its policies which have been overlooked in most studies on the topic.

She said that the country spends a proportionate amount of money on public healthcare, but the outcome of the country’s health budget falls short of its goals if compared to other countries which provide similar public health coverage, such as Japan and Canada.

“It’s like sending your kids to schools and they get all ‘A’s’ in class, but cannot really read,” said Worawan allegorically.

The research shows that in 2007, there were 421 maternal deaths per 673,441 births. This means that according to the international method of measuring maternal deaths per 100,000 births, the maternal death rate in Thailand in 2007 was 62.51, which is about six times higher than the official figure from the Public Health Ministry.

The research found that in 2011, although the rate decreased to 36.69 deaths per 100,000 births, the figure is still about three times higher than the official figure of 8.9.

“The Health Ministry did not include many cases of maternal death in the figures,” said Worawan. “Maternal death is a big issue and when it happens the physicians are under immense pressure and normally have to investigate and hold briefings on the case. Therefore, the real figure might be even higher.”

The report pointed out that remote areas of Thailand outside the metropolitan areas of Bangkok and the industrialized eastern seaboard are where the highest maternal death rates occur. From the data collected from 2007-2011, the three restive Deep South provinces, plus the adjacent province of Songkhla had a maternal death rate of 69.79 per 100,000 births, three times higher than Bangkok.

The maternal death rate in the lower Northern region and Isan, Thailand’s Northeast, is also about two times higher than that of Bangkok and the East, the research shows.

Worawan Chandoevwit (right), head of the TDRI research project on public health, presents the research findings on Thailand’s public health policies on 25 August 2015

Worawan said that in the predominantly Muslim Deep South of Thailand, cultural factors and the violent conflict might contribute to a higher rate of maternal death compared to the rest of Thailand, but it is obvious that disparities in the health system, where resources are concentrated in the central part of the country is a major factor.

In infant mortality, the research findings show a similar trend. From 207-2011, about 14 infants per every 1,000 in the Deep South died before reaching their first birthday, which is about twice the rate of Bangkok and the East.

Infant mortality rates in other parts of Thailand also average higher than in Bangkok and the East.

The TDRI infant mortality rate from 2007-2011 is also slightly higher than that of the Health Ministry.  

In the last part of the research, which compares the quality of health care of the elderly who use healthcare scheme for government officials and those who use the universal health coverage, the research shows that government officials and their families tend to live longer and enjoy more generous coverage.

The average annual cost of healthcare for Thai government officials paid by the Comptroller General’s Department is about 38 per cent greater than under the universal health scheme, aka the 30 baht (about 1 USD) policy or ‘gold card’ scheme.

The report shows that from 2007-2011, elderly people in the health scheme for government officials who were suffering from chronic diseases such as diabetes, heart disease, hypertension, and cancer, spent an average of 98,961 baht on healthcare in the last 365 days of their lives, all of which was reimbursed by the state.  

The figure is in stark contrast to the average of 52,181 baht paid to a comparable group with similar diseases under the gold card scheme.

Thaksin Shinawatra, the controversial ex-prime minister renowned for his so called ‘populist policies’, introduced the universal health coverage scheme in 2001. The scheme was called the ‘30 baht policy’ where people receive a ‘gold card’, allowing them to access medical treatment in their registered district with a co-payment cost of 30 baht per illness.

According to the World Bank, 99.5 percent of Thailand’s population have access to public healthcare, which is provided under three schemes, one for government officials and their families, a social security system for employees in the formal private sector, and the universal health coverage.

When Thaksin’s government was overthrown by the coup in 2006, the next military-appointed government chose to retain the universal health care policy. However, they cancelled the co-payment and relied fully on tax revenue for funding health care.

Although most Thais have access to public health coverage schemes, there are two apparent problems; one is the imbalanced distribution of health personnel, who are scarce in rural areas, and inequality in the medical treatment provided to patients covered by different healthcare schemes.

Annually, 5-6 million government officials and their family members in Thailand consume six to seven billion baht a year for health care, all paid for by the Comptroller General’s Department, whereas ten million people eligible for social security consume only two to three billion annually and the rest, numbering more than 50 million people, get 10-20 billion baht a year.

According to Sureerat Treemaca from the People's Health Systems Movement, people under the universal health coverage and social security schemes usually get different medicines, which are cheaper than those provided under the government officials’ scheme. The allocation of medicines is not standardized.

Another major problem of the public health system in Thailand is the commoditization of health institutions in the country. Hospitals in the private sector operate in a manner similar to for-profit businesses.

“Thailand allows private hospitals to become profitable businesses that can even be listed on the stock exchange. It allows private hospitals to absorb important public health resources. In addition, the promotion of Thailand as a ‘medical hub’, with state support for private medical businesses, will take more resources away from the public health sector,” Sureerat told Prachatai.

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