Showdown over health funding

DR WINAI SAWASDIVORN, secretary-general of the National Health Security Office (NHSO), is standing defiant in the face of pressure from the Public Health Ministry and state hospitals, which are jointly pushing for crucial changes to NHSO’s universal healthcare scheme. 

The latest tactics include a ministry move to stop providing registrar services for the scheme from April 30 and the Thailand Regional and General Hospital Society (Thaihos)’s decision to no longer submit information on patients under the scheme to the NHSO. 

“The problem is temporary. These are just measures to pressure NHSO to yield to their demands,” Winai said. There was no reason for them not to submit the information – which is essential for the NHSO to base its request for budget – and the lack of talk on this would only lead to a standstill, he added. 

Thaihos resolved to stop submitting information for the per-head subsidy to the NHSO on January 9. 

The move follows years of state hospitals’ struggling with the universal health scheme, which has proved to be not just a burden in terms of workload, but also financially. 

When they began complaining about suffering huge losses from the scheme, Public Health Minister Rajata Rajatanavin set up a committee to look into hospitals’ performance in a bid to determine the cause of these losses.

Thaihos felt slighted by this and is now asking for a neutral panel to be established in order to investigate the NHSO and the Public Health Ministry, which oversees state hospitals. Plus, the hospital society is demanding that the NHSO hand funds to the 12 healthcare service area offices under the ministry’s jurisdiction, instead of sending the money directly to hospitals.

“We cannot just hand over money as proposed because our service coverage is wider than those of the ministry’s offices, which is only 70-80 per cent. The rest of it comprises private and military hospitals,” Winai explained. 

He said the problem partially stems from the fact that the scheme was created to categorise the NHSO as a buyer of medical services and the ministry as a provider of these services. He said the segregation was meant to maintain a balance in the management. 

For instance, Ratchaburi province, which has a lower population than Nakhon Ratchasima, has four regional- or provincial-level hospitals and was allocated a budget based on the size of the hospital. When the per-head budgeting method came into effect a decade ago, the hospitals began getting less money, which ended up leaving them in the red, he said.

“In principle, the buyer’s duty is to manage the fund, listen to suggestions and opinions or consult with the service provider. When asked who is to blame for people’s lack of access to service, I can say it is ‘joint accountability’. Suppose a hospital is a garage and the NHSO the insurance company, then the garage is obligated to repair the cars sent to it by the insurance firm. Now, if the insurance firm cannot find a garage or spends a long time looking for one, who is to blame? The garage or the insurance firm? It’s all a matter of service access,” he said. 

Since the NHSO’s duty is to ensure people have access to services as well as control the expenses, he said, it was not possible to put in place an “open-ended” budget, like the civil-service healthcare fund, as demanded by most hospitals. He said this method would only lead to doctors dispensing too much medication or collusion. 

The Public Health Ministry has also proposed that the NHSO cut its nine sub-funds to four – outpatient, inpatient, disease prevention and miscellaneous – as well have the 12 healthcare service area offices decide on budget-spending criteria and getting the NHSO to allocate money to service units. 

But Winai said this procedure, which seemed to base budget allocation on judgement rather than carefully crafted criteria, would violate the NHSO’s principles and turn it into an accountant or money-delivering unit. 

However, the NHSO had resolved to try this for the short-term in the second and 10th healthcare service areas so as to compare the pros and cons, he said. He added that hospitals may be in the red because their earnings are less than their expenses, noting that hospitals’ income also comes from various other sources including the NHSO, the Comptroller-General’s Department, the Social Security Office among others, while expenses were set by hospitals. 

“We need to discuss why 105 hospitals are in the red and information about their management and spending should be tabled so we can find out what is going wrong,” he said. 

In the 2015 fiscal year, the NHSO is set to solve the hospitals’ lack of liquidity with the following measures: 

Allocating Bt500 million to rural hospitals; 

Allocating Bt3 billion for affected hospitals to pay their personnel; 

Reserving Bt1.8 billion of the salary funds for “problem solving”; and 

Allocating some funds to cover outpatient expenses to help affected hospitals.