Chapter 16
The Thai Health System in Transition: The Challenge of Mutual Responsibilities

INTRODUCTION
HEALTH CARE AND HEALTH INSURANCE SYSTEMS IN THAILAND
UNIVERSAL COVERAGE ASSURANCE UNDER
CONCLUSION
References

Siripen Supakankunti

INTRODUCTION

Thailand is a lower middle-income country with a population of sixty-seven million. Historically, it was an agriculture-based economy in the eighteenth and nineteenth centuries but it rapidly made inroads into modernization in all fields, embracing industrialization and liberal capitalism, and adopting technologies with a scientific orientation. Ethnically, the country is quite homogeneous, with 95 percent of the people being Thai and Buddhist, 3 percent being Moslems, and about 0.5 percent hill tribes. The current population growth rate is 1.2 percent per annum. Demographically, the average age of the population is 30.1 years, with 24 percent of the population in the 0–14 age group, and the elderly over 65 years taking up 7 percent, leaving the majority of 69 percent aged between 15 and 64 years. However, following very successful family planning campaigns in the last three decades the country's population growth rate has dropped dramatically from 3.4 percent per annum in the 1970s to a contemporary estimate of 1.2 percent in 2003. It is anticipated that Thailand will go through a rapid demographic transition to a society with an ageing population with serious health consequences.

The last three to four decades saw a dramatic change in the country's politics and economy as the Cold War bipolar politics lost its intensity and Western imperial powers saw less need to influence or support the administrative regimes of small and middle-income countries. Thailand transformed itself from a subsistence agrarian society into a rapidly industrializing one in less than three decades. By 1990, the country was experiencing sustained economic growth, averaging 7 percent per year, driven by a thriving export- oriented industrialization. Economic progress was accompanied by significant achievements in health development. Reductions in population growth and the infant mortality rate, along with improvements in life expectancy, contributed to Thailand's rapid demographic

transition (Table 16.1). The Expanded Program of Immunization (EPI) successfully led to a decreasing incidence of a number of infectious diseases, such as malaria and tuberculosis. At the same time, the incidence of non-communicable, chronic, and degenerative diseases is rising. However, the leading cause of illnesses bringing people to health centers remains infectious diseases and acute diarrhoea (Kachondham and Chunharas, 1993).

The Impact of the Asian Financial Crisis on the Thai Health Service

The rapid economic growth between 1988 and 1993 had led to a much stronger Thai economy. The Thai government liberalized the financial markets in 1993, which resulted in overborrowing for investment and non-productive goods. This, compounded with rising consumption of luxury imported items and declining export competitiveness, led to a large trade deficit.

In 1997, Thailand went through a virtual financial meltdown, thus reinforcing the general perception of the public of the need for more equitable sharing of public services. The financial crisis had important implications for social and economic conditions in Thailand. The obvious social impacts were an increase in unemployment, and the consequent loss of income, affecting the poorest and most vulnerable segment of the population, whose share of health spending averaged 10 percent of their income, compared to only 2 percent by the wealthy.

Another important impact of the financial crisis was on health care delivery. Private hospitals were heavily affected by the crisis. In addition to the reduction in the demand for their services, they experienced a loss of roughly 10 billion baht from the devaluation of the Thai currency. A number of private hospitals faced the risk of closure, particularly since there had already been an oversupply in the past.

After the crisis, the inequality of access to the fruits of economic success and public services surfaced, alerting the country and the administration to the harsh facts about the scarcity of public funds and resources. Whilst resources were scarce, there were also incidences of misallocation and misappropriation of public funds, which resulted in inefficiency and wastage.

HEALTH CARE AND HEALTH INSURANCE SYSTEMS IN THAILAND

The Health Care System

In the field of health, Thailand has striven vigorously to provide the most advanced medical care by investing heavily, through financial resources mobilized both internally and externally, in hospitals, medical schools, and medical education. Such heavy investment has benefited the country greatly in the efficacy of medical services provided to the public. However, what was achieved in the efficacy of medical care and services was extensively lacking in the accessibility and equal distribution of health care services. It is undeniable that historically the country's health policy has not been exclusively defined by the people's health needs, but to some degree this has been subjected to realignment with the country's other priority needs, such as national security, economic development, and social investment.

