Legislating for public accountability in universal health coverage, Thailand

Abstract Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand’s universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand’s position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens’ rights and government accountability has been implemented. Thailand’s constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens’ voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens’ ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens’ trust.


Introduction
The World Bank worldwide governance indicators 1 comprise six dimensions of governance: voice and accountability; political stability and absence of violence; government effectiveness; regulatory quality; rule of law; and control of corruption. The indicators relate to national level governance, and none are specifically about health. The voice and accountability indicator "captures perceptions of the extent to which a country's citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association and a free media. " 2 Between 1996 and 2018, Thailand's overall ranking on the indicators deteriorated, affected by the country's protracted political conflicts since 2002. 3 From 2002 to 2018, Thailand's global rank has decreased from the 65th to below the 20th percentile for political stability and from the 60th to the 20th percentile for voice and accountability. However, government effectiveness remained relatively stable around the 60th and 70th percentiles (Fig. 1). Public services remain functioning with adequate quality, reflecting a degree of independence from political pressure and a capacity to formulate and implement policies among bureaucrats.
Sustaining universal health coverage (UHC) requires robust active public participation 5 in policy formation and accountability mechanisms. [6][7][8] Participatory governance can improve the performance of the health system. 9 Partnerships and opportunities for dialogue among multiple stakeholders are therefore important for health-sector governance. In New Zealand, Thailand and Turkey, accountability mechanisms have been shown to support quality and responsiveness of services through ensuring that health professionals respect patients' rights. 10,11 Since 2002, Thailand's entire population of 63 million has been entitled to a comprehensive health benefit package with a high level of financial risk protection through one of the three public insurance schemes. The civil servant medical benefit scheme for government employees, pensioners and dependents (spouse, parents and not more than three children younger than 20 years) is managed by the Comptroller General's department of the finance ministry. The social health insurance for private sector employees is managed by the Social Security Office of the labour ministry. The remaining population are covered by the universal coverage scheme, managed by the National Health Security Office, a public body established under the National Health Security Act 2002. 12 Since its introduction, the universal coverage scheme has contributed to favourable health outcomes. Access to health services by the whole population has improved, with low levels of unmet health care needs, 13 comparable to Organisation for Economic Co-operation and Development countries. 14 Outpatient and inpatient utilization of public health-care facilities has increased, preferentially benefitting elderly people. 15 Use of annual check-ups has increased, particularly among women, 16 with no evidence of greater consumption of health-care services. The scheme benefits poor households, who are more likely to use public health services than richer people, with pro-poor budget subsidies and services requiring no copayments. 17 Extensive geographical coverage by wellfunctioning district health systems, developed since before the introduction of the scheme, explains the pro-poor outcomes. 18 In this article we identify the provisions on voice and accountability in Thailand's legislation on UHC and consider Abstract Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand's universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand's position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens' rights and government accountability has been implemented. Thailand's constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens' voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens' ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens' trust.
how the universal coverage scheme is designed to ensure citizen's voices and concerns are heard and taken into consideration. The deliberative process in the scheme provides lessons for low-and middle-income countries and other sectors in Thailand where policy links are weak, such as education, environment and social welfare.

Legislation
Article 56 of the 2017 Constitution of Thailand requires the government to conduct public hearings and environmental and health impact assessments 19 for policies which may have a negative impact on culture, health and the environment. 20 The National Health Security Act, however, set up additional processes which foster implementation of voice and accountability. Embedded in the Act are six articles related to citizens' voices and the accountability of the National Health Security Office (Table 1). Article 18 (10) and Article 18(13) mandate the office to convene annual public hearings for health-care providers and patients on the challenges faced and to identify gaps for improving the performance of the universal coverage scheme. 21 Article 26(3) and Article 26 (7) mandates the office to register citizens to health-care provider networks and record the information in the national beneficiary database and re-register members to a new network if they relocate. Articles 26(8), 50(5), 57 and 59 further mandate the office to establish systems for citizens to lodge complaints and for conflicts to be investigated and resolved. 21 Article 41 mandates the office to earmark up to 1% of the total annual budget of the scheme for no-fault financial assistance to the patients or families affected by adverse events. 21,22 From legislation to action

