Universal Coverage and Its Impact on Reproductive Health Services in Thailand

Abstract

Thailand has recently introduced universal health care coverage for 45 million of its people, financed by general tax revenue. A capitation contract model was adopted to purchase ambulatory and hospital care, and preventive care and promotion, including reproductive health services, from public and private service providers. This paper describes the health financing system prior to universal coverage, and the extent to which Thailand has achieved reproductive health objectives prior to this reform. It then analyses the potential impact of universal coverage on reproductive health services. Whether there are positive or negative effects on reproductive health services will depend on the interaction between three key aspects: awareness of entitlement on the part of intended beneficiaries of services, the response of health care providers to capitation, and the capacity of purchasers to monitor and enforce contracts. In rural areas, the district public health system is the sole service provider and the contractual relationship requires trust and positive engagement with purchasers. We recommend an evidence-based approach to fine-tune the reproductive health services benefits package under universal coverage, as well as improved institutional capacity for purchasers and the active participation of civil society and other partners to empower beneficiaries.

Résumé

La Thaı̈lande a introduit une couverture médicale universelle pour 45 millions de ses habitants, financée par la fiscalité générale. Un modèle de contrat de capitation a été adopté pour acquérir des soins ambulatoires et hospitaliers, des soins préventifs et des activités de promotion, notamment en santé génésique, auprès de prestataires privés et publics. L’article décrit le système de financement de la santé avant la couverture universelle, et dans quelle mesure la Thaı̈lande avait atteint ses objectifs de santé génésique avant cette réforme. Il analyse ensuite l’impact potentiel de la couverture universelle sur les services de santé génésique. Son succès ou son échec dépendra de l’interaction entre trois aspects: information des bénéficiaires potentiels, réponse des prestataires de soins à la capitation, et capacité des acquéreurs de surveiller et faire respecter les contrats. En zone rurale, le système public de santé est seul disponible et la relation contractuelle demande de la confiance et un engagement positif avec les acquéreurs. Nous recommandons d’appliquer une approche concrète pour harmoniser les avantages de santé génésique dans le cadre de la couverture universelle, de relever la capacité institutionnelle pour les acquéreurs, et de demander à la société civile et d’autres partenaires d’informer les bénéficiaires.

Resumen

Tailandia introdujo recientemente una cobertura universal en salud para 45 millones de personas, financiado con impuestos generales Adoptó un modelo de contrato de capitación para comprar servicios ambulatorios y hospitalarios, de atención preventiva y promoción - incluyendo los servicios de salud reproductiva – de proveedores públicos y privados. Este artı́culo describe el sistema anterior de salud pública y los objetivos logrados con respecto a la salud reproductiva en Tailandia antes de la reforma. Analiza entonces el impacto potencial de la cobertura universal sobre los servicios de salud reproductiva. Que los efectos sean positivos o negativos dependerá de la interacción entre tres aspectos claves: el grado de información acerca de los servicios que tengan los beneficiarios, la respuesta de los proveedores de servicios a la capitación, y la capacidad de los procuradores de vigilar los contratos y hacerlos cumplir. En las áreas rurales, el distrito es el proveedor único de salud pública, lo que requiere una relación contractual de confianza y positiva con los procuradores. Recomendamos un enfoque basado en evidencia para refinar los servicios de salud reproductiva incluidos en la cobertura universal, el mejoramiento de la capacidad institucional de los procuradores, y la participación activa de la sociedad civil y otras partes interesadas a empoderar a los beneficiarios.

Key Words:

• health sector reform
• public health insurance
• reproductive health services
• Thailand

With the backing of strong political support, Thailand adopted universal health care coverage (UC) for the entire population in October 2001. Prior to universal coverage, a range of insurance schemes, which at least partially covered some 70% of the population, were fragmented, inefficient and inequitable, and left 30% of the population without any coverage at all [1].

