Health

 

Health system

The health system offers universal access to health services to all Thai citizens.

The system has a network of both public and private providers (see figure below). In 2006, the Ministry of Public Health (MoPH) owned about two-thirds of all hospitals. The public hospitals strive to attain widespread geographical coverage: in 2008, the MoPH owned 953 hospitals which cover more than 90% of all districts; and 9,762 health centres, which cover every sub-district[1]. Private hospitals can mostly be found in the Bangkok region and the Central region (where respectively 66.9% and 30.1% of the hospitals are private).

 

Source: MoPH (2009) 

Figure 2

 

 

Source: MoPH (2009) 

Over the last decade, the number of medical staff has increased: in 1994 the doctor/population ratio was 1:4,165, in 2005 this was 3,182; the nurses/population ratio in 1994 was 1:1,105, in 2005 it was 1:613[2]. The figure below shows health personnel/population ratios by region. Clearly, the Bangkok region enjoys the best ratios. The differences are particularly big when comparing the doctor/population ratios: Bangkok has 3.6 times more doctors than the Central region and over 8.1 times more than the Northeast region.

 

Source: MoPH (2009)

The national expenditure on the health system amounted to 3.5% of GDP in 2006. This is less than other countries in the region, such as Laos (3.6%), Cambodia (6.0%) and Vietnam (6.6%)[3]. The financing details of the health system are recorded in the National Health Accounts. Although these provide comprehensive details of the financial aspects of the health system, the most recent recently published date back to 2005.

The figure below shows the composition of total health expenditure in 2007: 48% of total expenditure is made by the publicly managed health schemes; central and local government spent about 25%; and private household expenditures amounted to 19% of total health spending.

 

Figure 4

 

Source: ILO (2008)

As can be seen in figure 4, there are three major publicly managed health schemes: the contributory Social Security Scheme (SSS), and the non-contributory Civil Servants Medical Benefit Scheme (CSMBS) and the Universal Coverage (UC) scheme. There also exist some minor health schemes for different target groups, but these are very small when compared to these three schemes. The characteristics of the major schemes are summarized in the table below.

 

Characteristics	I. Civil Servants:   CSMBS	II. Private formal sector:		IV.  Rest of the population:   UC
		SSS	WCS
I.  Scheme      nature	Fringe benefit	Compulsory	Compulsory	Social welfare
Model	Public reimbursement model	Public contracted model	Public reimbursement model	Public integrated model
II.  Population       coverage       2007	Government employee, pensioners and their dependants (parents, spouse, children)	Formal sector private employee, >1 worker establishments	Formal sector private employee, >1 worker establishments	The rest Thai population, who are not qualified to previous columns.
Coverage (% of population)	7%	15%	Same as SSS	76%
III.         Benefit Package
Ambulatory services	Public only	Public & Private	Public & Private	Public & Private
Inpatient services	Public & Private (emergency only)	Public & Private	Public & Private	Public & Private
Choice of provider	Free choice	Contracted hospitals or its network with referral line, registration required	Free choice	Contracted hospitals or its network with referral line, registration required
Cash benefit	No	Yes	Yes	No
Conditions included	Comprehensive package	Non-work related illness, injuries	Work related illness, injuries	Comprehensive Package1
Maternity benefits	Yes	Yes	No	Yes
Annual physical check-up	Yes	No	No	Yes
Prevention, Health promotion	No	Health education, immunization	No	Yes2
Services not covered	Special nurse	Private bed, special nurse	No	Private bed, special nurse, eye glasses
IV.                                                                                                                                                          Financing
Source of funds	General tax	Tri-parties 1.06% of payroll each	Employer, 0.2-2% of payroll with experience rating	General tax
Financing body	Comptroller General Office, MOF	SSO	SSO	NHSO
Payment mechanism	Fee for service for OP, DRG for IP	Capitation3	Fee for service	Capitation for OP3, DRG for IP4
Copayment	Yes: IP at private hospitals	Maternity, emergency services	Yes if beyond the ceiling of 30,000 Baht	No
Expenditure per capita in 2006 (Baht)	8,785	1,738	211	1,659
Per capita tax subsidy in 2006 (Baht)	8,785 plus administrative costs	579 plus administrative costs	administrative costs	1,659 plus administrative costs
1 Personal health prevention & promotion, medical services and dental services. 2 The UC scheme offers prevention and health promotion to the whole population. 3 Some medical and dental services are reimbursed by Fee for service. 4 The UC uses a fixed budget (‘closed end’) and allocates this to providers according to the relative weight of DRGs.

 

 

Challenges of the health system

 

Although the Thai health system offers universal coverage at comparatively high quality, it also faces some serious challenges. First of all, there are some equity problems within the system. The unequal government subsidies that are given to each scheme are the source of this problem. To illustrate this problem, figure 4 above shows the composition of total health expenditure in 2007. The UC scheme accounts for 22% of the total health expenditure, but is providing access to health care to 76% of the population. Compared to the CSMBS scheme, accounting for 19% of the total health expenditure and covering only 7% of the population, it is obvious that the disposable resources for both non-contributory schemes are unbalanced. This is both the result of an austerity policy of the UC scheme, as well as the lack of effective cost control measures within the CSMBS. Also, providers often use the CSMBS to make up for the (relatively) low payments received from the SSS and UC scheme[4]: in other words, the providers use the CSMBS for intra-hospital cross-subsidization. The chronic under-funding of the UC scheme can lead to poor quality for services offered to UC members compared to the beneficiaries of other schemes.

 

Another problem of equity can be observed in the SSS, where a contribution ceiling of 15,000 Baht (about 450 USD) exists. This means that all wage-amounts above the ceiling are exempted from contributions. The graph below shows that in 2008 of the 9.2[5] million SSS insured, about 1.4 million persons –or 16%- earned more than 15,000 Baht. The contribution ceiling prevents to collect contributions from higher incomes on an equitable basis and decreases potential total revenues. Furthermore, the imposition of a contribution ceiling turned SSS-financing regressive for individual households.

 

 Figure 5

Source: ILO (2008)

Furthermore, a problem of the Thai health system is the present split into a domestic system, serving predominantly the poor and middle-income households, and an export-oriented system. Due to its comparatively high quality, Thailand is the world’s leading export country of health services, attracting more than one million patients a year (in 2008, this amounted to 615 million dollar[6]). While the export of health provides substantial income to the country, it has enormous detrimental brain-drain-effects on the domestic system; at the same time, the domestic system is not given the required flexibility and resources that would allow for successful competition through improvement of service.

 

Régimes de sécurité sociale et programmes par branche