Therefore, for a country with a land size of 512,000 square kilometers, the challenge to provide adequate medical or health care services to people dispersed widely throughout the seventy-six administrative units or “provinces,” with an annual budget of roughly US$20 billion, is quite daunting. The distribution of the population throughout the country provides an even more daunting picture as more than one-quarter of the population are concentrated in the northeastern plain where land is not fertile and, in terms of income, the people are the poorest.

The health care infrastructure in Thailand comprises many types of establishments. Local people can seek health services from health posts in their localities, but they are not manned by medical doctors and are poorly funded. Hospitals are few and concentrated mostly in the capital and provincial towns. Medical school hospitals are sophisticated and concentrated mostly in or around the capital, with a few in remote provinces which are much sought after by the general public. In the early days, private hospitals were small and a handful of them were dispersed throughout the country. Private clinics operated by government doctors after their day's work at public hospitals were numerous but not significant as far as providing medical service is concerned, as they functioned mainly as extended outpatient posts for the doctors. Despite the array of health establishments in the early days, health care services and resources still fell short of public needs owing to both inadequate and misallocated health resources. As the economy progressed and people became economically better off, public dissatisfaction with the availability and accessibility of health services intensified.

Today, the health care system in Thailand consists of many levels of service, from private clinics or public health centers, to regional or university hospitals, which may provide tertiary care. The uneven distribution of these services, however, makes some areas of the country worse off than others. As shown in Table 16.2, there is an exceptional disparity of hospitals and hospital patient beds across different regions of Thailand. The total number of patient beds in Thailand is as many as 135,000, with an average of one bed per 456 people. However, the population-per-patient bed-ratio in Bangkok is significantly higher (1: 199) than that in the northeastern part of Thailand (1: 781). Thus, although health care has significantly improved, there is still a notable disparity across the country.

The distribution of physicians across the country is also uneven, although some improvement has been made in recent years. Even in 1996, there was an obvious and significant disparity in Bangkok where the doctor per population ratio (1: 728) was several times that in the northeastern region (1: 10,417). This ratio has shown some improvement in recent years. The figures for 1999 are given in Table 16.3. Although there is still a significant disparity, the gap between Bangkok (1: 761) and the northeast (1: 8122) has narrowed slightly.

It is estimated that 18,025 physicians are currently practicing in Thailand. This is far from the expressed need of approximately 25,000.¹ With only eleven medical schools producing less than 1,200 doctors per year, it will be difficult for the medical personnel to satisfy demand in the near future especially when some doctors seek to work abroad or in other sectors of the economy.

The national shortage of physicians is matched only by the need for nurses. Estimates show that of the 105,000 available, approximately 70,000 are practicing, but close to

¹ Thailand Health Profile, 1999–2000, available at the Ministry of Public Health web site, http://www.moph.co.th.

140,000 are needed.² With a mere 2,500 graduates per year, fulfilling the need for nurses will take an unreasonably long time. The new universal coverage for health care services will likely have a positive effect on household demand. Thus, there will have to be some consideration of the appropriate compensation for medical personnel. In other words, it is necessary for the universal coverage scheme to provide appropriate incentives for physicians and other health personnel to stay in the country and maintain a sufficient number of doctors, nurses, and other medical personnel to fill the needs.

The regional disparity noted among doctors is even more apparent in other medical fields, such as dentists and pharmacists. In each field, the population-to-personnel ratio in Bangkok is several times more concentrated than that of other regions of the country. A partial explanation for this disparity may be that the best opportunities to work in private facilities are in Bangkok. It is noted that of all medical personnel in the private sector, more than half—in all fields—work in Bangkok. Work in the private sector is often more attractive as it offers a higher salary and may have better working conditions.

Health Insurance in Thailand

Prior to the recent initiation of the universal coverage scheme, also called the thirty-baht scheme, in October 2001, the Thai people were served by several government programs. The four main ones were: the Low Income Card Scheme (LICS), the Civil Servant Medical Benefit Scheme (CSMBS), the Social Security Scheme (SSS), and the Voluntary Health Card Scheme (VHCS). As late as 1991, government investment in, and promotion of, these health insurance programs received very low priority—as much as 67 percent of the Thai population was not covered by any of these schemes. In the following decade, however, health insurance became increasingly important to both the Thai government and the people. As shown in Table 16.4, the government

² Thailand's Public Health Statistics, 2001.

expanded its LICS to include children, the disabled, and religious leaders. Similarly, promotion by the government and public interest resulted in a significant increase in the number of VHCS subscribers.

