Michelle Bromberg Ad-Hoc Honors NURS 413 Autumn 2012 Universal Health Care in Thailand, a Cultural Analysis This

is a review of the Thai Universal Care System (UCS) and coupled with a highlighting of the elements of Thai culture that appear to be relevant to the formation of the UCS in Thailand. I draw from both published texts as well as my notes taken while in Thailand from August to September 2012. From this analysis, I will show that culture can play an invisible yet central role in public health care systems. As such, culture must not be overlooked when designing a health care system. This information may be useful for countries that have yet to establish universal care, or for health care professionals who are involved in the implementation of health care programs in cultures with which they are not intimately familiar. Recent Health Care History of Thailand From the 1970s until 2000, Thailand had many different public coverage schemes, including the Medical Welfare Scheme, the Type B Exemption Scheme, the Civil Servant Medical Benefit Scheme, and the Social Security Scheme. Each of these schemes covered a different sector of the population, such as those who were below the poverty line, those who had low-income but were not impoverished, civil servants and their families, public sector employees, and those who were not covered by any of the other schemes but still lacked coverage. When the 1997 Constitution of the Kingdom of Thailand was written, Section 52 read, All Thai people have an equal right to access the quality health services This was a

commendable addition to the Constitution, but despite the creation of this article, the government had no law to enforce it. Four years later, though, the Ministry of Public Health addressed Section 52 by introducing the Universal Coverage System (USC, or the 30 Baht Scheme) for all Thais who did not have health care. This program, under which healthcare can be obtained for a small copayment of 30 Baht (~$1 US) per visit went through a trial period in six provinces in 2001. In 2002, the program was expanded nationwide. Four years after that, the copayment was abolished, and citizens could obtain care without a co-payment. Recently, the 30 baht system was reestablished in the hopes of increasing the budget of the universal care system. It is too soon to say how this has affected the UCS, but perhaps it will result in a better-funded and more mature version of what the Ministry of Public Health created in 2001. Current Program To receive the benefits of UCS, citizens (and foreign workers) register with a local contracted unit for primary care (CUP) to obtain a gold card, which grants them access to health services at their local district. The National Health Security Office pays CUPs on a per capita basis, thus patients can only receive the subsidized 30 baht treatment from their designated CUPs, except in the case of an emergency. If more care is needed, patients will be transferred to a larger hospital or to see a specialist without an extra fee. Thai health care facilities exist as a tiered referral system. CUPs are the place of basic care, and patients may be referred to higher levels from there. The hospitals are arranged in a tiered system. Patients first enter a community hospital, which

ranges from 10 to 150 beds, depending on demand and funding. These hospitals are the most numerous and can be found in most districts. General hospitals, which are placed in province capitals and major districts, have 200 to 500 beds. The largest hospitals are the regional hospitals, which have 500 or more beds and employ specialists. There are three different types of care packages under the UCS: a preventative package, a curative package, and a high-cost package. Dental care, annual check-ups, immunizations, and reproductive health services are all included in the preventative package. None of these packages cover all of the treatments one might hope to receive, but a number of treatments that were once excluded from coverage are being added to the packages. Both ARV treatment1 and renal dialysis2 have been included due to strong social pressure. Impacts With the creation of UCS, one third of the Thai citizens gained access to health care,3 bringing the total national health care coverage up to 99.5% of the population. 4 The use of health services has increased overall, which indicates that people who have gained access to care are actually using it. 5 On top of the increase, a shift in resource usage by rural residents and the urban poor shows that they are using primary healthcare more than before,6 which may lead to a reduction of the monetary burden for emergency care. A drop in the percentage of those who
Teerawattananon, et al. Kitajima et al. 3 Yiengprugsawan, et al. 4 Indaratna et al. 5 Yiengprugsawan, et al. 6 Yiengprugsawan, et al.
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became impoverished due to medical treatments has dropped from 1.01% prior to the UCS to 0.49% in 2004.7 As the UCS continues to grow and refine its model, the impacts should continue to increase Cultural Analysis Along with the governmental policies that led to the establishment of the current universal care system, there are certain components of Thai culture that seem to have contributed to the creation of this the UCS. Thai views on respect, religion, and solidarity are all candidates for such underlying social influences. A number of elements of Thai culture allow for effective community health campaigns, which lie at the basis of the UCS. From what I learned while in Chiang Mai, Thais generally appear to be a religiously homogenous, community-oriented, and respectful people. All of these aspects come together to create a welcome climate for universal health care that is strong all the way down to the community level. Over ninety percent of Thais identify as Buddhist. Because of this religious homogeneity, community health leaders realized that wats (Buddhist temples) could be used as venues for community exercise classes. 8 This is indeed a culture-specific aspect of Thai health care that would not work in countries that are more religiously diverse, as meeting at a site that has religious ties might make it uncomfortable for those of a different religion to visit.

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Yiengprugsawan, et al. Treerutkuarkul

Thai culture, particularly when explained in contrast to that of Western traditions, is noted as being very much a community/cooperative culture.9 This relates to the reason why Thai villages already had a culturally-induced cohesive community structure that facilitated the set-up of CUPs at the community level. This assisted in the creation of a comprehensive network of health care facilities, which is cited as a reason for UCSs infrastructural success.10 The concept of krenjai, showing respect for ones superiors, is an important piece of society in Thailand. As Jim Goodman writes in his book about Thai culture: Krengjai is translated as consideration, but it specifically means a demonstration of consideration for the feelings of others, particularly ones superiors. As such, krengjai contains the notions of humility, politeness, respect, and obedience. This principle is stressed throughout every Thais upbringing and is important in all forms of Thai social behavior. 11 The corollary to krengjai is the mercy that one of higher social position is supposed to show toward those who are below them. With these two forces acting in balance in the same way that they have for centuries past, it makes sense that the upper class sought to provide health care for all, and that the lower class supported this choice. Thais hold deep respect for physicians, something that may not exist in other cultures. As, Dr. Prawase Wasi, Vice-Rector of Mahidol University, writes: Physicianswere considered a privileged group, called upon to exercise Buddhist universal compassion for suffering humanity in uniquely effective ways. Entrusted by the community with the care of the bodies and minds of

Help International Yiengprugsawan, et al. 11 Goodman, 59.