Annual public hearings
The annual public hearings are an integral part of the universal coverage scheme since 2004 (the civil servant medical benefit scheme and social health insurance have no such mechanism). In implementing the legislative mandate, the National Health Security Office strives to create a sense of ownership among members of the scheme and gain broad-based support from other stakeholders. 23 Engagement with healthcare providers strengthens the scheme and ensures it benefits its members. 24 Although public hearings for providers and beneficiaries are mandatory, the office also creates opportunities for other stakeholders, in particular representatives from local administrative organizations and academia, to express their views and provide recommendations. 25 Regional health security offices request provincial health offices to nominate representatives of health-care providers. Provincial coordination centres, managed by civil society organizations, nominate lay people to attend the hearings and inform attendees about the process. 26 To accommodate distinct interests and avoid possible conflict, provider and citizen hearings are convened separately. Reports on the public hearings and the management responses are circulated to affirm that the members' voices were heard.
The office, as a conscious learning organization, has made several modifications to the public hearing process. In the first year, annual public hearings were trialled in the capital city Bangkok and four regions. They were later implemented in all 13 public health regions in 2005 and all provinces in 2006. 27 In 2013, seven issues were identified for discussion at annual hearings: type and scope of essential health services; health service standards; office management; national health security fund management; local health security fund management; public participation; and other specific issues relevant to the locality. 28 The opinions and suggestions from the 13 regional public hearings are compiled, synthesized and used as inputs for the final national level public hearing. All inputs and responses to proposals from the hearings are considered to identify further actions to be taken: a genuine and meaningful process demonstrating transparency and accountability. 25 A few notable changes have stemmed from public hearings and the advocacy efforts of civil society organizations. Access to emergency health services was harmonized across the three public health insurance schemes in 2012, while in 2013 the criteria for no-fault financial assistance were revised. In 2015, the two-child limit on the number of birth deliveries eligible for the universal coverage scheme was abolished. 28 Finally, stakeholders (policy-makers, medical experts, academia, research and innovation organizations, private industry, patient groups, civil society organizations and the general public) were able to participate in submissions of topics for consideration and the prioritization of new interventions included in the benefit package. [29][30][31][32][33][34]

Registration of members
To ensure citizens' rights to standard health care the National Health Security Office is mandated to register eligible members in the national beneficiary database and to update the database for births, deaths and movement across Public accountability in universal coverage, Thailand Kanang Kantamaturapoj et al.
insurance schemes and health-care facilities. Citizens must be registered to a primary health-care contractor network in the district where they live and be re-registered to a new network if they relocate. As scheme members are required to use the network they are registered with, prompt re-registration for people seeking job opportunities away from their home district reflects the office's accountability to protect members' right to health services. The beneficiary registration system is publicly accessible via the office's website and the system is updated monthly.

Helpline
Since 2002 the National Health Security Office has managed a 24-hour, 7 days a week telephone helpline for people to obtain information about the universal coverage scheme and its benefit package, to locate the services they require and to lodge complaints. The Social Security Office also operates a 24/7 helpline, while the Comptroller General department's call centre is only active during office hours.
Over the past two decades, the helpline service has evolved to make the universal coverage scheme more responsive to members' needs and has analysed the data gathered to improve the scheme's performance. Initially, only 10 staff members operated the call centre using a paper-based recording system. From 2004, record-keeping as well as information for call-centre workers was computer-based. A patient referral coordination service, facilitating referrals from one hospital to another, was incorporated in 2013. In 2018, Thai sign language services were introduced along with a telecommunication relay service, extending the service to 0.38 million beneficiaries with hearing disabilities, reflecting the office's accountability to disabled users. 35 By 2019, there were 78 full-time staff in the call centre, and an additional set of 21 staff managing complaints.
In 2018, 930 302 calls were received, of which 900 984 (96.8%) were enquiries about the benefit package, entitlements and co-payments, how to register for the health-care provider network and how to access health services. Complaints from patients accounted for 0.6% of the total calls (5248 complaints); 3672 of the 4531 resolved complaints (81.0%) were settled within 25 days, while 65 complaints (1.2%) were serious and submit-ted for investigation by the Quality and Standards Committee. 36

