Health sector reform in Thailand : policy implementation in three provinces

• Main Author: Leethongdee, Songkramchai
• Published: Swansea University 2007
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.752084

This thesis examines the implementation of the universal coverage (UC) health care reforms in Thailand, introduced from 2001 onwards. It aims to investigate the interaction between top-down and bottom-up influences on policy implementation in the local health system, based on comparative case studies of three provinces. The study was conceived as a 'policy ethnography', an approach which uses mixed methods to investigate the perspectives of local policy actors. The Thai Ministry of Public Health (MoPH) did not specify all aspects of the UC policy 'blueprint' in detail, and allowed provinces to make important decisions in certain areas, such as the choice of financing model. The research found that it was generally actors at the higher levels of the provincial health administrations who had actual potential to influence the way the reforms were implemented. However, there were interesting examples where middle-level provincial actors gained influence at particular junctures of the implementation process, usually either when they were in a strategic position with regard to the roll-out of a particular policy, or if they could get support from powerful allies higher up the MoPH hierarchy. The degree of engagement and knowledge of lowerlevel actors were more limited, and many at this level saw the reforms as overly top-down. Over the period covered by the study, the relative influence of top-down and bottom-up influences ebbed and flowed. There was a cycle whereby local adaptations usually led to a reaction at the centre, and further policy statements and top-down directions. Many problems arose in implementing the UC reforms, including difficulties in achieving progress on the original objectives of reducing geographical inequalities of funding and workforce distribution, problems in allocating resources fairly within the local health system, lack of progress in developing primary care, and tension between curative and preventative approaches.