Health

Despite being deemed a success in giving the general public access to medical treatment, the 30-baht health care programme has put a severe strain on state hospital finances and caused many doctors to become disillusioned"

by CHAROEN KITTIKANYA

Budget allocation woes

The 30-baht medical care programme, launched in April 2001, is one of the headline populist policies of Prime Minister Thaksin Shinawatra which gave him a sweeping electoral victory in January 2001.

The universal health-care scheme is again at the top of the agenda among his promises announced in October 2004 at the kickoff of the Thai Rak Thai Party's election campaign.

The premier has pledged to expand the 30-baht medical care programme with more funding derived from taxes on cigarette and liquor sales and other vices, despite growing concerns over the financial conditions of state hospitals and a brain drain of state doctors.

Nevertheless, the incumbent government's health-care policy is considered a great success for the service users at the expense of the providers, as it provides greater access to health care and medical services to the general public.

"I think most Thais have realised how useful the universal coverage is. The health-care scheme has created more confidence for the general public, particularly the poor and underprivileged to walk into hospitals for medical treatment without concerns of huge medical bills," said Dr Nipit Piravej, a health-care expert and a member of a sub-committee under the aegis of the the National Health Security Office (NHSO).
A recent survey by Assumption University for the office found that most of the 5,604 people surveyed in 13 provinces liked the service.

Satisfaction had increased 10 percentage points to 77% compared to a year ago, despite claims that issues related to health personnel shortages, long waits and low-quality medicine still needed to be addressed.
A research study by a working group of the National Economic and Social Advisory Council also confirmed that the government's 30-baht medical care scheme was a good programme and that most people wanted it to continue.

According to the National Health Security Office (NHSO), for fiscal year 2004 as of the end of September, people who have health security totalled 59.77 million representing 95.48% of the population. The coverage rose by 2.85% from what was found in fiscal year 2003.

Some 47.09 million people were registered under the 30-baht universal coverage, up 2.44% from a year earlier.
The survey by the NHSO also found that members of the population who were not covered by any health plans dropped to 2.83 million from 4.37 million in 2003.

However, for service providers particularly state-run operators, the scheme has left them in a dire situation.
The surveys have found that the scheme still was riddled with management and budget problems.

The National Economic and Social Advisory Council's research study showed that the new method of allocating separate budgets for patients and medical staff was "unfair", particularly in the case of primary health care units or rural hospitals which received less money despite large numbers of patients.

Some rural hospitals had only young doctors with just a few years of work experience, the study said.
This could affect the quality of treatment received by rural people.

In the first year of the 30-baht scheme, hospitals were given budgets based on the numbers of their patients.
In 2003, however, the Public Health Ministry changed the budgeting formula, setting aside part of the total budget for staff salaries before allocating the rest to hospitals.

The research suggested that the government give more priority to primary health-care units, as well as include alternative and traditional medicine and therapies as part of the basic treatment provided under the scheme.
It also recommended that the government allow local people, especially community leaders, to play an increased role in health-care issues, such as including them in hospital advisory teams or health security committees at the district and tambon levels.

Public participation would help increase the general public's understanding of the 30-baht scheme as well as promote good health among the people, the study said.

There should also be more co-operation from local administrative bodies, particularly in terms of financial support for some basic health-care services, such as patient transfers from primary care units to hospitals. This would help the state cut expenses on the scheme, the study said.
Critics have warned the government about a pending financial crisis if problems in the health-care sector are not addressed quickly.

Doctors, particularly those in rural hospitals, and other health experts are worried that hundreds of state hospitals are running out of money and will be left heavily in debt by the scheme.
They point to the Public Health Ministry's changing budget allocation methods for regional, provincial and smaller community hospitals as the root cause.

Several hospitals with heavy workloads, especially those in rural areas, have long complained about having too little money to handle the patient load, while a handful of hospitals with smaller caseloads have excess funds.
Of the 819 ministry-run hospitals, 265, mostly community hospitals in the North and Northeast already have accumulated debts of 1.3 billion baht, says the Rural Doctors Society.

Community hospitals are defined as having between 10 and 120 beds. General hospitals have 150-500 beds and regional hospitals have more than 500 beds.

The government allocated 43 billion baht for the scheme when it was introduced nationwide on Oct 1, 2001. State hospitals then received 1,202 baht for each person in their care.

At the start, community and regional hospitals were supposed to be equipped with technology to handle reasonably complicated cases, while provincial hospitals would deal with more difficult cases.

Stemming the mass exodus

A man undergoes a blood test at Chulalongkorn Hospital. According to a health-care expert, in general, about 400-700 doctors at state hospitals move over to the private sector annually.

GOVERNMENT authorities desperately need to speed up the implementation of a strategy aimed at stopping the mass exodus of doctors working at state hospitals.

According to Dr Nipit Piravej, a health-care expert, in general, about 400-700 doctors at state hospitals move over to the private sector annually, induced by better salaries.