No-fault financial assistance
Financial assistance for patients or families affected by adverse events, such as disability or death after using medical services, also reflects the high level of accountability in the universal coverage scheme.  36 Additionally, 511 health professionals filed for compensation due to adverse events from providing services to patients, of whom 427 (83.6%) received compensation, totalling 6.31 million THB (US$ 0.21 million). 36 Legislation under the universal coverage scheme has also influenced other government schemes. In 2018, the Social Security Office instituted a similar regulation to compensate social health insurance members for deaths, disability and conditions requiring long-term support. In the same year, the finance ministry has issued regulations to provide compensation to public health-care providers for adverse events, financed by the annual budget. 37,38

Governance and capacities Inclusiveness
The National Health Security Board directs and oversees the performance of the National Health Security Office. The multistakeholder nature of the Board is effective in ensuring accountability in decision-making and representing the views of the taxpaying public and beneficiaries of the universal coverage scheme. Board members include the health minister as chair, eight ex-officio members (permanent secretaries from the relevant ministries, including public health) four local government representatives, five civil society organization representatives, five health professionals including representatives from the private hospital association and seven experts in the fields of health insurance, medicine and public health, Thai traditional medicine, alternative medicine, health financing, law and social sciences.
Representation by civil society organizations demonstrates the participation and empowerment of citizens. Organizations choose five from nine civil society organizations constituencies whose works are related to: children and adolescents; women; elderly people; disabled people and mentally ill patients; people living with human immunodeficiency virus and chronic diseases; labour issues; slum inhabitants; agriculture; and ethnic minorities. These constituencies reflect the broad-based representation of civil society organizations from throughout the country, whose strong advocacy on the board has helped expand the members' benefit package. 39 Another benefit is the greater continuity and institutional memory among civil society representatives than the eight ex-officio board members, owing to the rapid turnover of senior officials at the permanent secretary level. Although each term of office is only four years and civil society representatives are limited to two terms, new civil society representatives on the board always follow-up on issues of concern through their networks and maintain the continuity of their work in the board's discussions.
Article 48 of the National Health Security Act established the Quality and Standards Committee, equivalent to the National Health Security Board. There are 39 committee members, including five civil society representatives, who oversee the quality and standard of health-care providers and approve nofault financial assistance.
Public accountability and transparency are ensured through the provision in Article 18 (12) of the law, which states that the board shall provide annual reports on performance and challenges, including audited financial reports to the Cabinet, the House of Representatives and the Senate within six months of the fiscal year end. There are no such provisions in the Social Security Act or in the Royal Decree of the Civil Servant Medical Benefit Scheme, despite both insurance schemes also being publicly financed. All National Health Security Office annual reports are made publicly available on the organization's website and the board's decisions have been published on its website since 2002.

Institutional capacities
The National Health Security Office's institutional capacity is crucial for ensuring citizens' voices are heard and that office and health-care providers remain accountable to the citizens they serve. Without these capacities, the legislative provisions would be empty promises. In 2018, a total of 893 staff members worked across office headquarters and its 13 regional offices, of which about one-third had a health background. 36 Almost all executive positions are held by experienced and highly qualified medical and health professionals. 23 Unlike the Social Security Office which has two functions -collecting payroll tax and purchasing health services -the National Health Security Office's only function is to purchase health services with additional efforts going into ensuring accountability to its members.

