Policy Choices for Progressive Realization of Universal Health Coverage Comment on "Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage"

Abstract

In responses to Norheim’s editorial, this commentary offers reflections from Thailand, how the five unacceptable trade-offs were applied to the universal health coverage (UHC) reforms between 1975 and 2002 when the whole 64 million people were covered by one of the three public health insurance systems. This commentary aims to generate global discussions on how best UHC can be gradually achieved. Not only the proposed five discrete trade-offs within each dimension, there are also trade-offs between the three dimensions of UHC such as population coverage, service coverage and cost coverage. Findings from Thai UHC show that equity is applied for the population coverage extension, when the low income households and the informal sector were the priority population groups for coverage extension by different prepayment schemes in 1975 and 1984, respectively. With an exception of public sector employees who were historically covered as part of fringe benefits were covered well before the poor. The private sector employees were covered last in 1990. Historically, Thailand applied a comprehensive benefit package where a few items are excluded using the negative list; until there was improved capacities on technology assessment that cost-effectiveness are used for the inclusion of new interventions into the benefit package. Not only cost-effectiveness, but long term budget impact, equity and ethical considerations are taken into account. Cost coverage is mostly determined by the fiscal capacities. Close ended budget with mix of provider payment methods are used as a tool for trade-off service coverage and financial risk protection. Introducing copayment in the context of fee-for-service can be harmful to beneficiaries due to supplier induced demands, inefficiency and unpredictable out of pocket payment by households. UHC achieves favorable outcomes as it was implemented when there was a full geographical coverage of primary healthcare coverage in all districts and sub-districts after three decade of health infrastructure investment and health workforce development since 1980s. The legacy of targeting population group by different prepayment mechanisms, leading to fragmentation, discrepancies and inequity across schemes, can be rectified by harmonization at the early phase when these schemes were introduced. Robust public accountability and participation mechanisms are recommended when deciding the UHC strategy.

Full text

Policy Choices for Progressive Realization of Universal
Health Coverage
Comment on “Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal
Health Coverage”
Viroj Tangcharoensathien*, Walaiporn Patcharanarumol, Warisa Panichkriangkrai, Angkana Sommanustweechai
Abstract
In responses to Norheim’s editorial, this commentary offers reflections from Thailand, how the five unacceptable
trade-offs were applied to the universal health coverage (UHC) reforms between 1975 and 2002 when the whole 64
million people were covered by one of the three public health insurance systems. This commentary aims to generate
global discussions on how best UHC can be gradually achieved. Not only the proposed five discrete trade-offs
within each dimension, there are also trade-offs between the three dimensions of UHC such as population coverage,
service coverage and cost coverage. Findings from Thai UHC show that equity is applied for the population coverage
extension, when the low income households and the informal sector were the priority population groups for coverage
extension by different prepayment schemes in 1975 and 1984, respectively. With an exception of public sector
employees who were historically covered as part of fringe benefits were covered well before the poor. The private
sector employees were covered last in 1990. Historically, Thailand applied a comprehensive benefit package where
a few items are excluded using the negative list; until there was improved capacities on technology assessment that
cost-effectiveness are used for the inclusion of new interventions into the benefit package. Not only cost-effectiveness,
but long term budget impact, equity and ethical considerations are taken into account. Cost coverage is mostly
determined by the fiscal capacities. Close ended budget with mix of provider payment methods are used as a tool for
trade-off service coverage and financial risk protection. Introducing copayment in the context of fee-for-service can
be harmful to beneficiaries due to supplier induced demands, inefficiency and unpredictable out of pocket payment
by households. UHC achieves favorable outcomes as it was implemented when there was a full geographical coverage
of primary healthcare coverage in all districts and sub-districts after three decade of health infrastructure investment
and health workforce development since 1980s. The legacy of targeting population group by different prepayment
mechanisms, leading to fragmentation, discrepancies and inequity across schemes, can be rectified by harmonization
at the early phase when these schemes were introduced. Robust public accountability and participation mechanisms
are recommended when deciding the UHC strategy.