For more than 15 years, reproductive health services have been fully integrated into the national health system, with the Department of Health (DOH) of the Ministry of Public Health (MOPH) as the programme coordinator. Sub-district health centres, district and provincial hospitals and non-MOPH and private hospitals are the major providers of a range of reproductive health services.

The negative impact of health sector reforms, especially devolution, on disease control (e.g. for tuberculosis) is well documented in several countries [2][3] and occurs when local government officials have little capacity or interest in handling public health programmes. In decentralised health systems, where local government is responsible for local health care provision, if poorer areas receive too little financial support from central government, public health programmes will deteriorate. Furthermore, local governments tend to give higher priority to curative hospital services than to preventive public health programmes [4]. Thus, in rural China, basic reproductive health services were adversely affected, especially for the poor, when local government did not adequately finance them [5].

Reforms are affecting the way health services are provided and financed, and this has major effects on access and utilization, and patient and health care provider behaviour. It is therefore crucial for health policymakers in Thailand to understand the potential impact of universal coverage on reproductive health services, so as to mitigate any negative consequences and maintain the current level of service. Such an understanding is also of value for international audiences, as this subject is currently one of the key policy discussions internationally.

This paper analyses how the universal health care coverage system is likely to affect reproductive health services in Thailand. We reviewed documents on the provision of reproductive health services in Thailand prior to reform, and analysed the new Thai policy and plans for its implementation. This is a transitional period, and there is as yet no data on the effects of universal coverage on reproductive health services. We therefore based our analysis on empirical data from the Social Security Scheme (SSS), a health care financing scheme in which capitation was also the mode of paying providers.

First, we describe the health financing system prior to universal coverage and then the main characteristics of the universal coverage system. Next, we discuss to what extent Thailand has achieved reproductive health objectives prior to reform and analyse in detail the universal coverage services package in relation to reproductive health. Lastly, we analyse the potential impact of universal coverage on reproductive health services, and make a number of policy recommendations on how Thailand can safeguard and build upon past achievements.

Health financing systems prior to UC

There were four main public health insurance schemes that paid for health care services in Thailand prior to universal coverage.

The poor, the elderly and children under 12 were covered by the Public Welfare Scheme (PWS), which was financed by general tax revenue and suffered from under-funding and low satisfaction on the part of users/patients.

Government employees and their dependents were covered by the Civil Servant Medical Benefit Scheme (CSMBS), which was one of the most generous schemes but very expensive and suffered from rapid cost escalation. This scheme was inefficient as it employed a “fee-for-service” reimbursement model, in which individual medical services were reimbursed by the insurance agency. Providers had the perverse incentive to provide more and sometime unnecessary services in order to generate more revenue.

Employees in the private sector were covered by the SSS through a “capitation contract” model, in which the social security office purchased care from competing public and private providers for a flat fee per capita registered worker. This scheme was more efficient and well able to contain costs. Unlike the fee-for-service model, provider revenue depended on the number of workers enrolled at an individual contracted hospital rather than on the volume of services given. This is a more efficient use of resources and cost containment. Providers have the incentive to maximise the number of registered members on their list, but they also have the incentive to select healthier members of the population in order to minimise the risk of expenditure. Furthermore, they have the incentive to minimise services provided in order to save costs.

The Voluntary Health Card Scheme (VHC) covered the borderline poor who were not eligible for PWS and was seen as a temporary measure in the period before UC. Due to the voluntary nature of this scheme, it suffered from “risk selection”, i.e. those who were sick tended to join and those who were healthy tended to leave the scheme. Risk selection resulted in the scheme becoming financially non-viable, despite the fact that the government subsidised more than 50% of the costs [6].

Both the CSMBS and SSS remain in place alongside UC. Private voluntary schemes covering the better off also exist but are not discussed in this paper.

