For more than two decades, Thailand’s Universal Coverage Scheme has been a lifeline for millions of families, protecting many from medical bankruptcy. However, for hospitals that provide that care, the picture is far bleaker – mounting funding shortfalls and late or reduced reimbursements are driving many into deepening financial crisis.
This month, Surat Thani Hospital sounded the alarm after the National Health Security Office (NHSO) retroactively deducted 52 million baht in its account and transferred funds amounting to just 161.33 baht for the latest payment period – a move the hospital said has left it struggling to cover its routine costs.
“Who is affected when the hospital cannot foot its monthly 170-million-baht bill for medicines, supplies, lab costs and other expenses?” it asked.
Other hospitals tell a similar story, with doctors from both state and private hospitals calling on the NHSO to introduce reforms to stop more medical providers from collapsing.
Call for reform, not repeal
Dr Pawinee Eamchan, director of Saraburi Hospital and president of the Thailand Regional and General Hospital Society, said the medical profession is not pushing to abandon the scheme, which remains central to Thailand’s health policy, but to reform it. She said hospitals want meaningful discussions with the NHSO before new policies are imposed, so funds, staffing and feasibility are considered in advance.
“Nobody wants to abolish the scheme. It’s just that we need to discuss the problems related to its implementation,” she said.
Hospitals under the Public Health Ministry have reportedly used up to 18.79 billion baht of their reserves on the scheme so far.
Senator Dr Veerapun Suvannamai, deputy chair of the Senate committee on public health, warned that state hospitals are running down their reserves and many are likely to go broke in the next three years unless the reimbursement problems are fixed.
The University Hospital Network said the actual cost of treating inpatients comes in at about 13,000 baht per head per time – far higher than the 8,350 baht the NHSO currently reimburses.
How big is the gap?
Veerapun said the main reason for this problem is the NHSO’s practice of retroactive deductions, delayed payments and year-end downward revision to compensation rates, often using the adjusted relative-weight formula.
Under this formula, each type of treatment or diagnosis is assigned a relative weight reflecting how resource-intensive it is (for example, a heart surgery has a much higher weight than a mild infection).
When the NHSO adjusts the relative-weight formula, it changes how much money each treatment is worth.
The resulting reimbursement shortfall, he said, forces medical providers to cover the gap from their own reserves and puts patient care at risk if the squeeze continues.
The NHSO usually defends these cuts by citing complicated rules and incomplete documentation.
In one recent example, Buddhachinaraj Hospital in Phitsanulok was compensated only 15 million baht for a bill of 238 million baht.
“The NHSO, of course, justified the deductions by pointing to rules, but these rules don’t align with the reality in hospitals,” Veerapun said.
Critics say the NHSO focuses on finding errors when auditing patients’ files so it can justify deductions. Plus, the slow reimbursement of funds leaves hospitals struggling with serious cash-flow problems.
Making matters worse, the NHSO recently launched the “treatment anywhere” policy, in which beneficiaries can seek treatment at any hospital providing they present their national ID. Many critics say this is a populist policy that fails to recognise the burden hospitals are already under.
Since this expansion was introduced, many Thais have come to believe that all medical care is free for gold-card holders. In reality, however, the NHSO limits what is covered, meaning that if a doctor prescribes a treatment not on its approved list, the hospital will not be reimbursed for it.
“Treatment anywhere” has also encouraged patients to flock to secondary and tertiary hospitals, overwhelming them. Previously, Gold Card holders could only use the local hospital they had been assigned to, except in emergencies.
Comprehensive access
Launched in 2002, the universal healthcare scheme now covers roughly 47 million beneficiaries. This year, the government allocated 264 billion baht for the scheme, which the NHSO has divided between a flat-rate subsidy and other programmes, such as rehabilitation and traditional Thai medicine.
This budget already covers hospital staff wages, which adds up to about 65 billion baht.
According to NHSO records, by the end of the last fiscal year (September 30), the scheme had covered about 176 million outpatient visits and nearly 7 million inpatient admissions. The scheme is also credited with almost halving the number of people driven into medical bankruptcy – from 663,000 in 2002 to 357,600 in 2023.
Proposed fixes
Dr Kalapat Rachitroj, an opposition People’s Party MP and a member of the House committee on public health, said lack of funds was not the only problem plaguing the scheme. “Better budget management is urgently needed,” she said.
Dr Surapong Suebwonglee, who helped design the universal healthcare’s original 30-baht scheme while serving as deputy health minister under Thaksin Shinawatra’s government in 2001, has suggested modernising the reimbursement formula using artificial intelligence and an integrated data platform.
“When we launched the scheme more than two decades ago, we didn’t have the technology that is now available. If the latest technology is applied, the compensation can better reflect real costs while reducing errors,” he said.
Pawinee, chief of the Thailand Regional and General Hospital Society, called for NHSO reforms, to ensure its funds are managed more efficiently and transparently.
“The compensation paid should also be fair and realistic,” her group said.
The Thailand Research Development Institute (TDRI), meanwhile, said reform should start by preventing former NHSO board members from moving to its subcommittees at the end of their term, only to return to the board later.
“While not illegal, this practice is certainly unprincipled,” it said.
Kalapat added that the process of nominating NHSO board members should also be transparent and accountable.