Keywords: Progressive Realization of Universal Health Coverage (UHC), Equity and Efficiency Trade-off, Political
Choices, Thailand
Copyright: © 2017 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
Citation: Tangcharoensathien V, Patcharanarumol W, Panichkriangkrai W, Sommanustweechai A. Policy choices for
progressive realization of universal health coverage: Comment on “Ethical perspective: five unacceptable trade-offs
on the path to universal health coverage.” Int J Health Policy Manag. 2017;6(2):107–110. doi:10.15171/ijhpm.2016.99
*Correspondence to:
Viroj Tangcharoensathien
Email: Viroj@ihpp.thaigov.net
Article History:
Received: 5 June 2016
Accepted: 23 July 2016
ePublished: 31 July 2016
Commentary
International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand.
hp://ijhpm.com
Int J Health Policy Manag 2017, 6(2), 107–110 doi 10.15171/ijhpm.2016.99
Background
In Norheim’s editorial,1 based on fairness, equity and ethical
grounds, his five “unacceptable trade-offs” in implementing
universal health coverage (UHC) seems convincing. Our
analysis found that three out of these five are related to equity
goal; trade-off II (prioritize those who are able to pay than the
poor and informal sector), trade-off IV (prioritize the well-off
than the worse-off) and trade-off V (move from out of pocket
payment by households to a less progressive mandatory
prepayment source of finance).
The remaining two are related to efficiency goal: trade-off I
(extend coverage to the low or medium priority services than
the high priority services) and trade-off III (provide costly
services with low health benefits than less costly high impact
services). Note that the unacceptable trade-off II and IV are
very close. In this editorial, efficiency is regarded as part of
fairness.
Since health resources are finite, using it for one purpose,
policy-makers have to sacrifice other alternates; hence trade-
off and priority setting is unavoidable. These unacceptable
trade-offs are theoretically sound and convincing; they are
useful caveats for which policy-makers in low- and middle-
income countries (LMICs) may use to make informed, fair
and ethical choices in their paths towards UHC.
This commentary offers reflections from a country
experiences, Thailand, how these trade-offs were (or were not)
applied in implementing UHC reforms since 1975 until UHC
was reached in 2002,2 and achieved favourable outcomes.3
This commentary aims to generate global discussions on how
best UHC can be gradually achieved.
Politics and Power in Global Health: The Constituting Role
of Conflicts
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Challenge of Researching the Norms, Politics and Power of Global Health”
Clemet Askheim, Kristin Heggen, Eivind Engebretsen*
Abstract
In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of
global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing
the politics of global health as a question of individual morality. Drawing on the theoretical works of
Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception.
Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we
underline the opportunity for political changes, through political articulation of an issue, and collective
mobilization based on such an articulation.
Keywords: Global Health, Liberal Politics, Chantal Mouffe, Conflict, AIDS, Antiretroviral (ARV)
Treatment
Copyright: © 2016 by Kerman University of Medical Sciences
Citation: Askheim C, Heggen K, Engebretsen E. Politics and power in global health: the constituting role of
conflicts: Comment on “Navigating between stealth advocacy and unconscious dogmatism: the challenge
of researching the norms, politics and power of global health.” Int J Health Policy Manag. 2016;5(2):117–
119. doi:10.15171/ijhpm.2015.188
*Correspondence to:
Eivind Engebretsen
Email: eivind.engebretsen@medisin.uio.no
Article History:
Received: 5 September 2015
Accepted: 13 October 2015
ePublished: 15 October 2015
Commentary
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
hp://ijhpm.com
Int J Health Policy Manag 2016, 5(2), 117–119 doi 10.15171/ijhpm.2015.188
In a recent contribution to the ongoing debate about the
role of power in global health, Gorik Ooms emphasizes
the normative underpinnings of global health politics.
He identifies three related problems: (1) a lack of agreement
among global health scholars about their normative premises,
(2) a lack of agreement between global health scholars and
policy-makers regarding the normative premises underlying
policy, and (3) a lack of willingness among scholars to
clearly state their normative premises and assumptions. This
confusion is for Ooms one of the explanations “why global
health’s policy-makers are not implementing the knowledge
generated by global health’s empirical scholars.” He calls
for greater unity between scholars and between scholars
and policy-makers, concerning the underlying normative
premises and greater openness when it comes to advocacy.1
We commend the effort to reinstate power and politics in
global health and agree that “a purely empirical evidence-based
approach is a fiction,” and that such a view risks covering up
“the role of politics and power.” But by contrasting this fiction
with global health research “driven by crises, hot issues, and
the concerns of organized interest groups,” as a “path we are
trying to move away from,” Ooms is submitting to a liberal
conception of politics he implicitly criticizes the outcomes
of.1 A liberal view of politics evades the constituting role of
conflicts and reduces it to either a rationalistic, economic
calculation, or an individual question of moral norms. This
is echoed in Ooms when he states that “it is not possible to
discuss the politics of global health without discussing the
normative premises behind the politics.”1 But what if we
take the political as the primary level and the normative as
secondary, or derived from the political?