Main features of universal health care coverage

Population coverage

UC is replacing the existing PWS and VHC scheme and will also incorporate the 30% uninsured population all into one scheme. It is important to understand the socio-economic profile of the uninsured, as they are the ones who have a lot of gain under universal coverage. A study in 1996 showed that the uninsured in Thailand were poorer and less educated than the rest of the population. Most (86%) were concentrated in the poorest income bracket; 27% had a monthly income of less than 2000 Baht (US$ 80) and 59% of 2001–8000 Baht (US$80–320). Heads of these households were mostly primary school educated [1].

Financing

UC is financed by general tax revenue with a fixed co-payment of 30 Baht (US$ 0.70) per visit or per hospitalisation at point of service, through a contract model [7][8]. A flat rate capitation is used. There has been no risk adjustment for the initial year, but the policy is to aim for risk-adjusted capitation in subsequent years. Capitation will cover a wide-ranging benefits package, including ambulatory care, in-patient care, preventive and promotion services, high-cost care, and accident and emergency (A&E) services. High-cost care and A&E will be paid on a fee schedule. Reproductive health services fall under all the categories in this package.

Model

Registration of beneficiary is a pre-condition under the capitation payment method. The policy goal is to permit beneficiaries to attend their preferred provider. This is only feasible in urban areas where there is an ample choice of public and private (for-profit and not-for-profit) providers. In the rural areas, where more than 70% of the total population live, the district health system (district hospital and affiliated health centres), under the jurisdiction of the MOPH, is the sole provider. The private sector is not well developed – only a few individual private practitioners are available, and they are not able to provide a comprehensive range of services. Thus, geographical monopoly inhibits selective contracting, especially in rural settings.

Under UC, an annual contract will be granted to the provider network. However, due to the haste with which UC was implemented, there remains a lack of detail in the contract, e.g. a lack of indicators for monitoring performance, a lack of requirements regarding information systems, a lack of capacity and mechanisms for the purchaser to monitor and enforce the contract or handle user/patient complaints.

Benefits package

One of the objectives of this reform was to standardise the core benefits package across the three former public health insurance schemes by gradually closing the gaps between the three schemes, thereby reducing the inequities fostered. The benefits package of UC is based on the SSS package, with slight modifications.

Table 1

Table 1 Summary of reproductive health services packages before and after introduction of universal coverage

Components of reproductive health service	Before reform				After reform
	CSMBS	SSS	PWS	VHC	CSMBS	SSS	UC
Sex education and adolescent reproductive health	Poorly defined	Poorly defined	Poorly defined	Poorly defined	Poorly defined	Poorly defined	✓
Family planning	✓	×	✓	✓	✓	×	✓
Essential obstetric care	✓	✓	✓	✓	✓	✓	✓
Abortion and abortion complications	✓	✓	✓	✓	✓	✓	✓
Menopause services	✓	×	×	×	✓	×	×
Reproductive tract infections including HIV/AIDS	✓	×	Partial	Partial	✓	×	✓
Reproductive tract cancers	✓	Partial	Partial	Partial	✓	Partial	✓
Infertility	Partial	×	×	×	Partial	×	×

shows the entitlement of beneficiaries of the various schemes to reproductive health services before and after the reform. The benefits package favours CSMBS members both before and after reform compared to the other two schemes, especially in terms of access to menopausal and infertility services. Those who gain most, however, are the previously uninsured group, as they are covered for the full cost of services. There is a minor favourable change in the benefits package for previous VHC holders and PWS beneficiaries.

Health financing systems after UC

Since the reform in October 2001, there are now three public health insurance schemes. The CSMBS covers 7 million people, the SSS 10 million and the UC scheme for the rest of the population of 45 million. Figure 1

Fig. 1 Model of Health Insurance System in Thailand, 2002 [25]

depicts the relationship between these three major players – population and patients, health care purchasers and health care providers – and the flow of funds and services through the different health care provider payment mechanisms. As UC and SSS both have a capitation contract model, we believe the overall efficiency of the Thai health system will increase significantly.

Reproductive health services before reform

Thailand has had a population policy since 1970. As a result of a successful strategy over more than two decades to reduce the population growth rate, the country has reached a below-replacement fertility level.

