Since the 1960s, Organisation for Economic Cooperation and Development (OECD) countries have learnt from each other on macroeconomics, trade and social policies. India could well be on its way to join the OECD eventually and is no doubt learning from these countries already. But in health, there is a closer neighbour—Thailand—with some success stories worth examining.
Thailand’s demographic and economic similarity to India makes this sort of comparison relevant. Health expenditures as a share of GDP (gross domestic product) are similar—4.4% for Thailand and 4.1% for India. However, outcomes vary widely: In Thailand, the under 5 years’ age mortality is 12.3 per 1,000 live births; maternal mortality, 20 per 100,000 live births. By contrast, the numbers in India are higher by multiples: 47.7 and 174.
In the early part of this century, with strong macroeconomic growth in Thailand, the Thai government launched a universal health coverage (UHC) scheme for the informal sector covering 70% of Thailand’s 70 million people. But this UHC push was wisely matched by structural reforms, which may explain a big part of the huge gaps in expenditures and outcomes between the two nations.
The Thais initiated a purchaser-provider split, with a new quasi-independent purchasing that paid on the basis of services and performance and not inputs like beds and staff, as is the case in India. If doctors and nurses did not perform, they were not paid. Literally overnight, line-item budgets were pooled and managed by a contractual relationship with the provider. Incentives were built into these contracts for efficiency and equity through models such as age-adjusted capitation and per admission payments adjusted for diagnosis. These mechanisms add up to “strategic purchasing” for healthcare services, which placed Thailand on a level seen in Western Europe. Both public and private providers were brought into the system, though private providers remain at a relatively low level of around 25%.
The Thai government brought new revenue into the system with a cigarette tax, which improved health, cut demand, and expanded funding space. The new money was used in part for health promotion and disease prevention programmes—from HIV to diabetes to hypertension. They developed incentives and administrative dictates to redistribute providers to serve in remote areas for some minimum tenure, often tapping those fresh out of medical school.
The benefit package for all Thai citizens has been comprehensive. Perhaps more importantly, quality of care became a national priority through an independent accreditation body that developed a three-step system of quality improvement. The government established a world-class technology assessment process to bring in the new and cost-effective, while eliminating obsolete and unsafe drugs, devices and procedures. Thailand’s Quality and Outcomes Framework (QOF), used to measure the quality of health services, offers immense learning opportunities for India.
The Thai government also decided rather early on to invest heavily in information technology focused at the central level to provide mobility and convenience to citizens, easy monitoring of the overall fiscal performance of the health sector, as well as to facilitate the gleaning of information from health claims to calculate quality and utilization measures. Most district hospitals run their own hospital management systems, which are connected to linked primary care units (PCUs). PCUs use an online supply management system with automated reordering to ensure they are always well-stocked.
Thailand has leveraged technology extensively. Its national civil registration database forms the backbone of all health schemes in the country, ensuring that a beneficiary cannot enrol in two schemes at the same time—something India could well learn from as Aadhaar becomes pervasive and as we approach the launch of the National Health Protection Scheme (NHPS). The Thai universal coverage authority’s IT management has been pivotal in the development of Thailand’s health systems. It has progressed steadily on this front by formulating three-year master plans for its IT vision, leveraging a four-level enterprise architecture model effectively. The system, in its current form, has evolved as a consequence of the integration of smaller, functional applications
and processes close to eight
million in-patient transactions and more than 160 million out-patient transactions every year.
The Thai health sector still faces substantial challenges. The distribution of providers across urban and rural areas remains inequitable. Most records are still maintained in paper form, some as electronic medical records (EMRs), but not shareable across facilities. Further, the EMRs are not stored on the national ID smart cards, which would have made the ID a coverage verification tool.
Taking a cue from its neighbour, India needs to improve prepayment and strategic purchasing, expand the health care provider network in rural areas, and also stimulate digitization. An Aadhaar-enabled NHPS, with a robust information and communications technology platform to support it, could mark the beginning of effective universal health coverage for India. However, an integrated health information system can only be arrived at if the appropriate standards for data exchange, a unified data model and a constricted description of IT infrastructure are put in place.
Jack Langenbrunner and Rahul Mullick are senior program officers, the India country office of the Bill & Melinda Gates Foundation.