That is what we will try to do here, by introducing an
alternative conceptualization of the political and hence free
us from the “false dilemma” Ooms also wants to escape.
“Although constructivists have emphasized how underlying
normative structures constitute actors’ identities and
interests, they have rarely treated these normative structures
themselves as defined and infused by power, or emphasized
how constitutive effects also are expressions of power.”2 This
is the starting point for the political theorist Chantal Mouffe,
and her response is to develop an ontological conception of
the political, where “the political belongs to our ontological
condition.”3 According to Mouffe, society is instituted
through conflict. “[B]y ‘the political’ I mean the dimension of
antagonism which I take to be constitutive of human societies,
while by ‘politics’ I mean the set of practices and institutions
through which an order is created, organizing human
coexistence in the context of conflictuality provided by the
political.”3 An issue or a topic needs to be contested to become
political, and such a contestation concerns public action and
creates a ‘we’ and ‘they’ form of collective identification. But
the fixation of social relations is partial and precarious, since
antagonism is an ever present possibility. To politicize an issue
and be able to mobilize support, one needs to represent the
world in a conflictual manner “with opposed camps with
which people can identify.”3
Ooms uses the case of “increasing international aid spending
on AIDS treatment” to illustrate his point.1 He frames the
View Video Summary
Politics and Power in Global Health: The Constituting Role
of Conflicts
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Challenge of Researching the Norms, Politics and Power of Global Health”
Clemet Askheim, Kristin Heggen, Eivind Engebretsen*
Abstract
In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of
global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing
the politics of global health as a question of individual morality. Drawing on the theoretical works of
Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception.
Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we
underline the opportunity for political changes, through political articulation of an issue, and collective
mobilization based on such an articulation.
Keywords: Global Health, Liberal Politics, Chantal Mouffe, Conflict, AIDS, Antiretroviral (ARV)
Treatment
Copyright: © 2016 by Kerman University of Medical Sciences
Citation: Askheim C, Heggen K, Engebretsen E. Politics and power in global health: the constituting role of
conflicts: Comment on “Navigating between stealth advocacy and unconscious dogmatism: the challenge
of researching the norms, politics and power of global health.” Int J Health Policy Manag. 2016;5(2):117–
119. doi:10.15171/ijhpm.2015.188
*Correspondence to:
Eivind Engebretsen
Email: eivind.engebretsen@medisin.uio.no
Article History:
Received: 5 September 2015
Accepted: 13 October 2015
ePublished: 15 October 2015
Commentary
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
hp://ijhpm.com
Int J Health Policy Manag 2016, 5(2), 117–119 doi 10.15171/ijhpm.2015.188
In a recent contribution to the ongoing debate about the
role of power in global health, Gorik Ooms emphasizes
the normative underpinnings of global health politics.
He identifies three related problems: (1) a lack of agreement
among global health scholars about their normative premises,
(2) a lack of agreement between global health scholars and
policy-makers regarding the normative premises underlying
policy, and (3) a lack of willingness among scholars to
clearly state their normative premises and assumptions. This
confusion is for Ooms one of the explanations “why global
health’s policy-makers are not implementing the knowledge
generated by global health’s empirical scholars.” He calls
for greater unity between scholars and between scholars
and policy-makers, concerning the underlying normative
premises and greater openness when it comes to advocacy.1
We commend the effort to reinstate power and politics in
global health and agree that “a purely empirical evidence-based
approach is a fiction,” and that such a view risks covering up
“the role of politics and power.” But by contrasting this fiction
with global health research “driven by crises, hot issues, and
the concerns of organized interest groups,” as a “path we are
trying to move away from,” Ooms is submitting to a liberal
conception of politics he implicitly criticizes the outcomes
of.1 A liberal view of politics evades the constituting role of
conflicts and reduces it to either a rationalistic, economic
calculation, or an individual question of moral norms. This
is echoed in Ooms when he states that “it is not possible to
discuss the politics of global health without discussing the
normative premises behind the politics.”1 But what if we
take the political as the primary level and the normative as
secondary, or derived from the political?
