Summary of the impact

Swansea-led research on Thailand's universal healthcare coverage (UHC) reforms (1) helped change perceptions by showing researchers and policy makers in governmental and non-governmental organisations that UHC was viable in a lower-middle income country, (2) provided lessons about implementation challenges for other countries planning UHC reform, and (3) led to improved funding mechanisms in Thailand through the adoption of ring-fenced budgets for health centres and national priority services, and area-based commissioning. The study influenced the fine-tuning of Thailand's demand-side financing system to help develop a sustainable funding model that other aspiring UHC countries are emulating. Research recommendations were incorporated into the recent 10-Year Assessment of the Universal Coverage Scheme (UCS), which informed the Thai government health sector plan for 2013-15.

Underpinning research

This case study describes underpinning research done by the following Swansea researchers: David Hughes (Personal Chair, 2001-present), Songkramchai Leethongdee (Ph.D. student, 2002-06), and Siranee Intaranongpai (Academic Visitor, 2010-11). The primary study examined the implementation of Thailand's health reforms in three rural provinces in 2002-05. It investigated the formation and evolution of UCS policy, provided a theoretical account of implementation processes emphasising the importance of policy networks and local actors, and discussed the challenges encountered. The original fieldwork involved140 interviews undertaken by Hughes in 2002-2003, plus focus groups completed in 2005 to update the study and additional recent doctoral research by Intaranongpai involving fieldwork in one of the study provinces in 2010-11.

The research findings that were key to impact [see: R1, R2] showed that:

• the original capitation-funding model led to considerable system disturbance and conflict, with the provincial hospitals and powerful doctors wrestling back money passed to community hospitals,
• community hospital directors controlling local budgets did not share resources equitably so that funding went to curative hospital services rather than health centres and other community facilities.
• these problems reduced the re-distributive effects of the reforms, which needed compensatory adjustments, such as a better system of local commissioning, and protected, ring-fenced budgets for health centres and national priority services, including disease prevention and health promotion.

A lesson for other aspiring UHC countries was that economic incentives built into the financing system design were partially neutralised by professional power and political economy, so that economic levers alone were not sufficient to change provider behaviour. Professor Yip (Oxford), associate editor of Health Economics, notes the importance of economic incentives, and writes that `Professor Hughes' writing demonstrates with scientific evidence how political economy interferes when larger hospitals, both financially and politically more powerful, [slice] off the budget community hospitals hold ... thus limiting their role as purchaser...[The research] also provides valuable lessons for the World Health Organisation and ... international organisations pushing for [`strategic'] purchasing' (testimonial on file). The 2007/10 papers [R1, R2] documented this problem of `equity of distribution' in local health care systems, and recommend establishing a strong local purchasing organisation to oversee contracted providers.

Hughes was a visiting professor at Mahasarakham University (MSU) supported by a Nuffield Trust Study Abroad Fellowship (2002-03). He supervised Leethongdee's 2003-06 doctoral study, linking it to the main study funded by the British Academy and Leverhulme Trust. The findings were updated in two 2011 publications with Dr Intaranongpai, which examine evolving policy in one of the original study provinces, and illustrate the long implementation time cycle.

References to the research

The main outputs are (Swansea researchers underlined):

More recent spin-offs include:

R1 has 81 Google Scholar citations (appropriate because includes Asian journals) and R2 has 10.

The 2002/03 research was supported by two peer-reviewed grants, both awarded to Swansea.

• 2002: Implementing Thailand's Bt30 health care reforms: from plan to operational reality, British Academy, £4,999 (July to November 2002). Award to Hughes.

• 2002: Implementing the Thai Bt30 health care scheme, Leverhulme Trust, Study Abroad Fellowship, £3,745 (Nov 2002-September 2003). Award to Hughes.

The Thai purchaser/provider reform study [R1, R2] was an offshoot of earlier research conducted in Swansea on the NHS internal market reforms. This strand of work goes back to Hughes' involvement in the ESRC Contracts and Competition Programme (Award L11425102101,1993-96), and has included three other awards, culminating in an NIHR-funded study of internal markets in England and Wales (HS&DR 08/1618/127, 2008-2011) in the REF period.