The current population policy prioritises the qualitative dimension of population development, shifting the focus away from reduction of population growth to meeting the basic reproductive health needs and well-being of individuals. The first Thai reproductive health policy, in 1997, stated that all Thai citizens, of all ages, must have good reproductive health throughout their lives; it aimed to ensure this through improving accessibility, equity, rights and choices in reproductive health services.

The main components of sexual and reproductive health services in Thailand include sex education, adolescent reproductive health services (condoms, contraception, sex education and safer sex promotion), family planning, essential obstetric care, a limited number of abortions permitted under the law, and treatment for complications of unsafe abortion, infertility, menopause services, reproductive tract infections (including syndromic management of sexually transmitted infections), HIV/AIDS and reproductive tract cancers.

Sex education and reproductive health promotion for adolescents were integrated into general health education in health facilities, schools, factories and other institutions through the public media and NGO projects. A remarkable record on HIV/AIDS education and safer sex campaigns, as well as condom promotion, has been achieved [8]. The condom use rate has been sustained at a very high level, even after the economic crisis of mid-1997. The condom use rate among brothel-based sex workers has continued to increase and is now 97.5%, despite a 72% budget cut in free condom distribution [9].

Family planning is also very successful in Thailand. In 2000, the total fertility rate was 1.9; the contraceptive prevalence rate among married women of reproductive age increased from 53.4% in 1978 to 79.2% in 2000 [10]. The Pill, injectables and female sterilisation have made the most significant contribution to the success of family planning in Thailand.

Essential obstetric care is fully integrated into the health care delivery system. Nurses and midwives at sub-district health centres and district hospitals are the major providers of antenatal services, 64% of total services in 2000. They are the backbone of maternal health services, as of all other public health services, including curative services. In 2001, Thailand achieved these key health indicators: infant mortality of 21.5 per 1000 live births, maternal mortality of 28 per 100000 live births, low birth weight 8.1%, the standard of four antenatal visits for 92.2% of all pregnant women and 97.9% of total deliveries by trained health personnel [11].

Abortion services are provided in public hospitals only as indicated by law – in cases of rape and where there is a risk to the woman’s health. The majority of abortions for unwanted pregnancies in Thailand are unsafe, however, and carried out by non-health personnel [12].

Infertility services from public providers have not been adequate or adequately funded. There has been a perception among policymakers, especially during past family planning campaigns, that infertility is a reproductive health problem of the better-off and should be left to the private market and self-financed. As a result, poorer couples, who could not afford high-cost private infertility services, have experienced long waiting times for public services.

Publicly funded menopause services have an increasing role and are becoming more adequately funded. However, coverage is limited to urban medical centres where specialist care is available, for example, for hormone replacement therapy. Counselling services are available at all levels.

The Communicable Disease Control Department is the national programme manager for sexually transmitted infections (STI), including HIV/AIDS. Services for counselling, prevention and treatment were already well integrated at district and provincial levels across the country before UC. The STI incidence per 1000 population continued the downward trend from before the 1997 economic crisis, from 0.494 in 1996 to 0.379 in 1997 and 0.305 in 1998. This is a sustained result of the pre-crisis campaign for 100% condom coverage in brothels to prevent HIV/AIDS among sex workers [13].

Thailand adopted a nationwide programme of prevention of mother-to-child transmission of HIV (PMTCT) since 2000. The programme provides free voluntary counselling and testing for HIV for all pregnant women. Program enrollment is voluntary; free services are provided, including antiretroviral drugs for mothers and newborns as well as breastfeeding substitutes. Programme evaluation revealed that cost per paediatric HIV infection averted was US$4,483 and US$144 per disability-adjusted life years (DALYs) gained [14].