He said that the government's 30-baht universal health-care coverage _ a flagship policy of the Thai Rak Thai party during its election campaign four years ago _ was also a factor behind the exodus.

Under the 30-baht universal health-care coverage scheme, a patient pays only 30 baht for a hospital visit and the rest is subsidised by the state.

According to a Suan Dusit poll taken in 2004, more than half of the country's hospital workers affected by the government's low-cost health-care scheme are unhappy with their jobs due to hospital budget shortfalls and increased workloads.

The top factor cited by health-care workers resigning from their jobs was workload, followed by low wages and the high number of complaints that hospitals received, according to the poll based on interviews with 4,417 hospital workers in 11 provinces in all major regions of the country in July and August. Respondents included doctors, dentists, pharmacists and health officers, mainly at state-run hospitals.

Health-care personnel surveyed said their daily workloads had increased 50% compared to last year due to the 30-baht scheme including more people who were uninsured for health-care services before the programme was introduced three years ago.

This has put a strain on the hospitals' workforce and budgets, the poll found.

According to a recent report from the Rural Doctors Society, more than a third of the hospitals run by the Public Health Ministry are in the red after having joined the government's 30-baht universal coverage.

All 819 ministry-run hospitals across the country provide cheap health care services under the government's flagship policy. Some 265 of these hospitals were in financial trouble, with an accumulated debt of 1.365 billion baht.

The problem is serious at hospitals mainly in the North and Northeast, especially community hospitals, said to Dr Pongthep Wongwatcharapaiboon, the president of the society.

The 246 community hospitals had total debts of 1.04 billion baht and the rest were held by general and regional hospitals. The ministry defines community hospitals as those having 10-120 beds. General hospitals have 150-500 beds and regional hospitals have over 500 beds.

The study, conducted by experts headed by leading economist Dr Olarn Chaipravat, also found similarity in the fate of state hospitals.

The study found that different rates charged for treatment by the three different levels of hospitals are the prime source of the problem.

Bumrungrad Hospital has embarked on an aggressive marketing strategy to attract clients from the oil-rich Gulf markets of the United Arab Emirates, Oman, Kuwait and Qatar.

The present system makes it possible for large hospitals providing more advanced care and treatment to overcharge for services, said the study.

To treat even common ailments like colds, large hospitals charge 1.6 times the rate of small community hospitals, while middle-sized provincial hospitals charge 1.4 times the amount, according to the study.

Such discrepancies in the way services are charged are the result of errors in the original formula for calculating treatment costs, which was based on data that has turned out to be very "rough"estimates, it says.
To close the gaps the study suggests scrapping the grouping of hospitals into three tiers and calculating costs based on the actual type of treatment provided instead.

At the same time, budgets are allocated to hospitals at a fixed per-capita rate based on the number of patients registered at each hospital. The cost of treatment of additional patients is reimbursed later.

But if a smaller hospital with a lower charge rate refers patients to a larger hospital, the agency in charge of the scheme will not reimburse the bigger hospital at the higher rate. Thus hospitals charging a higher rate suffer budget constraints, which inevitably affects the quality of service.

"The 30-baht scheme still needs time and a lot of effort to address the problems. But at least, the scheme has got off the ground and provides greater medical access to the general public. The scheme is not all bad and the model is acceptable," said Dr Nipit. "But what the government desperately needs to do is to appeal to the consciences of doctors and their basic responsibility."
_ CHAROEN KITTIKANYA

Small hospitals enjoyed funding in the early days of the scheme because they were primary care providers. But the ministry's concern that large hospitals should receive more money to provide more complicated services led to a change in fund allocations in the second year.

The ministry then allotted 400-500 baht per patient based on the number of people under a hospital's care and its financial situation, and kept the rest for administration of the scheme, staff salaries, and funding large hospitals dealing with complicated ailments such as cancer.

More than half the overall budget has been deducted by the ministry over the past couple years for those purposes.

Viroj na Ranong, a public health researcher at the Thailand Development Research Institute was even more pessimistic.

"The 30-baht scheme has changed the face of health services at state hospitals and has been embraced by the public," he said..

"But without infrastructure and good financial management, the change has badly affected state hospitals, medical professionals and the public's access to health-care services as a whole."

Critics also are fretting about the government's medical hub plan to promote private hospitals as high-end health-care providers for foreign patients.

The medical hub idea might "lure" more specialised doctors and new medical graduates into leaving state-run hospitals for the private sector due to higher salaries and less of a workload.

There are about 10,000 doctors working at state hospitals. Only one in three are based in provincial and community hospitals which take care of up to 38 million people.

The government has introduced a five-year plan from 2004-2008 to turn Thailand into a medical services hub for Asia, and set aside more than 2.6 billion baht to make Thailand the region's "centre of health-care excellence".

The plan focuses on developing medical services, health promotion services _ with an emphasis on spa and traditional massage services, and health tourism.

In 2004, the number of foreigners seeking such services in Thailand was reported to be one million.

To capitalise on the government's medical hub plan, several private hospitals are now developing and expanding its services to cover foreign patients.