Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.

Background:Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients. Methods:A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied. Results:In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist. Conclusion:Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

Partnerships, particularly, South-South and Triangular Cooperation play an important role in the 2030 Agenda for Sustainable Development. The Partnership Project for Global Health and Universal Health Coverage (UHC) between Japan and Thailand (the Project) was launched in 2016 as a four-year flagship project for Triangular Cooperation and continued to the second phase in 2020. Participating countries include Asian and African countries who are striving to drive global health and to move towards UHC. However, the COVID-19 pandemic has made coordination of partnerships more difficult. The Project needed to find a "new normal" approach to conduct our collaborative work. Struggling with public health and social measures for COVID-19 has made us more resilient and has increased opportunities to collaborate more closely. In the past year and a half, during the COVID-19 pandemic, the Project successfully conducted a number of online activities between Thailand and Japan and with other countries on global health and UHC. Our "new normal" approach led continuing dialogue of networking both at the project implementation and policy levels, focusing on desk-based activities regarding the targets and the objectives of the project and creating a golden opportunity for pursuing a timely second phase. Our lessons learned include as follows: i) Closer prior consultation is required to hold satisfactory online meetings; ii) Effective "new normal" approaches include emphasizing practical and interactive discussions on each countrys priority issues and expanding target participants; iii) Commitment, trust, teamwork, and sharing common goals can enhance and sustain partnerships, especially amid the pandemic.

Since 2018, this Lancet Commission has sought to understand how to maximise synergies between the global health agendas of universal health coverage, health security, and health promotion, and what drives dis-synergies. By synergies the Commission is referring to an intervention, institutional capacity, or policy, that positively and substantially contributes to the achievement of two or more of these agendas in the areas where they intersect. We gathered data through desk reviews; case studies at the subnational, national, and global levels; consultation with two subregional bodies; and periodic Commissioner meetings both face to face and online to review, analyse, and synthesise data. Several key findings and implications for action arise from the analysis and the gathered data, particularly the in-depth country case studies, which provided several examples of these issues in action.

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict’. The third quarter of 2022 saw COVID-19 cases and deaths in Thailand reduced significantly, and high levels of COVID-19 vaccine coverage. COVID-19 was declared an “endemic” disease, and economic activities resumed. This paper reviews pre-pandemic health systems capacity and identifies pandemic response strengths, weaknesses and lessons that guided resilient and equitable health system recovery. Robust health systems and adaptive strategies drive an effective pandemic response. To support health system recovery Thailand should (1) minimize vulnerability and extend universal health coverage to include migrant workers and dependents; (2) sustain provincial primary healthcare (PHC) capacity and strengthen PHC in greater Bangkok; (3) leverage information technology for telemedicine and teleconsultation; (4) enhance and extend case and event-based surveillance of notifiable diseases, and for public health threats, including pathogens with pandemic potential in wildlife and domesticated animals. This requires policy and financial commitment across successive governments, adequate numbers of committed and competent health workforce at all levels supported by over a million village health volunteers, strong social capital and community resilience. A strengthened global health architecture and international collaboration also have critical roles in establishing local capacities to develop and manufacture pandemic response products through transfer of technology and know-how. Countries should engage in the ongoing Inter-government Negotiating Body to ensure a legally binding instrument to safeguard the world from catastrophic impacts of future pandemics.

Introduction Increased Disability Adjusted Life Year (DALY) of diabetes and hypertension draws policy attention to improve effective coverage. This study assesses effective coverage of the two conditions in Thailand between 2016 and 2019. Method We estimated total diabetes and hypertension cases using age and sex specific prevalence rates for respective populations. Individual data from public insurance databases (2016-2019) were retrieved to estimate three indicators: detected need (diagnosed/total estimated cases), crude coverage (received health services/total estimated cases) and effective coverage (controlled/total estimated cases). Controlled diabetes was defined as Haemoglobin A1C (HbA1C) below 7% and controlled hypertension as blood pressure below 140/90 mmHg. In-depth interview of 85 multi-stakeholder key informants was conducted to identify challenges to better effective coverage. Results In 2016-2019, among Universal Coverage Scheme members residing outside Bangkok, estimated cases were around 3.1-3.2 million for diabetes and 8.7-9.2 million for hypertension. For diabetes services, all three indicators have shown slow increase over the four years (67.4%, 69.9%, 71.9%, and 74.7% for detected need; 38.7%, 43.1%, 45.1%, 49.8% for crude coverage; and 8.1%, 10.5%, 11.8%, 11.7% for effective coverage). For hypertension services, the performance was poorer for detection (48.9%, 50.3%, 51.8%, 53.3%) and crude coverage (22.3%, 24.7%, 26.5%, 29.2%) but was better for effective coverage (11.3%, 13.2%, 15.1%, 15.7%) than diabetes service. For both diseases, the estimates were higher for the females and older age groups than their counterparts. Complex interplays between supply and demand side barriers were a key challenge. Database challenges remain which hamper regular assessment of effective coverage. Conclusion Given the increased diabetes and hypertension prevalence, strategic recommendations cover long term actions for primary prevention of known risk factors as unhealthy diet and sedentary behaviour. Short term actions aim to improve effective coverage through the application of Chronic Care Model, increase attention to non-pharmacological intervention and patient empowerment. What is already known? What are the new findings? What do the new findings imply? ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Walaiporn Patcharanarumol received funding from Thailand Science Research and Innovation (TSRI) under the Senior Research Scholar on Health Policy and System Research \[Contract No. RTA6280007\] (<https://www.tsri.or.th>) with no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This study is funded by National Health Security Offices (<https://www.nhso.go.th>) with no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was obtained from the Institute for the Development of Human Research Protections (IHRP) reference IHRP2019030, obtained on the 27th of March 2019. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data cannot be shared publicly because of the confidential policy of the owner. Data are available from the National Health Security Office, Thailand. Institutional Data Access (contact via <https://www.nhso.go.th>) for researchers who meet the criteria for access to confidential data. <https://www.nhso.go.th>