The two leading reproductive organ cancers among Thai women are cervical and breast cancer. Thailand has not achieved a high level of coverage of cervical cancer screening or breast screening through self-examination, clinical examination or mammography. Coverage of breast screening is only 20%. According to Thai national guidelines, Pap smear screening should be carried out annually for all women over age 35 years for three consecutive years, and if the finding is normal, then every three years. However, cervical screening (Pap smear) coverage is less than 40%.

Potential impact of UC on reproductive health services

After UC implementation, there was a small assessment of the effects of UC on reproductive health services [15], indicating that approximately 30% of UC beneficiaries had to pay for family planning services, mainly because they were unable to identify themselves as UC beneficiaries to the primary care contractor with whom they were registered.

Different provider payment mechanisms send a strong message to providers and have a major influence on providers’ behaviour in relation to commanding resources. Table 2 [16] highlights the strengths and weaknesses of different provider payment mechanisms to achieve the following four objectives: preventing health problems, delivering adequate services, responding to legitimate expectations and containing costs. While fee-for-service schemes create an incentive to deliver services and be more responsive to patient demand, they do not adequately contain cost or emphasise prevention of health problems. Unnecessary prescriptions and investigations, and cost escalation, are confirmed by the CSMBS fee-for-service reimbursement model [17].

Table 2 Provider payment mechanisms: effect on provider behaviour [16]

	Prevent health problems	Deliver services	Respond to legitimate expectations	Contain costs
Line item budget	+/−	−−	+/−	+++
Global budget	++	−−	+/−	+++
Capitation with competition	+++	−−	++	+++
Diagnosis-related payment	+/−	++	++	++
Fee for service	+/−	+++	+++	−−−

+++=very positive effect.

++=some positive effect.

+/−=little or no effect.

−−=some negative effect.

−−−=very negative effect.

There is no perfect single payment method that will achieve all four objectives; each has advantages and disadvantages. Capitation with competition not only contains costs, it also provides an incentive to prevent health problems. Providers become responsive to consumer demand, as money follows patients. However, it may also create a perverse incentive to limit necessary services, resulting in low patient satisfaction and poor quality care, as evidenced by some contractors under the Social Security Scheme [18]. Line item budgets and global budgets have strengths and weaknesses similar to those of capitation, but are less responsive to patient expectations and do not send a signal to prevent health problems. The application of fee-for-service mechanisms to preventive care and health promotion services would generate more services, increase utilisation and achieve reproductive health goals.

Conceptual framework

We developed a conceptual framework for analysing the potential impact of UC on reproductive health service utilisation and provision (Table 3

Table 3 Conceptual framework for analysis of impact of UC on utilisation and delivery of reproductive health services

	Preventive services and health promotion	Curative services
Demand side	• No effect on utilisation among unaware consumers.	• Positive effect on utilisation of services with high consumer awareness and felt need.
	• Positive effect on utilisation among highly aware consumers.	• Positive effect on utilisation when financial barriers are abolished, especially among the previously uninsured.
Supply side	• Positive effect on prevention of health problems if providers have long-term contract to minimise curative expenditure.	• Positive effect on service delivery and response to legitimate expectations if capitation is adequate and fee schedule for high-cost care is attractive.
	• No effect on prevention of health problems without long-term contract.	• Negative effect on provision of adequate services, and poor response to legitimate expectations, especially by errant providers.
Purchaser	• Positive effect on utilisation, responsiveness and prevention of health problems if purchaser has good capacity to monitor contract and vice versa.	• Positive effect on utilisation and responsiveness if purchaser has good capacity to handle complaints and grievances and vice versa.

). Reproductive health services are divided into preventive care and health promotion, which includes family planning, sex education and adolescent reproductive health care, and curative services, including emergency obstetric services, treatment of reproductive tract infections and cancer. The effects of universal coverage are shown as interactions between the three parties involved: users/patients on the demand side, health care providers on the supply side and the mediator. The National Health Insurance Office is the mediator with UC, and acts as the health care purchaser and regulator of the system.

