What price Thailand's 30-baht healthcare?

The scheme is so ingrained among the public that no government has tried to halt it
By Tan Hui Yee, Thailand Correspondent In Bangkok, The Sunday Times, 12 Apr 2015

Ms Kesorn Sukchit fiddles with her stir-fried cauliflower at the cafeteria of a hospital on Bangkok's outskirts. She looks a little wan.

Her 72-year-old husband, weakened by diabetes, high blood pressure and kidney disease, is warded and waiting for dialysis.

Treatment is free under Thailand's 14-year-old universal healthcare scheme. But the 58-year-old housewife needs to travel one hour daily to get to his assigned hospital and wipe him down in bed.

"The nurses are very busy," she says. "They will not do it if they see he is accompanied by a relative." She has even lugged a table fan from home because his ward is stuffy.

"If we had the money, we wouldn't use this scheme," she sighs.

Medical treatment in Thailand is a tale of contrasts. Asean's second-largest economy draws tourists seeking nose jobs, sex changes or fertility treatment. Middle-class Bangkok residents take their pick from comfortable, efficient private hospitals in the capital.

But millions of other Thais who cannot afford it face a different reality: a two-hour wait to see a doctor for seven minutes.

It wasn't supposed to be so, at least in principle, when then prime minister Thaksin Shinawatra launched his so-called "30-baht healthcare scheme" in 2001. It made healthcare available to Thais not covered by existing health insurance for a modest sum of 30 baht (S$1.25) per visit.

It was a radical idea for South-east Asia that endeared Thaksin to millions of rural voters. But budget constraints have since stretched waiting times, prompting many to avoid it altogether and pay for private treatment instead.

According to the National Health Security Office (NHSO), which runs the scheme, some 47 million people covered use it to seek medical treatment an average of 3.3 times a year, twice as often as when the scheme first started. But the annual budget allocated for every person has not kept pace, despite more than doubling to 2,895 baht currently.

In 2013, Thailand had just 3.9 physicians for every 10,000 people, compared with 11.6 in Vietnam, 12 in Malaysia and 19.2 in Singapore.

"Much of the middle class has exited the scheme," says prominent economist Ammar Siamwalla. "The public hospital system has become a slum for the poor."

It is hard to sieve the reality from the rhetoric about the scheme. This is partly because it is so closely associated with Thaksin, who upended the old order dominated by royalist elites and polarised Thailand over the past decade despite being ousted by a 2006 military coup and living in exile since 2008. Such is the rancour between the two camps that the post-2006 coup administration waived the 30-baht fee to distance the scheme from Thaksin. It was later reintroduced by his sister, Yingluck Shinawatra, who was elected in 2011 - but ignored by some hospitals.

The scheme relegated the Ministry of Public Health - which controls state hospitals - to a service provider of the cash-rich NHSO, creating enmity that has lasted over the decade.

Just last month, the ministry's permanent secretary, Mr Narong Sahametapat, was transferred to another post by the military government after refusing to cooperate with the NHSO. Some 500 of his supporters reportedly turned up at the ministry to protest, stumping a junta that has kept a tight lid on political gatherings since taking power last May.

Other factors burden the system: An under-developed primary healthcare system means few think about visiting a clinic for common ailments, crowding hospitals that have higher running costs. A lucrative medical tourism sector lures doctors away from public hospitals.

But the appeal of nearly free medical care is so firmly lodged in Thai consciousness that no government - even those installed by diktat in the coup-prone country - has ever tried to roll back the scheme.

"Our system is the system for the most, not a system for the best," says NHSO's deputy secretary-general, Dr Weerawat Phancrut. "We want all Thai citizens to have access to healthcare, but not be bankrupted by catastrophic disease."

He adds: "No government, politician or party dares to stop this project."

To its credit, it has lowered infant mortality rates. The NHSO says it has also reduced waiting times for heart, cataract and kidney stone operations through a financing formula that allows even private hospitals to treat those covered under the scheme.

It is possible, for example, for a low-wage gardener to get heart surgery in Bangkok's top Siriraj Hospital - where ailing King Bhumibol Adulyadej has been staying since last October - without paying a single baht.