Although only the CSMB Scheme, the SSS, and the Workmen's Compensation Scheme (WCS) are still in existence after the implementation of the thirty-baht scheme, it is important to know the benefits and beneficiaries of the previous programs in order to understand its drawbacks and the need for universal coverage in Thailand.

The government implemented the SSS program for all employees of the formal sector. This program requires that all workers contribute 1.5 percent of their earnings to the Social Security Fund. This contribution is matched by the employer and the government, each of which contributes 1 percent. The Social Security Fund covers the cost of health care services utilized by these workers throughout their lifetime, as well as insurance for any injury that may occur in the workplace.

Government employees and their families are provided health insurance under the CSMBS. This form of medical insurance, which now coexists with the thirty-baht scheme, provides coverage for health care services for all government employees, their spouses, their parents, and up to three children. Using a fee-for-service payment method, this is easily the most generous of all Thai health care insurance schemes.

The VHCS is a program under which any Thai citizen can purchase government-provided health insurance at a yearly rate of 500 baht. This purchases a health insurance card for inpatient and outpatient services for a family for one year. Upon its inception, this program had very few subscribers, but through government publicity and with the economic crisis, a large number of Thai people showed increasing interest and purchased the plan.

The LICS was initially set up by the government to provide medical services to the poor and underprivileged. In its early stages, eligibility was determined by means tests. However, the primary problem with this scheme was that often people receiving low-income cards were not in the low-income bracket, and many people who fell in the low-income bracket did not receive low-income health insurance cards. This rendered the program quite ineffective as it did not reach its target population. It is likely that the target population that was missed went uninsured and were forced to bear the full cost of health care on their own, or in the best situations, shared that burden with the treating hospital. If a hospital is repeatedly forced to bear the cost of treatment for low-income patients, it will no longer be profitable—or even sustainable—and will be forced to close. If this happens, it will create a larger burden for the people who live near it, as they must find another facility for their health care needs.

It is clear that a majority of the uninsured were those who could not afford insurance and should have fallen under the LICS. The composition of the uninsured is shown in Table 16.5. The information, although slightly dated, indicates that most of those who were without insurance were those with an income below 2,000 baht per month. The table shows how inefficient the LICS was. As much as 28 percent of the total population that was eligible for the card was not admitted into the program. The lack of fairness in

the former Thai health care system showed the urgency and necessity for a universal coverage program for Thailand.

Health Care Financing in Thailand

In the past, there were several different types of health insurance available, from the LICS provided by the Thai government to private insurance or out-of-pocket payments by the patient. These schemes resulted in a poorly organized health care insurance market, in which many eligible recipients—particularly those in the low-income category—did not receive health care. In addition, it was difficult to monitor the hospitals to ensure quality service at the lowest possible cost. A study by Yip et al. (2001) on the effects of a capitation payment system in the SSS showed that such a system promotes efficiency, compared to the fee-for-service system adopted by the CSMBS. However, the study also suggested that without an independent body monitoring the quality and efficiency of service in each hospital across the country, it would be impossible to know whether the people received the quality of care that should be provided equally to every patient entering a health care facility.

With the implementation of universal coverage in October 2001, the system has changed significantly, as two government programs have been replaced by one. Moreover, private insurance and out-of-pocket payments are expected to be eliminated almost completely. Instead, a National Insurance Board will govern over three types of health insurance: the CSMBS and the SSS, which will provide for those working in the formal sector, and the thirty-baht scheme, which covers the remainder of the population. Each medical insurance scheme has its own method of payment set by the health care providers. For the CSMBS, a fee-for-service payment schedule has been implemented, while the SSS and the universal coverage schemes use a capitation payment method. Through the specified payment method, the insurance schemes pay health care providers, which in turn provide health care services to ensure a healthy population. Finally, an improved health status

contributes to the economy in the form of productive workers and innovation, which leads to higher wages earned and thus higher taxes reaped by the central government. In this way, the population pays “premiums” for their respective health insurance schemes.

