Commentary: Thailand: Sexual and reproductive health before and after universal health coverage in 2002

Thailand has achieved wide access to health services, including sexual and reproductive health (SRH) services, through two major reforms (Balabanova et al., 2013). Beginning in the early 1980s, physical barriers to care were minimised by increased investment in the health system, particularly nation-wide expansion of well-functioning primary health care (PHC) to all sub-districts, and expansion of financial risk-protection mechanisms. Equity in access to health care, including SRH services, and also in health outcomes, improved significantly (Kongsri, Limwattananon, Sirilak, Prakongsai, & Tangcharoensathien, 2011; Limwattananon, Tangcharoensathien, & Prakongsai, 2007; Teerawattananon & Tangcharoensathien, 2004), though 30% of the population was still uninsured by 2001. A new universal health coverage (UHC) initiative was thus launched in 2002, extending financial risk protection to the remaining population. The UHC benefits package covers almost all relevant SRH services envisioned in the Programme of Action (POA) of the International Conference on Population and Development (ICPD), including treatment of reproductive tract cancers. Significant progress in SRH was achieved well before the 1994 ICPD and the 2002 UHC initiative. Exemplary achievements include: 80% of pregnant women used prenatal care in 1987 and 92% in 2000. With UHC, utilisation reached 100% in 2012. Likewise, use of skilled birth attendance was 90.8% in 1990, 99.3% in 2000 and 99.7% in 2012. The contraceptive prevalence rate (CPR) for all methods also increased from 14.8% in 1970, prior to the 1971 launch of the National Family Planning Programme, to 74.5% in 1995, 78.9% in 2000 and 79.3% in 2012 (National Statistical Office, 2009, 2013). During the 1980s, intra-uterine devices (IUDs) and hormonal implants, provided by doctors and trained nurses, were added to widely available contraceptive pills and condoms (Tangcharoensathien, Suthivisessak, Siripornpanich, & Seriratanakorn, 1990). Oral contraceptives, available over the counter, were and remain the most widely used method (32.1% of the CPR), followed by tubal ligation, injectables, condoms and IUDs (National Statistical Office, 2013). All methods, except emergency contraceptive pills, are offered free to the entire target population. The total fertility rate has fallen from 5.9 children per woman in the 1970s to 1.6 in 2011.