Rural hospitals have been able to expand their offerings because the scheme corralled new patients otherwise excluded from the healthcare system - allowing the hospitals to get more government funding. Their doctors dismiss the notion that free healthcare leads to its over-consumption.

"The hospital is not a resort," says Dr Kriengsak Vacharanukulkieti, who chairs the Rural Doctors Society.

In any case, the scheme runs on a tight budget. The NHSO reimburses each hospital 50,000 to 100,000 baht for each heart bypass, less than a quarter of what private hospitals charge. This has restrained healthcare spending in Thailand, which amounted to 3.9 per cent of its gross domestic product in 2012. Welfare-averse Singapore, which runs a broad co-payment system, spent 4.7 per cent.

The NHSO is now mulling over a co-payment system that would charge patients more than the nominal 30 baht.

Introducing it would be an uphill task. Prime Minister Prayut Chan-o-cha, who came to power vowing not to bend to populism, recently shelved a new land and buildings tax after opposition from the middle class and businesses.

Dr Ammar thinks it may be too late to introduce co-payment as middle-class patients who can afford it "have already opted out". Meanwhile, "the poor in Thailand, they are so grateful for this scheme, they don't demand better service".

This is true of Ms Kesorn.

"As long as I don't have to pay, I am okay with it," she says. Waiting a whole day for treatment is better than having her savings cleaned out.

"There are many people using this service," she says, sounding weary. "I need to understand."

For the poor, it's a long wait to see the doctor
By Tan Hui Yee, The Sunday Times, 12 Apr 2015

There are three ways to get healthcare, Thai economist Ammar Siamwalla muses. You pay a lot of money. You use your connections. Or you spend a lot of time.

Asean's second-largest economy has many healthcare options for the rich and influential but far slower lanes for those with a lot of time but little cash to spare. The last group is covered by the 14-year-old universal healthcare system, which provides medical treatment free or for 30 baht (S$1.25) per visit, depending on the policy of each hospital.

Dubbed the "30-baht scheme", it is closely associated with exiled former premier Thaksin Shinawatra, who was elected in 2001 on the strength of his appeal to the rural masses.

Today, the scheme covers some 47 million people in Thailand, with the government subsidising each person an average of 2,895 baht per year.

The funding cap, coupled with expanding demand, has stretched the queue so much that it is normal to wait two hours or more to see a doctor.

Mr San Srikaysuk, a 58-year-old spectacle shop employee, is nodding off in a corner of a Bangkok hospital waiting room when I approach him. He had arrived at 7am for an 8am appointment, only to be told his doctor would be available only in the afternoon.

"They said 'afternoon', but I have no idea what time in the afternoon," he mutters, pulling out from his back pocket a rolled-up M2F tabloid distributed free on the streets.

But he is used to waiting. He sees the doctor every three months to collect medicine for hypertension. All of that is free, but each outing lasts from 7am to 3pm, and requires him to take leave from work.

"It's not that long," he insists.

A few rows away, a woman snoozes with her palm on her cheek next to a teenager engrossed in his smartphone. The front row is filled by patients with their eyes glued to the local drama played out on a flat-screen television set. A boy leisurely chomps his way through a bag of meatballs dipped in chill sauce.

No one seems even vaguely miffed at the long wait.

"Our system can prevent people from becoming bankrupt," says Dr Weerawat Phancrut, deputy secretary- general of the National Health Security Office (NHSO), which runs the scheme. "But for minor ailments, common ailments, we still have problems."

The NHSO hopes to shorten queues by convincing more private hospitals to serve patients on the universal healthcare scheme. According to Dr Weerawat, just about 50 of the roughly 500 private hospitals nationwide do so now.

In the meantime, it is thinking of introducing co-payment significantly higher than the nominal sum of 30 baht collected by some institutions now.

That is something Mr San is open to, if it helps to shorten the wait.

"I don't mind paying a few hundred baht," he says. "But if they increase the price, they have to improve the service.

"They should have called me beforehand and told me the doctor was coming late."