The new system of universal coverage is an improvement over the old health insurance schemes in several ways. First, it means that every Thai citizen has an equal opportunity to improve his or her health status and become actively involved in personal health. It is no longer possible for anyone to claim that he cannot seek help at a hospital because he is too poor. Furthermore, the use of universal coverage, which requires membership from everyone, would prevent problems of adverse-selection and moral hazard that may result from voluntary insurance plans, such as the voluntary health card. In addition, with the thirty-baht scheme, information is expected to be more organized. The Social Security Office already keeps careful and detailed records of its hospitals. Because universal coverage reduces the number of plans available to the public and requires initial registration at a local hospital, the new system should allow for much easier tracking and record-keeping for research and review purposes. As previously noted, in the organization of the health insurance system, it is expected that data collected through the maintenance of the thirty-baht and Social Security Schemes will help in the accreditation process for each hospital.

Although the health care system and health care expenditures have been simplified with the introduction of universal coverage, there are also some disadvantages from its introduction. The most obvious concern is that of sustainability. For instance, cards for registration with the thirty-baht scheme are sent to each citizen based on the address of that person's identification card. This is a problem for many people who move to Bangkok to work or to attend school, but whose permenant residence remains at the given address. The card requires a person to register at the hospital closest to his or her home, which means that someone in Bangkok, for example, may have to travel quite a distance to receive health care services reimbursable by the thirty-baht scheme. Another problem is that it is not yet clear how the capitation fee will be fairly distributed across the health care providers in a province or district. Health centers or clinics are likely to receive a larger proportion of registrants for primary care because of their close proximity to homes. However, where these smaller health care providers are unable to provide a particular service, the patient will be referred to a larger district, provincial, or regional hospital, which is likely to have more advanced technology, higher capacity, and more specialized doctors to serve the patient's needs. In this case, it is extremely difficult to determine in advance how much of the capitation should be apportioned to health centers versus larger, specialty hospitals.

Another potential issue is that of utilization. A preliminary study of the pilot thirty-baht health insurance program revealed that the poor or lower income sector increased their utilization of health care services upon implementation of the thirty-baht scheme (see Wibulpolprasert, in Pramualratana et al., 2002). There are two implications from this. The first is that these people were too poor to afford health care prior to the implementation of the thirty-baht scheme and thus did not seek medical attention. In this situation, the availability of public health insurance is a way of giving all citizens an opportunity to obtain and maintain a high standard of health and quality of life. The

second, more cynical, explanation for the rise in the utilization rate is that the poor are displaying their moral hazard—that is, once someone realizes that health insurance is available, he may become more careless with regard to caring for himself. He may even take part in risky activities with the knowledge that if he is injured, there is someone to take care of him, without concern for the price of the medical care.

Health care expenditure has become an increasing proportion of gross national product (GNP) in Thailand. In 1980, expenditure on health totaled a mere 3.82 percent of Thailand's GNP. Since then, health expenditure has steadily grown and now represents a significant 6 percent of GNP (Table 16.6). This shows how important investment in health has become to the Thai people (see Pramualratana et al., 2002).

Increasingly more important to the survival of hospitals is the pattern of government spending. With the thirty-baht scheme, the public should find little (if any) need to pay for their medical services out of pocket. Thus, most health care expenditures can be best estimated as public health care spending by the government, as shown in Table 16.7.

The government budget for public health has steadily increased in recent years. After the implementation of the thirty-baht scheme in 2001, there has been an approximately 10-billion-baht jump in the budget allotted to public health. It is important to note, however, that although the government has made a financial commitment to universal coverage, most of the money channeled toward universal coverage was redirected from the allocation to other ministeries, which may include the maintenance of social programs, or grants for investment in capital equipment. Thus, these budget cuts and their effects must be considered as part of the transition in the implementation of the thirty-baht scheme. If this trend continues, there may be significant problems in the future.

The Social Security and Voluntary Health Card schemes are able to reap some revenues from their subscribers. In fact, the Social Security Fund is currently in surplus as most of its contributors are still of working age and healthier and thus at lower risk than the young or the elderly. Costs incurred by those under both the CSMB and LICS are covered by general tax revenue which may vary with the tax rate and the performance of the economy in a particular year. With the implementation of universal health care coverage, the potential revenues from the VHCS will inevitably be lost. This is a small price to pay for the achievement of equal access to health care for the Thai people. The more urgent concern is not how lost revenues can be recovered, but how new costs will be financed with the implementation of universal coverage.

