The Universal Health Care Coverage (UC) policy was a major reform in Thailand. It established a national health insurance scheme to which all Thai citizens are entitled to. It reduced geographical barriers and financial barriers to accessing health care and promoted equitable access through setting the expectation of a high quality primary health care unit for every 10,000 population. The major affect on Ministry of Public Health (MOPH) (state health) providers was a change in budget allocation, with budgets being linked to the number of UC beneficiaries rather than to the costs of providing care. This study aims to explain how the health care providers and health managers at local level responded to national changes in the budget allocation of the UC Scheme; to determine the main factors that shaped these actors responses; and, to explore the extent to which equity concerns were taken into account in decision making on the budget arrangement at local level. The study found that the implementation of the UC resource allocation tended to involve a bottom-up approach. Decision-making powers were delegated to Provincial Health Boards and Boards of Contracting Units for Primary Care (CUP). The results of the decisions depended on how power was distributed among members of these Boards (networks) and their relationships with each other. The responses of the local actors depended on the pressures they faced, with levels of available health resources the main cause of difficulty in implementing the UC policy. Where the experience and knowledge of the central administration could not properly guide the implementation at local level, the local implementers needed more time to learn how to execute the policy by trial and error. The UC payment system could somehow push the providers to change their organizational behaviors to improve efficiency in service delivery and, at the same time, to develop primary care units. The implications for implementation drawn from this study are as follows: 1. The provincial authority is well positioned to manage the smooth implementation of the budget allocation reforms; therefore, for its behavior to be trusted by the provider network, it should promote consensus in decision-making and demonstrate good progress in implementation. 2. In resource reallocation, a budget increase should not exceed the providers capacity to absorb new funds. By contrast, a budget decrease should not result in too great a gap between current expenditure levels and the budget level. Phasing of budget changes is recommended. 3. CUP Boards require capacity strengthening to respond to the new budgetary system, especially in supervising health centers in planning for disease prevention and health promotion services; and health centers require capacity strengthening to absorb increased budgets from the new system of budget allocation.
Consortium for Research on Equitable Health Systems, London, 37 pp.