Is co-payment the answer for Thailand’s universal healthcare crisis?

Barely two decades since its introduction, Thailand’s universal healthcare scheme is tottering on the brink of collapse under a growing financial burden. Radical reforms now seem unavoidable.

Four hundred of the 903 public hospitals under the scheme have recorded an accumulated loss of 12.21 billion baht. This staggering deficit results mainly from the National Health Security Office (NHSO)’s failure to devote budgets that actually reflect operational costs.

The ballooning financial crisis has sparked urgent calls to overhaul the system by amending the law it is founded upon, the National Health Security Act. The Act has remained untouched since the scheme’s inception in 2002 despite years of mounting pressure.

Time for reform

The Senate’s public health committee recently took the first step towards reform by drafting a series of amendments to the Act. The revised National Health Security Bill must gain approval from the Public Health Ministry before being forwarded to the Cabinet for endorsement.

“We know the Act has created many problems over the past 24 years,” said Dr Anukul Thaithanan, who chairs the panel drafting the new bill.

The existing bill grants the NHSO board power to determine which medical services are provided free of charge under the universal healthcare scheme, which covers most Thai citizens.

Citizens accessed the scheme more than 192 million times in fiscal 2025 alone. Roughly 185.77 million of these visits were for outpatient treatment while the remaining 7.07 million were admitted as inpatients. However, government funding has failed to keep pace with demand.

The NHSO budget covered roughly 64% of the actual cost for treating inpatients four years ago, according to Dr Sombat Sathonsaowapak, president of Thailand Regional and General Hospital Society (Thaihos).

However, this year that figure plummeted to 55%.

Inside the new bill

Dr Anukul said that while the panel supports Thailand’s policy of universal healthcare, the model is only sustainable if backed by adequate funding. Since nearly half of the hospitals in the scheme are now struggling financially, changes are unavoidable, he added.

“The draft law we have drawn up mandates access to free standardised medical services for all Thais. However, anything beyond that baseline will fall under the co-payment category,” Dr Anukul said.

He added that the first step would be to boost representation of hospitals on the NHSO board. The governing body currently comprises 30 members, but critics argue it is weighted heavily in favour of the NHSO over medical providers.

Up until now, the universal healthcare scheme has been managed under a split “purchaser-provider” model, with the NHSO serving as healthcare purchaser and hospitals as providers. Most participating hospitals are state run.

“Conflicts have erupted due to this rigid separation,” Dr Anukul said. “To resolve this, our draft recommends shifting to a partnership between providers and the purchaser.”

Beyond governance, the draft bill separates funds allocated for medical staff salaries from the general budget for the healthcare scheme. It also promotes decentralisation by empowering district-level health committees to allocate funds according to local needs.

Dr Sombat of Thaihos supports the proposed amendments, arguing that voices of frontline hospital staff are ignored under the current framework.

He also pointed to the growing burden of social and technological changes.

“Thailand’s population is rapidly ageing and more elderly people are seeking treatment under the universal healthcare scheme. Also, advances in medical technology are making it far more expensive. Our operational costs are rising but we are not being reimbursed with enough budget to cover them,” Dr Sombat said.

Dr Somlerk Jeungsmarn, Public Health Ministry permanent secretary, echoed these concerns, saying he was surprised to be the only member speaking up for service providers at NHSO board meetings over the past six months.

“At least 40% of the board should represent hospitals, with 40% representing the purchaser [NHSO], and the remaining 20% drawn from the people’s sector,” he said.

The current structure reserves seven seats for medical specialists and five for non-governmental organisations, according to Asst Prof Dr Sanan Visuthisakchai from the Consortium of Thai Medical Schools’ University Hospital Network. However, Dr Sanan said board members often circumvent term limits by simply switching representation categories once their tenures expire.

Fierce public pushback

The proposed shakeup has attracted a backlash from the influential Rural Doctors Society (RDS), which warns that changing the National Health Security Act could jeopardise the entire system.

“These changes risk undermining check-and-balance mechanisms and allowing the bureaucracy to seize total control of NHSO funds,” the RDS said in a statement.

The RDS argues that giving service providers a larger say on the board would weaken the provider-purchaser split, which is designed to protect the public interest and keep costs transparent.

“If benefits granted under the scheme require adjustment, it can be achieved through existing administrative channels instead of altering the key law,” the RDS stated.

Dr Vachira Botpiboon, a former RDS chief, said the current financial problems should be resolved using existing mechanisms rather than overhauling the entire structure.

“I think problems have worsened over the years because of moves to force every participating hospital to provide comprehensive services to all beneficiaries, when in reality we should be placing a stronger emphasis on primary healthcare,” he said.

Dr Weraphan Leethanakul, NHSO deputy secretary-general, said the long-term solution lies in effective disease prevention and health promotion.

“These should be our primary tools to reduce the influx of patients and reduce treatment costs. We shouldn’t just focus on cutting hospital expenses,” he said.

Threat to the vulnerable?

As debate intensifies, public concerns are growing louder. Many low-income patients fear a co-payment model would result in them being turned away or having to pay for lifesaving treatment.

Recently, a 76-year-old was reportedly asked by a state-run hospital to provide a 30,000-baht deposit before undergoing critical surgery for an aortic aneurysm.

“Such demands are becoming common at many state-run hospitals because the actual cost of these advanced treatments far exceeds what the universal scheme currently covers,” Somlerk said.