That is what we will try to do here, by introducing an
alternative conceptualization of the political and hence free
us from the “false dilemma” Ooms also wants to escape.
“Although constructivists have emphasized how underlying
normative structures constitute actors’ identities and
interests, they have rarely treated these normative structures
themselves as defined and infused by power, or emphasized
how constitutive effects also are expressions of power.”2 This
is the starting point for the political theorist Chantal Mouffe,
and her response is to develop an ontological conception of
the political, where “the political belongs to our ontological
condition.”3 According to Mouffe, society is instituted
through conflict. “[B]y ‘the political’ I mean the dimension of
antagonism which I take to be constitutive of human societies,
while by ‘politics’ I mean the set of practices and institutions
through which an order is created, organizing human
coexistence in the context of conflictuality provided by the
political.”3 An issue or a topic needs to be contested to become
political, and such a contestation concerns public action and
creates a ‘we’ and ‘they’ form of collective identification. But
the fixation of social relations is partial and precarious, since
antagonism is an ever present possibility. To politicize an issue
and be able to mobilize support, one needs to represent the
world in a conflictual manner “with opposed camps with
which people can identify.”3
Ooms uses the case of “increasing international aid spending
on AIDS treatment” to illustrate his point.1 He frames the
View Video Summary

Tangcharoensathien et al
International Journal of Health Policy and Management, 2017, 6(2), 107–110108
UHC Cube: Trade-off Within and Across Three Dimensions
Trade-off is a situation where one must decide to choose
between or balance the two alternatives that are opposite or
cannot be taken at the same time. There are three dimensions
of the UHC cube (see Figure 1). The X axis is the population
coverage, the Y axis is the cost coverage measured by level
of out of pocket cost sharing by members, and the Z axis is
the service coverage, how comprehensive the benefit package
would cover? There are also trade-offs between these three
dimensions such as should the country cover more services
to certain groups, or same service for the whole population?
X Axis: Population Coverage
Within each of the three dimensions, there are trade-offs.
On the X axis, we concur with Norheim’s assertion, on an
ethical ground, that the poor, the worse off and certain
disadvantaged groups who are unable to pay their medical
bills should be covered first. This ethical choice will gain high
political support, if these population sub-groups are vocal
constituencies who cast their votes or influence others in
an election every four to five years in developing countries.
Unfortunately, very often they are voiceless and powerless.
Increasingly, private sector employment are growing
especially in middle-income context, that payroll tax financed
social health insurance (SHI) systems should be introduced
as soon as possible, in order to minimize the regressive out
of pocket payment, with a caveat that payroll tax finance
must be designed as a progressive source, where the higher
income employees pay higher contribution than the lower
income counterparts. When window of opportunities open,
SHI can be introduced immediately, and no need to wait for
full coverage of the poor.
In developing countries, implementing tax financed scheme
dedicated for the poor, or exempting them from paying user
fees is challenging. Thailand medical welfare scheme for
the low income households introduced in 1975; premium
funded voluntary health card scheme for the informal sector
in 1984; and payroll tax financed SHI scheme for private
sector employees in 1990 demonstrated the explicit political
decision on population extension on the X axis based on
ethical principles, the more vulnerable they are, the higher
priority they receive.
Z Axis: Service Coverage
On the Z axis, which service package is offered to different
population group is a political choice, often governed by
the government fiscal spaces and how priority is made;
either informed by cost-effectiveness evidence, financial
risk protection, equity or pragmatism. Often there is limited
technology assessment capacity in developing countries.
Though global evidence is available such as Disease Control
Priority4 and Cost-effectiveness and strategic planning
(WHO-CHOICE),5 countries need capacities to translate
them into policies and implementation. As comprehensive
benefit package was fully applied in all financial risk protection
schemes, it is not possible to apply a new positive list covering
basic essential package; hence pragmatism is applied by Thai
reform, with the application of negative list, where all services
are covered except a few in the list.