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their fellows, they were to serve each impartially, with loving kindness, considering only the patients benefit.12 Because of the status that physicians hold in Thailand, the physicians who promoted universal health care must have been faced with little dissent from their subordinate. The respect that Thais give towards those who have merit-making jobs, such as nurses and public health officials, allows for these workers to make decisions about public health by which the populace will abide. I imagine that Thai citizens were willing to support efforts to extend care to all because of the status of the public health reformers. Even if there were citizens who disapproved of a universal care system, those who are of a lower status are culturally bound to obeying their superiors, not to mention that those of a lower status probably had much to gain from the UCS. Similarly, if those in power were not in favor of the UCS, they may have felt pressured to approve it for the benefit of their subordinates. Thus, it is not difficult to imagine how the creators of UCS were able to gain support from those of varying degrees of status Thailand has a centuries-long tradition of medicine, including formal places for health care such as hospitals. Due to this pre-existing exposure to health care infrastructure, an organized public health care system was not a completely new concept that needed to gain public approval.13 In other countries where citizens are not as accustomed to the likes of hospitals and other health care facilities, more work might be required to orient their understanding of a more centralized model of health care.
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Lindbeck, 24. Lindbeck, 24.

As we can see, a number of elements of Thai culture may have added to the set of conditions that ripened the prospects for universal care. Even components of Thai culture that do not seem to be outright advantageous for universal care, such as the belief that There is no need for urgency, it will happen.14 At first glance, this cultural component might indicate a sense of collective apathy that would not be useful for attaining the lofty goal of medical care for all. Yet, perhaps due to this belief in the inevitable occurrence of events that must happen, the Thai Ministry of Public Health was able to patiently walk through the sequence of coverage schemes that existed in various forms from the 1970s until 2002. By eschewing a sense of urgency and allowing the groundwork of public health systems to accumulate before pushing for coverage of every citizen, Thailand realized its goal without the plague of premature implementation. It should be noted that my understanding of the interaction of culture is not based on personal native cultural knowledge, but rather a review of the literature about Thai culture, my experience in Thailand, and informal interviews with Thai nationals including Buddhist monks, health care professionals, and other residents of Chiang Mai. I acknowledge that my personal experience is based on a short period of time (four weeks) and was not based on rigorous ethnographic methods. Nonetheless, my observations and interpretations are intended to be culturally sensitive and relevant to the topic at hand. Conclusion

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The success of Thailands switch to universal health care makes UCS a prime example for universal care for other middle-income countries and beyond. The basic cultural elements that seem to have helped to give rise to the UCS are something to be noted by other countries hoping to establish universal care. By understanding the various models of universal care that exist in the world along with the cultures of those countries, nations that are considering universal care can glean valuable knowledge about what system would work best for their culture. They can also save time and money and prevent failure by avoiding parts of health care models that are not congruent with their culture. Cultural consideration is especially important for those working in the field of global health who commonly work across borders.

Works Cited Coronini-Cronberg , Sophie; Wongsa Laohasiriwong; and Christian A. Gericke. Health care utilisation under the 30-Baht Scheme among the urban poor in Mitrapap slum, Khon Kaen, Thailand: a cross-sectional study. International Journal of Equity Health. 2007 Sep; 6(11). Online. Goodman, Jim. Thailand. 2nd ed. New York: Marshall Cavendish, 2002. Print. Help International. Some differences between Thai and Western cultures. Online. http://www.hiphiphi.com/pr/culture1.pdf Hughes, David and Songkramchai Leethongdee. Universal Coverage In The Land Of Smiles: Lessons From Thailand's 30 Baht Health Reforms. Health Affairs. 2007; 26(4):999-1008. Online. Indaratna, Kaemthong and Nutta Sreshthaputra. The Universal Coverage Policy of Thailand: An Introduction.Asia-Pacific Health Economics Network. Jul 2001. Online. http://www.who.int/bulletin/volumes/86/1/08-010108/en/index.html Kitajima, T., Y. Kobayashi, W. Chaipah, H . Sato, S. Toyokawa, W. Chadbunchachai, and R. Thuennadee. Access to antiretroviral therapy among HIV/AIDS patients in Khon Kaen Province, Thailand. AIDS Care. 2005 Apr; 17(3):359-66. Lindbeck, Vioette. Thailand: Buddhism Meets the Western Model. The Hastings Center Report. 1984 Dec; 14(6):24-26. Online. http://www.jstor.org/stable/3561744 Teerawattananon Y, M. Mugford, and V . Tangcharoensathien. Economic evaluation of palliative management versus peritoneal dialysis and hemodialysis for endstage renal disease: evidence for coverage decisions in Thailand. Value Health. 2007 Jan-Feb; 10(1):61-72. Online Treerutkuarkul, Apiradee. Thailands Unsung Heroes. Bulletin of the World Health Organization. 2008 Jan; 86(1):1-80. Online. Yiengprugsawan, Vasoontara; Matthew Kelly; Sam-ang Seubsman; and Adrian C. Sleigh. The first 10 years of the Universal Coverage Scheme in Thailand: review of its impact on health inequalities and lessons learnt for middle-income countries. Australas epidemiol. 2010 Dec; 17(3):2426. Online.