A particularly useful format in which to present health expenditure is to use the National Health Accounts. These show how various amounts of spending from a variety of sources are distributed over several health expenditure categories. The National Health Account for 1998 shows that private households spent a total of more than 58 billion baht on health care services in that year—close to one-third of all health expenditures. All this expenditure was spent directly on the purchase of medical services, either inpatient or ambulatory. Clearly, with universal coverage available, household spending in this respect should fall to zero. If this happens, however, there will be a shortage of 58 billion baht in payments to the health care providers.

It would require most of the Ministry of Public Health's 59 billion baht budget to cover the payments that households no longer make to health care providers when universal coverage is achieved. Although the National Health Accounts reveal that the Ministry of Public Health spent more than 40 percent of its budget on health care services, it is highly unlikely that the Ministry will adjust its budget to allocate more than 95 percent of it to health care services. To do so could be potentially detrimental, as almost a third of the Ministry's budget is spent on investments in health care facilities and equipment.

It is clear, then, that the successful financing of health care in Thailand today faces several challenges. The proposed universal coverage system is to be paid through a capitation method, similar to that of the SSS. Use of this method has several advantages. The most obvious is that it should reduce the costs for the user of health care services. One researcher estimates that the funds needed for the implementation of universal coverage will be close to 20 billion baht (Yip et al., 2001). Although a significant amount, this figure is far less than the amount of 58 billion baht that private households previously had to pay for health care services. In reviewing the effectiveness of the capitation payments

method in the SSS, Yip et al. (2001) found it to be positive. Significant improvements in efficiency can be seen when compared to the fee-for-service method for patients under the CSMBS. The disadvantage of the capitation payments method is that it may reduce the quality of care for patients. In the SSS, the quality of care is not apparent. Patients served under this scheme, however, are of working age and currently in the labor force. Patients who are served under the thirty-baht scheme, on the other hand, belong to a different health category and have a different set of demands for health care services. Thus, the threat of a low quality of care is a serious one.

Utilization of the Thirty-Baht Scheme

Although only preliminary information is available, one study of the pilot program of the thirty-baht scheme presents some useful results regarding the utilization of health care services under this program. The main finding is that patients under this scheme seek health care at approximately the same rate as those under CSMBS, or the SSS. However, only about half of the visits by the thirty-baht scheme patients are covered by the universal coverage scheme. Moreover, the study finds that those in a high-income bracket show a significantly lower compliance (19.2 percent) compared with those in a low-income bracket who utilize the provision of universal coverage at a significantly higher rate (74 percent). As the study included one province from each of the four regions of Thailand, it is thought that this is quite representative of the nation. In this case, it is safe to conclude that this scheme will help the poor to access health care services more easily and efficiently.

UNIVERSAL COVERAGE ASSURANCE UNDER

MUTUAL RESPONSIBILITIES

This section will present the findings of a research project (Supakankunti, 2003) studying the issue of universal coverage assurance. The project made a qualitative investigation into the beneficiaries’ and health care service providers’ attitudes toward universal coverage (UC) assurance in four regions of Thailand. It was found that if UC is to guarantee every disease treatment, high-quality practice, and the thirty-baht co-payment, it will face a number of problems, which will be discussed in turn.

Fiscal Management

The evidence suggests that the Thai government will not be able to fully support UC since it does not have adequate revenue to keep up with total UC expenditure. Fiscal disbursement throughout the regions based on the residents’ census does not match the incurred expenditure. In search of employment, people migrate but do not report to the

local government agency. In addition, fiscal reimbursement among the provinces and hospitals is problematic.

It is recommended that there be more direct payments or co-payments. The government should collect more health care fees, such as direct fees, detailed diagnostic fees, co-payments, co-insurance payments, or deductibles. Nevertheless, each payment option has its own benefits and costs. No single solution will fit all circumstances. As the government's health care policy is the major determinant of co-payment options, it can be formulated such that people are held responsible for their own health care costs. This means that the beneficiaries of health care services will have to contribute more to offset health care budget deficits. For example, for the co-payment option, the government could raise per-time service charges, collect diagnostic fees based on the type of illness (the more complicated the treatment, the higher the fee), or establish a health care service fee at a progressive rate. If a patient visits a health care unit more times than the national average he should be made to pay 50 baht for the next visit. In some countries, governments levy a health care service fee for high-income families, and provide a safety net for low-income families. Co-insurance and deductible payments could be similarly designed.

