Health

The health system offers universal access to health services to all Thai citizens. The system has a network of both public and private providers. 

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Proportion of Hospitals

taux chomageIn 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)

 

Population VS Medical Staff Ratios

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Over the last decade, the number of medical staff has increased.

The figure on the right 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) 

 

Health Expenditure

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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. 

Source: MoPH (2009)

The figure on the left 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.

Health Schemes in Thailand

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 Scheme (UCS). There also exists some minor health schemes for different target groups, but these are very small when compared to these three schemes. UC, which merged separate schemes for the poor such as LIS(Low Income Scheme), MWS(Medical Welfare Scheme), HCS(Health Card Scheme) in 2001, especially is the product of the concerted effort to move towards universal health coverage for all since the 1970s (ILO, 2008, p.11; Sakunphanit, 2010, pp. 74-5).

Funding Mechanisms

Funding mechanisms of health care vary among each scheme as Table 1 below. It should be highlighted that copayment by servicer users exists even under public health care schemes; and that expense per capita of CSMBS is much higher than those of UC and SSS which is attributed mainly to different mechanisms of provider payment.

 

 Table 1: Funding Mechanisms of health care schemes

 

Scheme Source of Funding Co-payment
Per Capita Expense
(as of 2008) * 1,000 Baht
UCS General tax revenue
Previously Baht 30, now
Abolished
Copayment only required if
Using nonemergency services
From unregistered facilities
2.2 (USD 0.07)
CSMBS General tax revenue Yes, for some inpatient care and for private hospitals 12.1 (USD 0.37)
SSS Tripartite contributions
Maternity and emergency
Services beyond budget ceiling
1.8 (USD 0.05)
Private health insurance Out of pocket Varies by insurance plan Varies
 
(Adapted from ibid. pp.77-8:Table 3)
 
UCS is targeting every Thai citizen not covered under the CSMBS or SSS and has covered 74.6% of population as of 2007 (ibid., p.78:Table 4). “For the UCS, in order to be enrolled in the program, all members must register with a contracting unit (CUP) and receive a card for care in their home area (i.e., within 30 minutes travel time from home). Treatment outside this area is limited to accident and emergency care” (ibid., p.78).
 

Table 2: briefly explains how payment mechanisms are different between schemes. 

 

Schemes Payment Mechanisms
UCS Mainly capitation: risk-adjusted capitation for ambulatory services, DRG under global budget for in-patient
CSMBS Fee for service for out-patient services, DRG for in-patient services
SSS Mainly risk-adjusted capitation using utilization, chronic diseases and relative weight of DRG
Private Health Insurance Fee for services
 
(Adapted from ibid., p.81:Table 8)
 
 “Before reform in 2007, a fee for service system was employed in the CSMBS to pay for both outpatient and inpatient services. In 2007, the scheme reformed its payment for inpatient services to a Diagnosis Related Group (DRG) system with several base rates of payment according to previous charges by individual hospitals. The SSS and UCS use capitation as the main payment mechanism. The capitation budgeting system was expected to increase equity because it depends on the population size in each locality. It was also expected to increase efficiency because it includes all costs, and the hospitals must act like an insurer of registered beneficiaries, in essence, and for financial survival, hospitals must continue to improve efficiency” (ibid., p.81).
 
As three kinds of health care schemes have been divergent in terms of timing of introduction, target of coverage and source of funding, each scheme has its own institutional structure. “The Comptroller’s General Department of Ministry of Finance oversees the CSMBS. Private health insurance companies are overseen by another institute in the Ministry of Finance. The Social Security Office of the Ministry of Labor oversees the SSS. And the National Health Security Office manages and oversees the UCS” (ibid., p.82). The characteristics of the major schemes are summarized in the table below.
 

Table 3: Characteristics of Public Health Protection Schemes

 

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. 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.

 (Adapted from ILO, 2008, p.12:Table 3)

Challenges

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.

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The graph on the left  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.

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. Last, not the least, ‘Preparing for an ageing society’ also should be recognized. Surveys show that decreasing total fertility rates and longer life expectancies are contributing to an aging society in Thailand which necessarily will have a negative impact on financial sustainability of health care system (Skunphanit, 2010, p.85).

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[2] MoPH (2009)

[3] WHOSIS, total health expenditure as a percentage of GDP

[4] ILO (2009), Health Care reform: financial management, report 4

[5] ILO (2008)

[6] IHPP (2009), Trade in health-related services

* Skunphanit, T. (2010), “Moving Toward Universal Health Coverage : Thailand”, Joint Learning Workshop, Delhi, India, 3-5 February 2010.

* Original paper has not been provided for this page since administrative conditions have not been met.

Social security schemes and programs by branch