Hughes is currently investigating the influence of the Thai UCS on other Asian countries with funding from Khon Kaen University and ASEASUK. He has been assisted by Dr Li, a research fellow supported by a Chinese government scholarship, and three visiting Thai researchers based in Swansea for 6 months spells. Dr Laohasiriwong of Khon Kaen University was awarded funding for a twinned study and is completing interviews in Laos and Vietnam.

Details of the impact

Thailand became a pathfinder in 2001 when it introduced UHC while a lower middle-income country. Hughes' research on the Thai reforms had impact by (1) providing a case study demonstrating the viability of UHC in poorer countries to the international policy community, (2) highlighting the importance of policy implementation challenges such as the `equity of distribution' problem and (3) suggesting changes in the Thai resource allocation mechanism to safeguard the finances of community health services. Evidence from the study has been used by the National Health Security Office (NHSO — the UCS purchasing organisation for 47 million beneficiaries) to support technical changes, like ring-fenced budgets for health centres and national priority services (see extracts from testimonials from high-level officials).

Regarding (1) above, the 2007 article [R1] provided an accessible account of the Thai reforms and the financing mechanism. It was cited to illustrate the viability of pro-poor health reforms in developing countries in the WHO World Health Report 2008 (p.112) (C1), and the World Health Report 2010, Background Paper 28 (p. 31) (C2). It was one of two illustrative case studies featured in the launch document for the Ministerial Leadership Initiative for Global Health Reform, funded by the Bill and Belinda Gates Foundation (file on RIS). As Prof. Yip states above, the 2007/2010 papers [R1, R2] are seen as adding a political economy dimension to economic analysis, which has extended the `reach' of the impact beyond Thailand. No other published study of the UCS involves a large field study by a Western academic. Strengths and weaknesses of the Thai reforms identified by Hughes are discussed in the India Health Report 2010 (C7 p.121), Global Healthwatch 3 (Alternative World Health Report 2011, p. 93) (C6), and in publications from the International Labour Organisation (C3), Rockefeller Foundation (C4, C5), the World Bank, and the Public Health Foundation of India (C8, pp. 17, 101). R1 has been used as source material for policy workshops on UHC in India organized by Results for Development and the Joint Learning Network for UHC. See for example:
http://www.ilo.org/gimi/gess/RessShowRessource.do?ressourceId=18697 (Page numbers above show where Hughes' research is cited. URLs are in section 5).

Under (2), the study found problems in implementing the UHC reforms relevant to both Thais and policy makers in other countries. The Rockefeller Foundation, Senior Advisor Health, Bangkok, writes that Hughes' research is 'useful not only to the Thais but the broader development community like ours' (testimonial on file). Thai policy makers addressed the problems identified by conducting further studies (e.g. Srithamrongsawat, 2010). A testimonial from the Director of HISRO says, `Evidence from the 2007/2010 papers was a factor that led HISRO to carry out a larger national survey published in 2010 [that] confirmed there had been problems in some areas. These early studies have helped us to evaluate ... policy options in this area, and to provide evidence to the NHSO and MoPH in support of a policy that separates off [some budgets]'.

This led to (3) impact via changes in the resource allocation mechanism. The Director Bureau of Policy & Planning, NHSO writes: `The research by Professor Hughes suggests the need to "ear-mark" some monies specifically for health centres and to prioritize certain areas of public health activity by funding these from the centre, and so supports a strand of policy we have strengthened in recent years' (testimonial). This led to more funding for health promotion projects and benefit for rural people among the 47 million UCS members. The substantial improvements the reforms have made to health care for poorer Thai people regarding access to care and reduction in catastrophic health expenditure are documented in the recent 10-Year Assessment of the UCS (R5).

Hughes was invited by HISRO to join the 10-year assessment team, focusing on evaluation of policy implementation, and helped plan and administer research interviews for the assessment exercise. Hughes co-authored A Decade of Thai UCS Implementation (Srithhamrongsawat et al. 2011 — R4), which borrows some implementation theory from the 2010 paper [R2], and he was in the Thai team that helped prepare the main 10 Year Assessment (`synthesis') report (R5).