Despite the cost-ineffectiveness and large budget impact,
renal replacement therapy for kidney failure patients, a life
threatening condition, was approved by the government in
2008 on equity ground and financial protection. Two other
schemes, the government employee and the private sector
employee schemes have full coverage of renal replacement
treatment; should not the universal coverage scheme (UCS)
get this similar service? Cost of treatment is catastrophic to
UCS members, certain patients died from inadequate out of
pocket financed dialysis, leaving behind a large debt to repay
by family.6-8
Inequity arises when certain services are not available in
remote rural areas where the poor live, but enjoyed by urban
rich population. Introducing UHC without adequate and
equitable distribution of supply side capacity is prone to pro-
rich outcomes, as demonstrated in China9 and Philippines.10
While extensive geographical coverage of functioning primary
healthcare determines the pro-poor UHC outcomes.11,12
The Thai UHC was introduced after three decades of
government investment in health service infrastructure in
particular district health systems, and ensuring functioning
of health service through mandatory rural services by health
professional graduates.13 Skilled birth attendance had reached
99.3% of total births; and contraceptive prevalence 79.2% of
women age 15-49 in 2000, well before UHC achievement in
2002.14 An extensive geographical coverage of functioning
health services is the foundation for effective UHC
implementation.
Y Axis: Cost Coverage
On Y axis, cost sharing is interlinked with X axis, which
population group should or should not co-pay, and interlink
with Z axis, which services should be fully subsidized.
Clearly, Thailand applied equity principle where the poor
are exempted from payment or copayment; and efficiency
principle where services such as maternal and child health,
immunization, cost effective interventions and community-
based public health interventions are fully subsidized to the
whole population, not only the poor due to external benefits.
Until recently when UHC was achieved in 2002 that all
services in the benefit package are fully covered, free at point
of services; this is not because improved fiscal capacity but the
application of close end payment which has the merits of cost
Figure 1. The Three Dimensions of WHO UHC Cube.
Abbreviations: WHO, World Health Organization; UHC, universal
health coverage.
Y Axis
Z Axis
X Axis

Tangcharoensathien et al
International Journal of Health Policy and Management, 2017, 6(2), 107–110 109
containment and system efficiency. Efficiency frees up more
resources for zero co-pays.
A caveat on copayment, introducing copayment as percentage
of the medical bills in particular when insurance agency
applies fee-for-service is harmful to the patients in particular
the low income; ample evidence shows that fee-for-service
stimulates supplier induced demand (demand in excess
of what patient would choose) because of information
asymmetry in healthcare market, hence professional acts as
patients’ agent and making decision on their behalf. Fee-for-
service provides opportunities for professionals to maximize
services.15 Copayment can be applied to discourage bypassing
primary healthcare. However, ensuring quality at primary
healthcare to gain citizens’ trust and confidence are important
prerequisites.
Strategic purchasing comes into play to contain cost and
protect members from catastrophic spending and medical
impoverishment. Institutional capacities to manage
purchasing by insurance agencies are contributing factors to
efficiency and equity.3 Cost coverage in Y and service coverage
in Z axes are interlinked under the strategic purchasing design
and implementation.13
UHC achieves favorable outcomes as it was implemented
when there was a full geographical coverage of primary
healthcare coverage in all districts and sub-districts after
three decade of health infrastructure investment and health
workforce development since 1980s.
Thailand UHC Trajectory: A Long March Between 1975
and 2002
Figure 2 portrays three distinct groups of Thai population, for
which different prepayment schemes are introduced.
At the bottom layer, people living below national poverty line
was covered by publicly financed medical welfare schemes,
launched in 1975, which gradually extended to cover all
elderly, children under 12 years old, persons with disability
and village health volunteers.
At the top layer, government employees and their dependents
are historically covered by non-contributed tax financed
scheme, as part of the comprehensive welfare. Civil servants’
salary is claimed to be lower than labour market. The private
sector employees are covered by payroll tax financed SHI,
launched in 1990, as part of the comprehensive social security
including pensions and unemployment benefits.
The informal sector, at the middle layer, was covered by
Figure 2. Thailand Trajectories Towards UHC.
Abbreviation: UHC, universal health coverage.
voluntary premium financed public insurance launched
in 1984 by the Ministry of Public Health, and later 50% of
premium was subsidized by the government in 1992. Despite
Ministry of Public Health’s efforts, coverage remained low;
by 2001, 30% of total population was uninsured. Clearly,
voluntary nature of prepayment scheme cannot achieve UHC.
In 2002, in keeping UHC political manifesto in the 2001
general election, decisive political decision was made to
cover the whole bottom and middle layers by UCS, financed
by general tax. Tax is one of the most progressive sources of
financing.3 Squeezing from the bottom described in Figure
2, by tax financed reflects strong government commitment
on UHC. It is technically not feasible to enforce premium
payment by the large size informal sector and their irregular
income; while premium financed UCS is political non-
palatable. Effectiveness of premium collection and equity
in financial contribution were the two main concerns in
extending coverage to the informal sector. Additional budget
required to finance UCS is within fiscal capacities in 2002.