Consumer awareness of entitlements under the benefits package plays a key role in utilisation of services, especially those of a prevention and health promotion nature. Preventative needs, such as for cervical cancer screening, breast examination and screening and family planning services, tend to be neglected by beneficiaries compared with those of a curative nature, such as treatment of reproductive tract infections or emergency obstetric care.

Health care providers under capitation with a long-term contract have incentives to invest in preventative services in order to keep their patients healthy and save costs in the long run. Attractive as it is, however, capitation alone does not guarantee proper service provision; it needs strong monitoring and enforcement by purchasers. Responsiveness among providers is realistic under capitation where there is competition. A geographic monopoly does not allow competition or result in responsiveness.

The National Health Insurance Office, the sole purchaser of care under UC, will play a new regulatory role and requires the technical capacity to design contracts, define service packages, and monitor and enforce contracts. Guidance on immediate corrective actions in cases of misconduct by contractors should be firmly in place to cope with poor quality care to reduce costs, inadequate service provision and non-responsiveness to user/patient expectations. Mechanisms to handle complaints and listen to patient voices and feedback are also key components of social control and sanctions.

As there is as yet no concrete evidence of the impact of UC on reproductive health services, we referred to experiences from the capitation model of the SSS. This showed that workers in the scheme were poorly informed about it; 11% could not name their contractor hospital, and most reported that their employers chose a contractor hospital for them. There was lower compliance to use the contractor hospital when they got ill, reflecting unmet need; 32% of hospitalisations were in non-contractor hospitals, for which they had to pay out-of-pocket [19]. A preliminary UC assessment showed similar low compliance in using ambulatory care (59%) and hospitalisation (69%) by UC beneficiaries [20]. The previously uninsured population and beneficiaries of the PWS and VHC scheme had a similar socio-economic profile to SSS beneficiaries; they were poorer and had less education. We are concerned that these problems might also affect utilisation of services under UC, including reproductive health services, as the following examples illustrate.

Prior to UC, all family planning methods were purchased centrally in bulk by the DOH. Health facilities were given incentives to increase the uptake of permanent methods (vasectomy and tubal ligation) and longer-term reversible methods (e.g. implants). However, the DOH could not maintain bulk purchasing.

Under the PWS and VHC scheme, there were no limitations on the number of deliveries women were entitled to have covered. Under UC, entitlement is restricted to two deliveries. Although the total fertility rate was 1.9 in 2000, women having more than two children may be adversely affected in terms of access to essential obstetric services. This may push the fertility rate lower over time, but meanwhile poor women may end up paying out-of-pocket for a third or higher order delivery.

Mammography was not included in the previous PWS and VHC benefits packages. A recent pre-UC study showed that less than 1% of users of public mammography centres were poor women; most were CSMBS beneficiaries who paid out-of-pocket [21]. Because UC covers mammography, greater use of breast screening may be expected, provided women are made aware of this entitlement.

For curative reproductive health services, we foresee long waiting lists for non-emergency surgery, e.g. for benign breast and uterine tumours, especially when monitoring and enforcement are poor. Rate and profile of referrals from lower to higher-level facilities are some of the key monitoring parameters. There is likely to be no impact on menopause and infertility services as neither has been well covered by the benefits package, before or after UC.

On a more positive note, access to treatment for reproductive tract cancers will be significantly improved under UC compared to the previous PWS and VHC scheme, as these were only partially reimbursed and out-of-pocket payments were prohibitive. Under UC, use of only certain kinds of chemotherapy will be problematic, as only a flat rate of 30,000 Baht (US$715 in 2002 terms) per case per annum can be reimbursed for high-cost care for any disease condition [22]. Health care providers have complained about this unrealistic rate and called for urgent revision. In fact, there is great variation in chemotherapy regimens and costs, which will help to reduce this problem.