The NHSO Director comments: `Professor Hughes' past studies helped him make a useful contribution to our analysis, and we borrowed parts of his implementation theory framework for our team report. We also discuss the "equity of distribution" problem in both the implementation theme report and the main synthesis report... Another major recommendation that was also in [Hughes'] early papers, is to strengthen area-based commissioning, so that there is a stronger local purchaser to operate beside the (..) provider'. The HISRO Director confirms this, saying that Hughes `assisted with the [10 year] research', `took part in the discussions about the overall synthesis report', and `commented on the various drafts' (testimonials on file).

The 10 Year Assessment received national press coverage. In February 2012 the WHO Office for SE Asia quoted the report and endorsed the Thai UCS as an attractive model for other low and middle income countries. The Rockefeller Foundation announced support for a capacity-building programme (`CAP UHC') in which Thai experts offer training on technical aspects of UHC to healthcare managers and professionals from other countries. At the ASEAN +3 Health Ministers' conference in Phuket in 2012 members agreed to set up a shared UHC network, with Thailand providing the secretariat for this initiative. Dr Samrit Srithamrongsawat, formerly of HISRO (co-author R4-R6), led the writing of the Thai health sector plan for 2013-15, which contains proposals for area-based commissioning and other recommendations from the 10-Year assessment report; he was promoted to Deputy Secretary-General of the NHSO in 2013.

Sources to corroborate the impact

Testimonials confirming impact from the Director, Bureau of Policy & Planning, NHSO, Thailand, the Director, HISRO (now Deputy Secretary General NHSO), Associate Director and Senior Advisor (Health), Rockefeller Foundation, and Professor Yip, Oxford University (latter re. research quality) are on file.

WHO documents citing the research:

C1 http://www.who.int/whr/2008/en/index.html (p. 112)

C2 http://www.who.int/healthsystems/topics/financing/healthreport/28UCefficiency.pdf (p.31)
Or: http://whqlibdoc.who.int/publications/2010/9789241564038_eng.pdf (p.71)

ILO documents citing the research:

C3
http://www.ilo.org/wcmsp5/groups/public/@ed_emp/@emp_policy/documents/meetingdocument/wcms_125994.pdf (p.6)

Rockefeller Foundation documents citing the research

C4 http://www.rockefellerfoundation.org/uploads/files/ebafb89b-2d68-45c0-885e-74d40e8c55d9.pdf (pp.80, 81, 82, 95):

C5 http://www.rockefellerfoundation.org/uploads/files/23e4426f-cc44-4d98-ae81-ffa71c38e073-jesse.pdf (p.60)

Global Healthwatch 3 (Alternative World Health Report 2011:

C6 http://www.ghwatch.org/sites/www.ghwatch.org/files/B3_0.pdf (Chapter B3, p.93)

Influence on UHC debate in India:

C7 http://www.scribd.com/doc/35345705/India-Health-Report (pp.121, 125)

C8 http://planningcommission.nic.in/reports/sereport/ser/ser_heal1305.pdf (pp. 17, 101)

Newspaper Coverage of the 10-Year Assessment:

C9 http://www.nationmultimedia.com/opinion/Healthcare-in-Thailand-a-story-to-inspire-confiden-30180854.html Or: http://uhcforward.org/headline/universal-access-saved-80000-families Or: http://www.nationmultimedia.com/national/World-urged-to-follow-Thai-model-30174457.html

The 10-Year Assessment Synthesis Report (linked to many sites):

C10 http://www.ilo.org/gimi/gess/RessShowRessource.do?ressourceId=28441 Or: http://uhcforward.org/sites/uhcforward.org/files/book018.pdf Or: http://whothailand.healthrepository.org/handle/123456789/1471

Links to other citations e.g. from World Bank and Indian policy documents, the Ministerial Leadership Initiative for Global Health Reform, and Srithamrongsawat (2010) on file.