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Case studies on Universal Health Coverage: Thailand and Rwanda

Let’s look at two countries which have approached the challenge of Universal Health Coverage in very different ways.
An African woman is shown smiling as she proudly holds insurance cards in her right hand.

The World Health Organization (2006), defines Universal Health Coverage (UHC) as when

“all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”

There is no formula for implementing UHC. Each country’s context determines questions of who pays, how much, what benefits are covered and how it is funded. These factors play a critical role in whether equity is addressed. Two case studies below highlight these different approaches.

Case study: UHC in Thailand

Thailand is hailed as an example of achieving UHC. Thai citizens have free universal access (98% population covered) to a comprehensive package of essential health services. The scheme is paid for by the government through general tax revenue (initially there was a co-payment of BHT30 (US$0.70) per visit, but this was eliminated, as collecting the co-payments was found to be more costly than the revenue it generated (Glassman and Temin, 2016).

Three insurance schemes cover the population in Thailand.

  1. Civil Servants Medical Benefits Scheme (CSMBS) (covers 6 million people): funded by general revenues and intended for Thai government employees.
  2. Social Security Scheme (SSS) (covers 9.8 million people): intended for formal sector workers (but not their dependents who are covered under UCS), and funded by contributions of employers, employees, and the government based on percentages of payroll.
  3. Universal Coverage Scheme (UCS) (covers 47.6 million people): financed from general revenues and covers all Thai citizens not covered by the other schemes. To enrol, citizens have to register with their local contracting unit (a district healthcare provider network), receive a gold card and are then entitled to access free care at health centres in their registered district, contracted hospitals and referrals to provincial or tertiary hospitals.

Utilisation rates among the poor have increased. A key achievement is that the equity gap in infant mortality has been closed, so there is no longer an association between poverty and infant mortality in the country (Glassman and Temin, 2016).

Three major reforms within Thailand’s health system occurred:

  1. Increase in the share of government revenue (i.e. taxes) to fund healthcare rather than through user fees
  2. Promoting primary care centres as the gatekeepers of a comprehensive benefit package
  3. Changing provider payment from historical allocations to payments per enrolled patient or diagnosis-based payments.

Case Study: UHC in Rwanda

Rwanda adopted a mandatory Community Based Health Insurance (CBHI) scheme to provide access to affordable health care. The CBHI model covers approximately 71% of the target population (the target population being 95% of the total population and including uninsured people who are not civil servants, military or privately insured) (Kalisa et al., 2015). The scheme draws on the traditional notion of ubudehe, meaning collective work, to create a progressive scheme that subsidises contributions for the poorest.

Three key features of the model include:

  1. Targeting of poorest for subsidies. To identify eligible people, communities were involved in defining criteria and allocating members to different categories. Several categories cover the range of disadvantaged populations (widows, the elderly, and orphans have been found to benefit), and are used to define exclusions, premiums and co-payments.
  2. Support to members to pay their premiums. Members not eligible for subsidy are assisted through annual microcredit grants. They are repaid over a 12-month period with a 4% interest rate. The banques populaires which gives these loans has found that 96% repay within the allocated timeframe.
  3. Mobilisation of additional financial resources. Additional government budget and funding from partners has been allocated to the CBHI scheme. The largest funding source remains household premiums.

Rwanda is unique in its ability to target the poor and vulnerable. Most countries struggle in identifying the poor, with many vulnerable groups getting left out. Countries also find rigid eligibility criteria failing to capture households that might become impoverished as a result of a health shock (Fenny et al, 2018).

Many low-and middle-income countries have attempted to provide free coverage of basic health services through publicly funded health systems with limited success – these services persistently tend to favour the rich, more educated and urban residents. What is one common element of both the Thai and Rwanda models which might explain their success? Ponder this for a moment before moving on to the next step.

Fenny, A.P., Yates, R. and Thompson, R., 2018. ‘Social health insurance schemes in Africa leave out the poor’, International Health, vol. 10, no. 1, pp. 1–3.
Glassman, A. and Temin, M., 2016. Millions saved: new cases of proven success in global health. Brookings Institution Press.
Kalisa, I., Musange, S., Saya, U. and Kunda, T., 2015. The Development of Community-Based Health Insurance in Rwanda: Experiences and Lessons. Technical report, School of Public Health, University of Rwanda College of Medicine and Health Sciences.
© Nossal institute for Global Health at the University of Melbourne
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