Lessons learnt
Voice and accountability in Thailand's universal coverage scheme is a deliberative process through which citizens' voices are heard. The National Health Act 2007 mandates the convening of an annual national health assembly that provides a participatory platform for public policy development 40 through multisectoral action. 41 The assembly brings together three elements to effect change: evidence from the scientific community; civic movement by civil society organizations; and decision through political engagement. 42 In Thailand this process is described as the triangle [of actions] that moves the mountain [of change]. Certain resolutions adopted by the assembly are endorsed by the Cabinet, giving implementing agencies within government the power to enforce them. On the other hand, the constitutional mandate for government agencies to conduct public hearings and environmental and health impact assessments is inadequate for responding to the concerns raised and challenges identified. This challenge undermines the objectives of public hearings 43 and future participation in environmental and health impact assessments. 44 We have identified two main factors, which we believe facilitated the effectiveness of voice and accountability in universal coverage scheme governance: legislative provisions and the deliberative process.
Public accountability in universal coverage, Thailand Kanang Kantamaturapoj et al.

Legislative provisions
The provisions in legislative documents are important because they legitimize all concerned agencies to implement the law. In the case of voice and accountability, it was the citizens themselves, through civil society organizations, who led the insertion of these provisions into the National Health Security Act 2002 to ensure that their voice would be heard once the Act was signed into law. Historically, Article 170 of the 1997 Constitution of Thailand 45 allows 50 000 eligible voters to submit a draft bill for consideration by the National Legislative Assembly. The citizen-led draft UHC bill in 2002 was the first action to test this constitutional right. Through the efforts of civic groups, over 50 000 signatures were collected and the bill was submitted. 24,46 Six competing draft universal coverage scheme bills were proposed to the government, one by the cabinet, four by political parties and one by citizen groups. After the first reading, which accepted the draft bill in principle, members of civic groups were appointed to the parliamentary committee to consider the second reading (article by article) and the third reading, which endorsed the final text. The key items of each draft bill were negotiated and eventually finalized as the National Health Security Act 2002. 47 Key provisions proposed by citizens in the draft bill, particularly in relation to accountability and voice, were included in the final text endorsed by the House of Representatives and the Senate. However, legislative provisions, although essential, are not enough on their own; the implementation capacities of the National Health Security Office also matter.

Deliberative process
Representation by civil society organizations in multistakeholder governing bodies is essential to sustain transparency and accountability. Allowing civil society to contribute to health policy decisions demonstrates a strong, connected relationship between the state and society. 48 In Thailand, the relationship has grown out of several opportunities for building networks and has enabled bureaucrats and civil society organizations to share ideas, tactics and resources. 39 Civil society representatives in the National Health Security Board are well educated and the recommendations they present during board delib-erations are based on evidence generated through their networks with research agencies. This evidence-based political culture has evolved gradually since the policy formation phase of the universal coverage scheme. 49,50 The continued engagement of civil society organizations in the central decision-making processes of the board has ensured that the scheme developed in ways that benefit citizens. Maintaining the universal coverage scheme requires commitment not only from policy-makers, but also from the civil society organizations 24 to play active roles in the board. Box 1 synthesizes challenges and lessons from Thailand's universal coverage scheme for low-and middle-income countries.

Conclusion
The worldwide governance indicators have not yet been developed to capture the progress of sectoral governance for policy interventions. Despite the overall deteriorating trend of voice and accountability in Thailand's indicators, and poorly managed public hearings and environment and health

Box 1. Challenges and lessons from Thailand's universal health coverage scheme
Key challenges

• Continuity
The current civil society organization cohorts that have been actively engaged since the inception of Thailand's universal coverage scheme will soon be retiring. Without well planned knowledge transfer and a careful succession plan, civil society contributions to the scheme may be interrupted.
• Transparency An increasing number of patient groups are supported by the pharmaceutical industry to voice demands for new medicines and technologies that are not currently in the scheme's benefit package. Although voices from all groups are welcome, the existing transparent process for expanding the benefit package, particularly the use of health technology assessment, must be maintained.
• Accessibility The platforms to capture citizens' voices require regular review and strengthening to ensure that they are still effective as intended, that is, to be widely accessible by all people. For example, a survey conducted by a university reported that only 2546 out of 7558 (33.7%) citizens were aware of the telephone helpline in 2018. In addition, the call centre reported that only 11 out of 5248 complaints (0.2%) were about unjustifiable charging by providers in 2018, while the satisfaction survey in the same year showed 73 (3.0%) of 2451 surveyed patients reported being charged by providers. 4 A constantly low level of complaints may reflect that a helpline may not be the preferred channel for people to voice complaints for which the National Health Security Office needs to test other innovative platforms.

