The health insurance system in Thailand is currently separated into three main programs,
namely the Civil Servants System (CSS), the Social Security System (SSS) and the National
Health Security Program (NHSP). Each of these programs has been developed and implemented
for different groups of beneficiaries. The CSS was created to finance the provision of health care
services for civil servants and their family including their parents and children under the legal
age. The SSS, on the other hand, aims to provide the social welfare for private employees. The
NHSP is the health care coverage scheme for the rest of population who do not benefit from the
first two schemes.
The multiple programs proved rather problematic as they lead to inequality of health
benefits and inefficiency due to duplicate administration and management.
This study aims thus to analyze the governance of Thailand’s national health system with
the objectives to establish equity in terms of benefits from the health care schemes among Thai
population as well as to create the budgetary sustainability for the health insurance system.
Reviews of health care regimes overseas reveal that multiple health care schemes (such
as in countries where health care benefits are provided through the social security system) is not
necessarily problematic if all are overseen by a single authority responsible for national public
health policy. However, the three healthcare programs of Thailand are governed by three different
public agencies: Ministry of Finance, Ministry of Public Health and Ministry of Labor, which
manage the CSS, the NHSP and the SSS respectively. Overlapping and duplication of
administration and management lead to inefficiency and more importantly, inequality of health
benefits as elaborated below.
1) Different charges of health insurance: the insured persons of the SSS are obliged to pay
their health insurance charges regularly in order to benefit the insurance co-payment from
their employers and the State. Whereas the beneficiaries of the CSS and the NHSP are
not to but still benefit the rights on health care services.
2) unequal health benefits: members of the “fee-for-service” CSS system are allowed to
obtain health care services provided in any public hospitals nationwide, while SSS and the NHSP members can obtain the services only in hospitals or health centers where they
have previously registered as a beneficiary under the “per capitation payment system”.
3) Discriminatory treatment: patients with “fee-for-service” health care scheme normally
obtain better treatment than those with “per capitation” counterparts. Also, different
schemes often use different DRGs. Different rate of reimbursement leads to different
service quality.
In terms of efficiency, the administrative separation of health insurance system into three
schemes leads to high costs for both the health services providers (hospitals) and the payers
(public agencies).
1) For the providers, the costs are generated from the complication of reimbursement
systems because each scheme necessitates different beneficiaries’ data collection and
documentation. The NHSP uses the database software called “NHSO” while the SSS and
the CSS require the “SSdata” and the “CSMBS” respectively.
2) For the payers, the costs are caused in the process of overseeing the systems separately.
This means that the State has to duplicate the process such as financial audit and clinical
audit for each scheme.
Consequently, the current health insurance system in Thailand needs to be reformed
regarding its structure and governance in order to
1) improve the efficiency and reduce the costs of administration and management and
2) reduce inequality in terms of health benefits and quality of services for beneficiaries
covered by each program.
To attain to the objectives mentioned above, Thailand has to choose whether its health
insurance system is operated in the same model as the Social Security or not.
The research team finds that Thailand’s health insurance system in the future
should be based on a single scheme and that this scheme should be fully funded by the
national budget. This is because the SSS covers only 10.3 million of over 40 million work force. This is because Thailand has a very large informal economy. The CCS, on the other hand, does
not make a feasible national scheme due to the uncontrollable surge in costs.
It is recommended that national health care scheme be managed by a single authority,
which should be the Ministry of Public Health so that the system is coherent and is easily
accountable. However, since the Ministry, with many hospitals and health centers under its
supervision, is also a service provider, the designated public agency in charge of the system
management should therefore be independent from the Ministry to avoid the problem of conflict
of role between policymaker/regulator and service provider.
In case the State finds that it is more advantageous to run Thailand’s health insurance
system under the same model as the NHSP with the financing from public funds, the practice
standards for the agencies integration should be the following;
1) Provide every citizen with standard health benefits currently offered by the NHSP free of
charges. The CSS and SSS may nevertheless offer additional peripheral benefits as “add
ons”. For example, the SSS may offer supplementary income for forgone earnings
during sick leave. However the calculation of the premium should be only based on the
cost of the add-on benefits only and not the standard healthcare.
2) Transfer the responsibilities of the Social Security Office (SSO) regarding the health
insurance to the National Health Security Office (NHSO).
3) Provide newly hired civil servants or public employees with the standard health benefits
according to the NHSP rather than the CSS and offer financial payment to compensate
for the lost healthcare benefits.
4) During the transition period, inequality of health benefits between the CSS and the two
other schemes can be avoided by
(1) Implement the same “DRG” for all schemes
(2) Revise the current drug reimbursement regulation which provides incentives for
hospitals to prescribe expensive drugs to CSS patients in order to eliminate the
perception about the discrepancy in drugs benefits between the CSS and the
other two health care schemes.