Thailand: health care for all, at a price.

In 1998 21-year-old Thunyalak Boonsumlit fell ill so her worried parents took her to hospital. "I thought I had food poisoning," she recalls. The doctor, however, told her she had acute kidney disease and would die without immediate treatment. There was more bad news: although her parents were insured by Thailand's Civil Servant Medical Benefit Scheme, this scheme only covers dependants up to the age of 20. Boonsumlit was treated for a month and sent home. In 2002 Thailand reformed its public health financing system. This extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less-comprehensive schemes. It was the realization of a project that had been a quarter of a century in the making, starting with the creation of a social welfare scheme for the poor in 1975. The new scheme offered comprehensive health care that included not just basics, such as free prescription drugs, outpatient care, hospitalization and disease prevention, but more expensive medical services, such as radiotherapy, surgery and critical care for accidents and emergencies. But it did not cover renal-replacement therapy due to budget constraints. Boonsumlit and thousands of fellow sufferers were on their own. [ILLUSTRATION OMITTED] "There was a concern that renal-replacement therapy could burden the system. Major health risks leading to kidney diseases, such as diabetes and hypertension, were still not well controlled," says Dr Prateep Dhanakijcharoen, deputy secretary general of the National Health Security Office, which oversees the Universal Coverage Scheme. And renal replacement therapy is expensive. The cost of haemodialysis is about 400 000 baht (US$ 12 100) per year. This is four times higher than the 100 000 baht (USS 3000) per quality-adjusted life year threshold set by the National Health Security Office's benefit package subcommittee for drugs and treatments. This threshold was adopted as a national benchmark. Dhanakijcharoen believes that the Universal Coverage Scheme plan should have included kidney disease from the outset, a view shared by Dr Viroj Tangcharoensathien, director of the International Health Policy Programme at the Ministry of Public Health. It was a simple matter of fairness: "There are three health-care schemes in Thailand," he says. "Only the Universal Coverage Scheme did not include renal-replacement therapy. " In 2005 Boonsumlit became ill again and was diagnosed with end-stage renal disease. For a year her parents had to pay 400 000 baht (US$ 12 100) to cover her dialysis. This time she was told that if a suitable donor could be found, a kidney transplant was the best option. The procedure cost 300 000 baht (USS 9000). Boonsumlit's mother donated a kidney, and once again she and her husband paid all the bills, including the cost of post-transplant medication required to prevent the rejection of a new kidney. But there was increasing community pressure for change. People like Subil Noksakul, who had spent his life savings on medical treatment over a period of 19 years, were tired of being treated like pariahs. "I once managed to save 7 million baht. But all my savings are now all gone," he says. Like everyone else, he found it unacceptable that the Civil Servant Medical Benefit Scheme and the Social Security Scheme, which rely on public funds, both offered treatment for kidney disease while the Universal Coverage Scheme did not. In 2006 Noksakul founded the Thai Kidney Club, which raised kidney patients' awareness of their rights and put pressure on the National Health Security Office to provide treatment. Finally, in January 2008, the then public health minister, Mongkol Na Songkhla, bowed to public pressure and included renal-replacement therapy in the scheme. …