Hospitals under Thailand's much-lauded universal healthcare scheme, which covers nearly 50 million people, are desperate for solutions that will keep them afloat amid mounting financial troubles.
University hospitals such as Siriraj, Ramathibodi, and Songklanagarind recently revealed that the government has yet to disburse a medical budget of one billion baht due last year.
Assoc Prof Dr Surasak Leelaudomlipi, president of the University Hospital Network (UHosNet), said the budget should have been disbursed in fiscal year 2023, which ended on September 30 last year.
He said the delayed payment had triggered cash-flow problems for hospitals, which face huge expenses for wage, medicine and equipment bills.
On top of the disbursement delay, the National Health Security Office (NHSO), which manages the universal healthcare scheme, has long underestimated the actual cost of medical services and provided insufficient budget to implement the scheme, Surasak said. “We demand solutions to this persistent problem,” he said.
The NHSO has allocated an annual budget of just 8,350 baht per inpatient, but the actual cost at state hospitals is around 12,000 baht, he continued.
And that figure can be as high as 25,000 to 30,000 baht at university hospitals. Worse still, the NHSO is now pressing to lower the budget per inpatient to 7,000 baht.
Cash-flow problems
Dr Anukul Thaitanundr, president of the Thailand Regional and General Hospital Society (THS), said public hospitals have turned to donations and other sources of funding in a desperate bid to make ends meet.
"We have to shoulder the [financial] burden because the NHSO is not fully covering the costs,” he complained.
Anukul said it was time for the NHSO to consider finding other means to finance the scheme, and stop including the salaries of medical staff in the budget. “Sometimes, after the salary bill is deducted, we hardly have anything left to keep the operation running,” Anukul said.
Worse to come?
Under a policy introduced by the ruling party Pheu Thai, the NHSO has permitted universal healthcare beneficiaries to receive treatment at any state hospital across most of Thailand, rather than the one they are assigned, as in the past.
This move has undoubtedly enhanced access for beneficiaries, but it has also sent the cost of the scheme skyrocketing.
The government has allocated just 74 million baht to cover this radical change in fiscal year 2024, which ends on September 30. However, costs for the "treatment anywhere" measure have already exceeded 4.56 billion baht.
Prof Dr Somsak Tiamkao, a neurologist at Khon Kaen University’s Faculty of Medicine, said the university’s Srinagarind Hospital had witnessed a fourfold jump in the number of cancer patients, from 6,000 to 25,000, since the Cancer Anywhere treatment programme was initiated.
The NHSO plans to expand the "treatment anywhere" concept to all provinces, including Bangkok.
Implementation in the capital has been postponed several times due to the complex system and the huge number of patients and medical facilities involved.
Concern is growing that when implementation starts, Bangkok-based university hospitals that usually serve as tertiary facilities will be overwhelmed.
Provider Board
UHosNet, the THS, and their allies have demanded that a "Provider Board" be established to sustain the country’s healthcare system.
“We need the Provider Board to ensure proper checks and balances, transparency and sustainability,” Surasak said.
He pointed out that the NHSO is tasked with purchasing medical services, using a budget from the government. But the NHSO does not know as much about the medical service system as providers do, he added. “We need a Provider Board to ensure fairness for all parties concerned.”
Eyeing co-payment
Surasak said the NHSO should also consider the fact that some patients want to co-pay to get extra services, something that is permitted under the social security medical scheme but not the universal healthcare scheme.
“In a sense, patients under the universal healthcare system are being deprived of their right to receive additional services they desire,” Surasak said.
Somsak cited as an example the standard cancer program, which offers 50% chance of two-year survival and is completely free under the universal healthcare scheme, the social security scheme, and the scheme for civil servants and their family members.
“However there is an alternative programme, which offers a 90% chance of five-year survival. But it is available at an additional cost of 60,000 baht or 5,000 baht per month across the 12-month treatment duration.
This means that only those for whom the option of co-payment is available can choose this better alternative,” he said.
Surasak believes extending the co-payment option to universal healthcare would be good for patients and also hospitals, helping to ease their financial burdens.
Widening the gap?
Nimit Tien-udom, who represents non-governmental organizations on the NHSO board, is against the co-payment idea, arguing that it would only widen healthcare inequality.
“State hospitals need to stop focusing on profit or loss. Instead, they should focus on how to provide services within their budget,” he said.
Dr Jadej Thammatacharee, secretary-general of the NHSO, said co-payment might be permitted for certain convenience-based upgrades, such as private rooms.
“But for basic treatment or medical technologies, we can’t charge patients,” he said.
Jadej said his agency was willing to hold talks with hospitals over their financial difficulties, but only if they agreed to share their detailed budget sheets. “We need to see your expense items. But no hospitals have let us have a look,” he said.
Surasak said state hospitals were not focused on profit but they needed to have financial resources to develop their personnel, equipment and medical technologies. “But right now, our financial resources are inadequate [to meet those needs],” he said.
Echoing that point, Somsak said that medicines, medical equipment, and medical technologies were advancing but also getting more expensive.
“That’s why we are hoping that all healthcare schemes in the country improve budgeting or the list of medicines and treatments covered so that disbursements are in line with actual costs. We really want to take the best care of patients,” the medical lecturer said.