Key lessons
• Legislative provisions for voice and accountability By giving citizens the constitutional right to submit draft bills, the government allowed civil society representatives to insert provisions on voice and accountability into legislative texts that were later adopted under the provisions of the Thailand's National Health Security Act 2002. Civil society representatives in the parliamentary committee at the second reading of the draft bill seized the opportunity to translate these inspirations into legislative provisions.
• Institutional capacity to implement legislation Ensuring citizens' rights to health services requires the office responsible for the scheme to have the necessary implementation capacity. In Thailand, the National Health Security Office needed the capacity to register all 47 million members of the universal coverage scheme and match them with the health-care provider network in the district where they live, and to re-register members to a new network if they moved districts. The full coverage of citizen registration for births and deaths using 13-digit unique national identification numbers and existing extensive geographical coverage of primary health-care services were key enabling factors. Establishing, sustaining and strengthening the call centre requires continuity of policy and financial support. Timely responses by management to complaints fosters trust among citizens. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders, such as local governments and patient groups. Subsequent policy and management responses are key for building trust in the process and citizens' ownership of the universal coverage scheme. Annual public reporting by the office responsible for the scheme (for example, implementation outcomes and performance of the scheme against targets) fosters transparency and increases citizens' trust in the universal coverage scheme and its management.

Resumen
Legislando para la responsabilidad pública en la cobertura sanitaria universal, Tailandia Para mantener la cobertura sanitaria universal se requiere una sólida participación activa del público en la formulación de políticas y la gobernanza. El plan de cobertura universal de Tailandia se implementó en todo el país en 2002, lo que permitió a Tailandia lograr una cobertura completa de la población a través de tres planes de seguro médico público y demostrar mejores resultados en materia de salud. Aunque la posición de Tailandia respecto de los Indicadores mundiales de gobernanza del Banco Mundial ha disminuido desde 1996, las disposiciones relativas a la voz y la rendición de cuentas estaban incorporadas en la legislación y en el diseño del plan de cobertura universal. Se discute cómo se ha implementado la legislación relacionada con los derechos de los ciudadanos y la rendición de cuentas del gobierno. La Constitución de Tailandia permitía a los ciudadanos presentar un proyecto de ley en el que las disposiciones sobre la voz y la rendición de cuentas se incorporaban con éxito en los textos legislativos y se aprobaban como ley. La legislación exige el registro de los beneficiarios, una línea telefónica de ayuda 24 horas al día los 7 días de la semana, audiencias públicas anuales y asistencia financiera gratuita para los pacientes que han sufrido eventos adversos. Para garantizar el derecho a los servicios de salud y que se escuche la voz de los ciudadanos y se adopten medidas, es necesario contar con la capacidad institucional para aplicar la legislación. Por ejemplo, Tailandia necesitaba la capacidad de inscribir a 47 millones de personas y ponerlas en contacto con la red de proveedores de servicios de salud del distrito en el que viven, y de volver a inscribir a los miembros que se trasladan fuera de sus distritos. Las audiencias públicas anuales deben incluir a los ciudadanos, los proveedores de servicios de salud, las organizaciones de la sociedad civil y las partes interesadas, como los gobiernos locales y los grupos de pacientes. Las respuestas políticas y de gestión subsiguientes son importantes para generar confianza en el proceso y en la apropiación del plan por parte de los ciudadanos. El informe público anual sobre los resultados y el rendimiento del plan fomenta la transparencia y aumenta la confianza de los ciudadanos.

Policy & practice
Public accountability in universal coverage, Thailand