Problems of Thai healthcare bigger than Toon can solve

Today (25 December) Artiwara Kongmalai or “Toon Bodyslam” is scheduled to finish his charity run from Yala to Chiang Rai to raise money for public hospitals. The run has exceeded its goal; it has received over 1,000 million baht. However, Thailand’s healthcare is a structural problem that needs a sustainable solution. Still, the charity run has raised a debate on healthcare funding in the face of an anticipated budget cut under the junta government. 
 
Prachatai has discussed with experts Thailand’s healthcare system and how we should improve it. 
 
 
 
 
Thira Woratanarat, a medical doctor and lecturer at the Department of Preventive and Social Medicine at the Faculty of Medicine of Chulalongkorn University says that Thailand’s universal health care system over the past 15 years has benefitted citizens, especially those with financial problems, by providing medical care as a human right. Fewer people have died from the inability to pay for medical costs and fewer have been bankrupted by hospital bills. Statistics also show increased access to better medical services such as nursing care, preventative medicine and medical rehabilitation. On the whole the universal health care system has improved, even with adjustments in the health care budgeting system that requires a provider and a client of the service to be stated and for the cost to be spread among citizens.
 
“Thailand’s basic model of universal health care is an accepted world standard model because even though Thailand isn’t a rich country, we still give importance to taking care of the people’s health to prevent premature illness and death,” Thira said. “We see the health of the people as a priceless treasure which can bring income to the country in the future.”
 
Thira Woratanarat, doctor and lecturer at the Department of Preventive and Social Medicine at the Faculty of Medicine of Chulalongkorn University 
 
Countries with strong universal healthcare systems like Japan and the UK, said the doctor, are funded by strong tax collection systems. Health care systems require a lot of funding and without a steady stream of income it would be difficult to maintain a reliable healthcare system, which is one of the major problems in Thai public health. The narrow tax base results in governmental budget shortages and lack of services in the healthcare system, he said. 
 
In order to ensure a universal health care system that is a reliable component of social welfare, the doctor says the system’s resources should increase while being fair to both taxpayers and public health service providers.
 
“I have to say that it’s on the right track, both in terms of creating equality in the human right of access to medical care, and in the government seeing the people as a valuable resource when they implement health care policies. We just have to make adjustments to bring about a greater balance so that all parties are ready to develop the universal health care system," Thira said. 
 

“Time Bomb” of the Gold Card

 
But other academics say that although the Thai health care system is accessible to citizens, a funding problem will present itself as people gradually switch over from using the social security system to the universal health care system, colloquially known as the “Gold Card.” 
 
Phudit Tejativaddhana, Acting Director of Naresuan University’s College of Health Systems Management
 
Phudit Tejativaddhana, Acting Director of Naresuan University’s College of Health Systems Management says there is an impending “time bomb” embedded in public health insurance funding.
 
Phudit says that the universal health care system provides health insurance for 48 million citizens, 6-8 million government workers and their families, and 11-12 million social security members. 
 
Although these three public health insurance funds cover virtually all citizens, there is an impending problem where fewer and fewer people are using the social security system and more are using the universal health care system, or “Gold Card”—which will require more taxpayers’ money.
 
Within the 48 million citizens eligible for health care through the Gold Card, some have the spending power to choose private health care. This group should have the freedom to choose their health care options while still maintaining public responsibility, said Phudit.
 
Retirees who switch from using social security or government official health funds to the Gold Card should be incentivized in advance to take care of their health in order to avoid overtaxing the Gold Card system.
 
“As people age, they inevitably get sick. This is like a time bomb for the Gold Card,” which must support heavy financial strains, Phudit said.
 
Although Phudit says having three public health funds is more complicated than having one, it’s unlikely they will be merged, so officials have to strategize which groups use which services and how they will be funded.
 
One issue that crops up is whether it is ethical to use the funding for the Gold Card to invest in preventative medicine in the two other funds. Gold Card users are citizens that the state has to take care of using taxpayers’ money, such as the elderly, children, and the poor, while social security and government worker fund members have the income and spending power to pay taxes. 
 
Phudit noted that some say it would be unfair to take the poor’s money, or the Gold Card fund, to take care of the rich. Good management that is fair to all sides would incentivize the group with spending power to take care of their own health if they don’t want to use public health care, while not punishing them for opting out, he added 
 

Hospitals Losing Profit

 
Although the public has been critical of public health care provided by the state, a former health minister says that hospitals often operate at a loss and run out of money for various reasons.
 
Surapong Seubwonglee, a former Minister of Public Health and one of the universal health care system legislators
 
Surapong Seubwonglee, a former Minister of Public Health and one of the universal health care system legislators, said public health administration swings back and forth between two schools of thought, like a pendulum, depending on the administration at any given time. At one end, lots of funding is pushed into public health, preventative medicine and new hospitals nationwide. 
 
At the other end, doctors strive for academic excellence and cutting-edge technology and research in big city hospitals rather than preventative care in rural hospitals. Directors on this end of the scale, said Surapong, think that investing in universal health care holds back medical technological development.
 
Public hospitals lose money for three main reasons, said Surapong. First funding is not spread out around many hospitals, causing resources to pile up unevenly in some hospitals. For example, in 2001 before the universal health care system was implemented there was a hospital in Kantharalak district in Srisaket Province which had to oversee a population of 200,000 with only 60 beds, 5-6 physicians, and a budget of less than 100 million baht. Meanwhile, other districts with the same number of people as Kantharalak had 4-5 hospitals with 500 beds each, over 100 physicians and hundreds of millions of baht in their budget.
 
The second reason that hospitals lose money, albeit one that only applies to special cases, is because it is located in an area that is extremely rural or inaccessible, but still requires a hospital. 
 
Finally, bad hospital management can make hospitals lose money. The National Health Security Office (NHSO) pays for hospital patients according to a diagnosis-related group (DRG) system, so it is up to individual hospitals to manage their resources. 
 
“So we have to look at every place that lacks funds.  Why don’t they have funds? It is easy to say they lack funds, but we must go and see why they lack funds,” Surapong said.