The use of closed end budget with mixed provider payment
methods in UCS contains cost and prevents supplier induced
demands.
Arguments arise on inequity in financial contribution that
private sector employees have double contributions: payroll-
tax for SHI coverage and general tax (direct and indirect)
while UCS members only contribute to general tax. This may
incentivize an increased informality in the economy. Tax
financed UHC is the political choice and societal preference
to maintain payroll tax financed SHI. It is a political correct
and technical sound decisions to apply tax-finance UHC in
2002 when Thailand decided to achieve UHC fairly quickly.16
Advocates to abolish contribution in SHI is not a political
correct and economic sound proposal given the increased size
of formal sector.
Finally, the reform in 2002 resulted in UCS for the bottom
and middle layers, 75% of total people; while keeping intact
the Civil Servant Medical Benefit Scheme for government
employees and SHI for private employees. The application
of close ended budget facilitates more comprehensive service
coverage and high financial risk protection for UCS and SHI
members.
The key designs contributing to favorable outcomes are; a
comprehensive benefit package and free at point of service
contributes to high level of financial risk protection as
measured by the incidence of catastrophic health expenditure
and medical impoverishment3; contracting with district
health systems contributes to pro-poor use of services and
public resources as measured by benefit incidence.11
After UHC: Fragmentation Across Different Schemes
Fragmented schemes are essential feature of UHC transition
when most countries apply targeting population groups.
Norheim assumes a single entity in making decisions about
how to expand coverage; there are many actors having stakes
on UHC, such as Ministry of Health, Ministry of Labour and
also private insurance agencies. Expansions of services that
are privately financed are hard to influence in a laissez fair
economy.
In the stride towards UHC, various countries extend
coverage to different population sub-group when windows
Bottom layer: the poor families,
measured by poverty or other arbitrary
measures
Middle layer: Informal sector
Borderline poor and non-poor
Top layer: formal public private sector
employees and dependants 15%
70%
15%
Contributory scheme
OR Subsidized contributory scheme
OR Tax -financed scheme
CSMBS,
SHI
UCS
Payroll tax financed
Social Health Insurance: tripartite
contributory scheme
Squeeze from the TOP
Squeeze from the BOTTOM
Tax -financed social welfare scheme:
The poor, elderly, children <12 years,
disable, village health volunteers

Tangcharoensathien et al
International Journal of Health Policy and Management, 2017, 6(2), 107–110110
of opportunity opened, for example the poor subsidized by
general tax, the private sector employees by SHI payroll tax
financed scheme, and informal sector by premium financed
voluntary community based health insurance, with or without
government subsidies, such as the case of Thailand,2 China,17
Lao PDR.18 These trajectories result in discrepancies across
different insurance schemes in term benefit package and
provider payment — causing inequity and inefficiency.
In the paths towards UHC, LMICs should recognize these
challenges facing the pathfinder countries; efforts should be
given to minimize the gap of inequity through harmonization
strategic purchasing (in particular benefit package, level
of public subsidies and provider payment methods) across
different schemes, if unavoidably different schemes for
different population groups are applied.
Conclusion
We fully support Norheim’s recommendation that “Robust
public accountability and participation mechanisms are,
therefore, essential when deciding on the overall strategy and
the appropriateness of central trade-offs on the path to UHC.”
However, not all LMICs have such platform. Cross country
learning and sharing lessons from UHC pathfinder countries
convened by international development partners, as well as
institutional capacity strengthening focusing on strategic
purchasing function are further recommended.
Expansions of financial risk protection are incremental
processes where there is no “clean slate” furnished with all
ethical options for making UHC choices; reformists should
stand ready when the political windows open to re-orient
toward more equitable and ethical choices.
Acknowledgements
We pay tributes to the late professor Nikom Chantaravitura
and Dr. Sanguan Nittayaramphong, who are the champions in
marshalling Thailand adoption of Social Security Scheme in
1990 and Universal Coverage Scheme in 2002. We acknowledge
policy-makers, managers, program implementers, front line
health workers and researchers for their contributions in the
design, implementation, monitoring, and evaluation of UHC.
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
VT conceptualizes and starts the first draft. All authors contribute to strengthening
the manuscript, reviewed and signed off the final version.
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