Exempting the poor : a review and evaluation of the low income card scheme in Thailand

Abstract

The purposes of this study were to assess the Thai Low Income Card Scheme (LIC scheme) and to derive inputs for policy debates concerning how to improve effectiveness of the scheme and increase coverage for the uncovered eligible. The LIC scheme provided coverage to the poor and their families, veterans, monks, village health volunteers, Tambon and village officials. In addition, The poor can be exempted without the card at the time of care seeking but interviews by social workers or other officials at public health facilities were carried out to ensure the eligibility (Type B exemption). The study was basically the review of existing document relevant to the LIC scheme and the interviews with number of policy makers on the context of the scheme effectiveness of targeting the poor, its historical development and their views on how to improve the LIC scheme. The second portion of data was based on qualitative measure at community level to get the picture of practical implementation, and to determine contributing and constraint factors to the scheme development. There was normally the revision of each round of the LIC card allocation so as to increase targeting effectiveness by strengthening community-based screening processes. The 1994/5 revision raised income threshold to 2,000 baht per month for single people and to 2,800 baht per month for a couple as well as the introduction of the migrant card. Even though the coverage of the poor was getting better in each round of the card allocation, the card distribution remained geographically inequitable for example the 45% of Northeastern poor covered by the scheme compared with the national coverage of 54% in 1992. Other problems found were leakage of the insurance to the ineligible groups, larger proportion of self health care expenditures by the poor relative to the wealthier. A variety of problems to the LIC effectiveness were : the lack of clarity in what issues should be revised for the scheme improvement, the communities’ normal perception of insurance leakage, the continued preference for private sources of care, the lack of informative data to equitably determine who should be insured, inequitable budget allocation to provinces followed by insufficient budget to meet total costs of health care provided to the poor and the perceived poor quality of public care led by lack of training and development budget for pubic health officials for example. Key elements of success to exempt the poor based on international experience were : appropriate balance of central guidance and local decision-making, inclusion of various interest groups in any process of decision making, use of obvious and flexible targeting criteria for practical implementation, and continuous improvement of health care quality to encourage the eligible for exemption application. At the initial stage of the LIC scheme development, clear monitoring and evaluation procedures which help identify practical problems and contribute the scheme’s targeting effectiveness, should be performed.