Discussion

Given Thai achievements in providing reproductive health services in the last two decades, we asked whether the current UC reform would sustain and improve existing provision. From our analysis, we believe there are both drawbacks and opportunities for reproductive health services. One of the main elements of the reform has been the introduction of a capitation contract model. In theory, and based on experience with the Social Security Scheme, the merits of capitation are cost containment and prevention of health problems, once long-term contracts are granted. Providers are likely to be responsive to the legitimate expectations of service users/patients, as they can choose annually to enrol with a preferred provider in a competitive market, at least in urban areas. Where capitation sends a signal not to provide adequate services in order to reduce costs, a strong regulatory capacity by the purchaser is warranted. The consequences for reproductive health services depend on how well the programme can manage to minimise the drawbacks and maximise the strengths of UC.

At the same time, the role of the State is changing. In the past, the MOPH played a combination of two roles, health care provider (where major public health facilities were under its jurisdiction) and purchaser (through budget allocation to its provider networks). Reform commands new roles. The MOPH will maintain only the service provision role, while a new entity – the National Health Insurance Office – will be separate from the MOPH and play a financing and purchasing role. These new roles require a significant growth in institutional capacity to design and enforce contracts.

However, institutional capacity is not yet adequate. Moreover, the stewardship and regulatory functions are among the weakest functions of the State. The MOPH, and consequently the National Health Insurance Office, are inexperienced in contract design and management [23]. There is a need for clear definition in the scope of the benefits package, its goals and operational targets, how to monitor the indicators, and what rewards and punishments there will be. Planned activities include accreditation of medical institutions to ensure quality of care, and the development of clinical practice guidelines, an auditing system and complaints and grievances procedures.

Is there a competitive market? There are ample public and private providers competing in urban settings, providing choices to UC beneficiaries. Where district health systems (DHSs) prevail as the sole provider in rural areas, neither beneficiaries nor the purchaser have a choice. The contractual relationship between the National Health Insurance Office and DHSs should be built on trust and positive engagement, as there is no way to quit this relationship. Fortunately, the nature of DHSs as non-profit entities with a public health background, philanthropic philosophy and no perverse incentive to provide inadequate services furnishes grounds to achieve public health and reproductive health goals.

As long as this geographic monopoly continues in rural areas, a “lifetime” contract must exist between purchaser and DHS, and the DHS has incentives to invest more in preventing health problems, thus minimising expenditures on future curative care. As 75% of people live in rural areas, we expect the DHSs to invest more in primary prevention of illnesses, active health promotion, development of community-based primary care providers and, eventually, boost national health system performance.

The new budgeting system, where “the money follows the patients”, has replaced the old mechanism of historical, incremental financing of supply side costs. This new mechanism empowers service users/patients to make choices and enables providers to be responsive to their legitimate expectations. Changes in the power relations between users and providers of services are an opportunity to develop sustainable, participatory and responsive health systems. Civil society, consumer groups, NGOs and public media can play a significant catalytic and empowerment role.

A national study of the burden of disease in Thailand [24] demonstrated a high burden from HIV/AIDS, 18% and 11% of the total DALYs lost in 1999 among Thai men and women respectively. This prompts us to put more effort into sex education and adolescent reproductive health, and management of STIs, including HIV/AIDS. We need more evidence on how to design an effective intervention programme, especially for primary prevention of HIV/AIDS. We need evidence of which cost-effective interventions should be included in the package to cover menopause and infertility services, which are currently not covered under UC. Two leading reproductive tract cancers, breast and cervical, need a higher rate of early detection, through adequate access to screening services, especially for the high-risk population.

Overall, research is required to generate evidence on cost-effective interventions for each reproductive health service to be included in the benefits package. The programme should put more emphasis on sex education, adolescent reproductive health and reproductive tract infections, including HIV/AIDS. Operations research to investigate the impact of fee-for-service and bonus payments for reproductive health services would give further insights into the form future payment mechanisms should take in order to attain the goal of reproductive health for all in Thailand.

Acknowledgements

We gratefully acknowledge financial contributions to the Senior Research Scholar Program in Health Policy and Systems from the Thailand Research Fund and Health Systems Research Institute.