Owing to current fiscal conditions and social trends, per-time co-payments are not sufficient. The government should consider more revenue or fiscal appropriation to finance health care services according to social values and community accessibility, especially for low-income families, and fund categories, depending on fund sources and objectives. The number of health care funds should be adjusted in line with national development plans. There are also other means such as medical savings accounts to ensure patient accessibility and to disperse medical risks, as well as tax increments to finance local and central government health care expenditures.

Health Care Service Selection Rights

People under the UC system do not have the right to choose health care service providers. If the government were to grant the right-to-choose, people would go to a health care service provider according to its service standard, or proximity to their dwellings or offices, and so on. This would lead to more administrative and fiscal problems, in particular, information management and referral costs.

It is recommended, therefore, that the right-to-choose is not allowed in the short-run, given the administrative problems and risks to long-term health care efficiency. However, in the long-run, when the health care information and co-payment systems are put in place, the UC should provide the right-to-choose for the citizens.

Health Care Service Quality

Health care service quality can be viewed in two ways: service quality, and quality control and health care standards. As far as service quality is concerned, some people worry that the standard of UC treatment could be lower than the earlier system because of

fiscal restrictions on hospital drug lists, with inferior drugs being provided compared with other programs. However, service providers insist that the service quality is identical, or may even have improved as a result of the Hospital Accreditation Program.

As far as quality control is concerned, people would like to express their views through professional and government committees which deal with quality control and standards. Service providers, however, disagree that ordinary people should decide on professional matters.

The recommendation here is that there should be an efficient and independent audit of health care service quality based on the principles of transparency, justice, and accounting principles in order to raise service standards. The committee should be equally represented by service providers, service recipients, and the government and adopt the principle of professional accountability. Health care professionals should independently police themselves and the government should not intervene in these organizations; rather it should help to augment their efficiency, transparency, and accountability and provide an appeal procedure for patients.

Fund Merger

A fund merger policy should be carefully considered in terms of the advantages and disadvantages. From the people's point of view it is recommended that no merger of funds should be considered. A single UC fund may not generate sufficient funds to survive and it is also not clear who will manage the merged funds. Moreover, health care funds should remain diversified to ensure accessibility. The providers are also not in favour of a merger since existing funds have proved efficient, and they have their own sources of revenue which should be independently managed under fair competition. Having said this, the UC has subsidized some expenses which other funds do not support, including hospital staff salaries, and investment costs. Hence, the UC administrators would like reimbursement for these expenses. When the economy is in recession, a merger of funds may be an option. Inter-fund borrowing and expense reallocation are other possible solutions.

CONCLUSION

This chapter has given an overview of Thailand's health care status, health care system, and the new health care insurance system. The country's new system of universal health care coverage provides virtually free health care to Thai citizens, by paying hospitals on a capitation basis. There are several important considerations when predicting the impact of this system. First, there is a shortage of health care personnel currently working in the health care system. If the implementation of universal coverage increases the demand for health care services, it is important to consider whether the current personnel will be able to manage the change. Secondly, implementation of the scheme will require a significant source of finance. It will be necessary to find a way to raise and maintain funds

for this insurance plan. It is likely that the funds will be raised primarily through general government taxes, but the resources needed for health care provision are unpredictable and can be immense. Given the drawbacks of the UC scheme as implemented by the Thai government, it is difficult to see how this plan can be successful. Preliminary studies based on pilot programs have shown, however, that utilization coverage is significant and there are substantial benefits for those with low incomes. With serious improvements to the system and its financing, this UC scheme may be a successful first step in improving the economic and social status of people in Thailand.

References

Kachondham, Y., and S. Chunharas. 1993. At the crossroads: Challenges for Thailand's health development. Health Policy and Planning 8 (3): 208–16.

Pramualratana, P., and S. Wibulpolprasert, eds. 2002. Health Insurance Systems in Thailand. Thailand: Thai Ministry of Public Health.

Supakankunti, S., W. S. Janjaroen, S. Piriyarangsan, K. Pacharavanich, and P. Promjak. 2003. The population's opinion research of universal coverage assurance under mutual responsibilities. Pzer Foundation through the Asia Foundation.

Yip, W., S. Supakankunti, J. Sriratanaban, W. Janjaroen, and S. Pongpanich. 2001. Impact of capitation payment: The social security scheme of Thailand. Mimeo, Partnerships for Health Reform.