Despite Thailand having had universal health coverage (UHC) with comprehensive benefit packages since 2002, services are neither listed nor budget earmarked for COVID-19 responses. Policy decisions were made immediately after the first outbreak in 2020 to fully fund a comprehensive benefit package for COVID-19. The Cabinet approved significant additional budget to respond to the unfolding pandemic. The comprehensive benefit package includes laboratory tests, contact tracing, active case findings, 14-day quarantine measures (including tests, food and lodging), field hospitals, ambulance services for referral, clinical services both at hospitals and in home and community isolation, vaccines and vaccination cost, all without copayment by users. No-fault compensation for adverse events or deaths following vaccination is also provided. Services were purchased from qualified public and private providers using the same rate, terms and conditions. The benefit package applies to everyone living in Thailand including Thai citizens and migrant workers. A standardised and comprehensive COVID-19 benefit package for Thai and non-Thai population without copayment facilitates universal and equitable access to care irrespective of capacity to pay and social status and nationality, all while aiming to supporting pandemic containment. Making essential services available, notably laboratory tests, through the engagement of qualified both public and private sectors boost supply side capacity. These policies and implementations in this paper are useful lessons for other low-income and middle-income countries on how UHC reinforces pandemic containment.

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Thailand achieved Universal Health Coverage (UHC) in 2002 through three main public health insurance schemes; the tax-financed Civil Servant Medical Benefit Scheme (CSMBS) covers public sector employees and dependants (7.1% of total population), payroll-tax financed Social Health Insurance (SHI) Scheme covers private sector employees (17.2%), and the tax-financed Universal Coverage Scheme (UCS) covers the remaining majority (75.7%) [1,2]. Registered migrant workers are covered by the SHI while voluntary premium-contribution migrant health insurance, managed by Ministry of Public Health (MOPH), covers undocumented migrants and their dependants. Hence, many unregistered migrant workers and their family members are not covered by any financial risk protection systems; services are paid for out-of-pocket [3]. Extensive geographical coverage of district health systems facilitates adequate and equitable access [4] with low levels of unmet needs [5]. The comprehensive benefit package [2] and free-at-point of services result in low and continually decreasing prevalence of catastrophic health spending [6] (6.7% in 1994 to 2.2% in 2017 [7]) and incidence of impoverishment (1.4% in 1996 to 0.4% in 2015 (using international poverty line of US$ 3.1 per capita per day)) [8]. This perspective analyses how Thailand has responded to the COVID-19 pandemic through the UHC lens, covering all Thai and non-Thai populations, including migrant workers, with a comprehensive set of COVID-19-related services for everyone--a key contributing factor to pandemic containment.

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Effective Public Financial Management (PFM) systems are crucial during COVID-19 pandemic to ensure timely mobilisation of sufficient resources and distribution to frontline service providers. All aspects of PFM, from budget acquisition to execution and expenditure reporting and auditing are important aspects in pursuing effective pandemic responses with transparency and accountability. This commentary analyzes how PFM in Thailand adapted to support purchasing of COVID-19 health services, including laboratories and treatment, vaccines and vaccination servicing, and no-fault compensation from adverse effects following immunisation. It also discusses the limitations which delay implementation. Financing COVID-19 services was decided by the Cabinet under a State of Emergency Decree, resulting in expedited budget approval process. Though delays in budget execution were caused by bureaucratic budget spending rules, regulations and approvals, PFM adaptation allowed for services to be provided through the use of hospital revenue with rapid budget execution rules and regulations while maintaining accountability, reporting and auditing. Lastly, while reporting is mandatory with internal audit by related government agencies, and external audit by Office of the Auditor General in place, as of September 2021, report of the COVID-19 expenditure in 2020 has yet to be made publicly available for transparency and check and balance by the public. It is unclear the degree to which audit systems are fully enforced. Overall, Thailand's PFM systems have provided rapid fund mobilisation sourcing from central budget and loans and clarity in authorisation of spending;the use of hospital revenue provides more flexibility and rapid budget execution.