Thailand

The main Strategic Purchasing units are as follows:

National Health Security Office (NHSO) for the Universal Coverage Scheme (UCS) — founded in 2002, covered 49.8 million people (74% of the population) as of 2021, and targets Thais without SSS or CSMBS. Its key feature is social protection by citizen right.

Strategic purchasing is an important policy instrument to achieve Universal Health Coverage (UHC), targeting improved equitable access and financial risk protection. The National Health Security Office (NHSO) exercises strategic purchasing actions, including the following:

1) Applying close-ended provider payment;
2) Promoting primary healthcare’s gatekeeping functions;
3) Exercising collective purchasing power;
4) Engaging views of members in decision-making processes.

Social Security Office (SSO) for the Social Security Scheme (SSS) — founded in 1990, covered 11.2 million people (17% of the population) as of 2021, targets private employees. It is a mandatory health insurance with state subsidies and private contributions).

Comptroller General’s Department (CGD) for the Civil Servant Medical Benefit Scheme (CSMBS) — founded in 1980, covered 6 million people (9% of the population) as of 2021, targets public employers and their parents, spouse and up to 3 children. Its key feature is of state welfare as a fringe benefit.

Medicines and vaccines (national level)
National Health Security Board (NHSB)
Ministry of Public Health (MOPH)
National Health Security Office (NHSO)

Medicines and vaccines (subnational level)
Local Administrative Organizations
Ministry of Public Health (MOPH) hospitals and other state hospitals
Private hospitals

Medical equipment and consumables (national level)
National Health Security Board (NHSB)
Ministry of Public Health (MOPH)
National Health Security Office (NHSO)

Medical equipment and consumables (subnational level)
Local Administrative Organizations
Ministry of Public Health (MOPH) hospitals and other state hospitals
Private hospitals

Healthcare services (national level)
National Health Security Board (NHSB)
Ministry of Public Health (MOPH)
National Health Security Office (NHSO)
Social Security Office (SSO)
Comptroller General’s Department (CGD)

Healthcare services (subnational level)
Local Administrative Organizations
Ministry of Public Health (MOPH) hospitals and other state hospitals
Private hospitals

Healthcare support services (national level)
National Health Security Board (NHSB)
Ministry of Public Health (MOPH)
National Health Security Office (NHSO)
Social Security Office (SSO)
Comptroller General’s Department (CGD)

Healthcare support services (subnational level)
Local Administrative Organizations
Ministry of Public Health (MOPH) hospitals and other state hospitals
Private hospitals

The National Health Security Office (NHSO) is the single monopsonist purchaser for the Universal Coverage Scheme (UCS), purchasing services from the Ministry of Public Health (MOPH) and other hospitals. Market strength through the negotiation process is possible through separating purchasers and buyers.

The reimbursement of inpatient service costs follows Diagnostic Related Groups (DRG) within a global budget ceiling, in which standardised unit costs can effectively contain costs.

The costs of outpatient services and subsidies for health promotion and disease prevention follow capitation as a fixed lump-sum to registered members, directed to each primary-level health facility.

The NHSO negotiates with suppliers of medicines and supplies over prices given and ensures quality. Most district health systems have only one provider with a durable relationship and trust with the local community. This informal, respect- and trust-based “accreditation” from the population interactively reflects quality in service delivery.

Each health insurance scheme has its own purchasing system and mechanisms through different methods of payment to health facilities.

Universal Coverage Scheme (UCS)
Method of payment: outpatient and prevention & health promotion uses capitation; inpatient uses DRGs within a global budget + fee-for-service with a ceiling for specific high-cost procedures
Annual public budget per capita: ~3,800 THB or 120 USD per person
Financing and regulatory body: National Health Security Office (NHSO)

Social Security Scheme (SSS)
Method of payment: outpatient uses capitation; inpatient uses DRGs within
Annual public budget per capita: ~7,000 THB or 220 USD per person
Financing and regulatory body: Social Security Office, Ministry of Labour

Civil Servant Medical Benefit Scheme (CSMBS)
Method of payment: outpatient uses DRGs with multiple cost bands
Annual public budget per capita: ~12,000 THB or 400 USD per person
Financing and regulatory body: Comptroller General’s Department (CGD), Ministry of Finance

There has not been progress on system integration. The Civil Servant Medical Benefit Scheme (CSMBS) has a higher per capita cost than other schemes.

The National Public Health Security Act B.E. 2545 has clauses in Sections 9 and 10 for CSMBS and the Social Security Scheme (SSS) to incrementally send their budget to the National Health Security Office (NHSO). However, there is another clause in Section 66 allowing the annual postponement of system integration.

According to the National Health Account, the top five agencies with highest public health expenditure in 2019 were the National Health Security Office (NHSO), Comptroller General’s Department (CGD), Social Security Office (SSO), Local Governments and other Ministries. The breakdown is as follows (in million USD):

The National Health Security Office (NHSO) evaluates new technologies through economic feasibility analysis with clear criteria and through systematic processes. Conceptually, the NHSO pursues better treatments with similar costs for technological replacement. The NHSO uses three criteria to evaluate purchases: 1) health outcomes/goals, 2) budget and 3) service performance.

The Social Security Scheme (SSS), Civil Servant Medical Benefit Scheme (CSMBS) and Local Administrative Organizations (LAO) primarily use the criterion of budget/price.

The National Health Security Office (NHSO) is an independent legal identity with its Board of NHSO (NHSB) chaired by the Minister of Public Health. The NHSO has a 5-year strategic plan. Its specific usage of funds depends on the Board and their strategies. The NHSO’s fund governance criteria are as follows:
• Effectiveness
• Efficiency
• People’s voice
• Accountability

The Social Security Scheme upholds the governance principle of effectiveness in governing its funds.

The Civil Servant Medical Benefit Scheme (CSMBS) and Local Administrative Organizations (LAO) do not have clear principles or mechanisms to govern their use of funds.

The main stakeholders include the following:

Politicians:
Cabinet
Parliament of Thailand

State agencies:
National Health Security Board
National Health Security Office (NHSO)
Ministry of Public Health (MOPH)
Ministry of Finance
Budget Bureau

Healthcare providers:
MOPH and its health facilities
Private sector

Thai population (patient groups/civil society organisations):
Five representative members in the NHSO Board
National Health Commission Office
National Health Assembly (NHA)

The National Health Security Office (NHSO) fulfils functions of strategic purchasing by making decisions on provider payments, evaluating purchases using collective purchasing power as Thailand’s largest purchaser of health services. The NHSO has a Board of NHSO (NHSB) chaired by the Minister of Public Health and including various stakeholders as members.

For medicines, the National List of Essential Medicines (NLEM) Sub-committee assists in the selection of medicines to be included in the NLEM and purchased across public healthcare facilities. The NLEM Sub-committee involves various working groups, and makes final decisions alongside the public health insurance schemes (including NHSO), also considering affordability.

For institutions part of the NHSO, a Procurement Committee makes purchasing decisions on essential medicines based on national and international specifications, demand forecasting and price negotiations.

The National Health Security Act B.E. 2545 (2002) is the comprehensive legislation on national health insurance. It covers the right to receive public health services, the Commission on National Health Insurance and its powers and composition, the Office of National Health Insurance, the Fund on National Health Insurance, service units and standard of public health services, the committee on quality and standard control of public health services, the provision for competent officers, the supervision of service unit standards, and transitory provisions.

The Constitution of the Kingdom of Thailand B.E. 2560 (2017) provides the basis for the rule of law in Thailand.

The Budgetary Procedures Act B.E. 2561 (2018) provides the basis for state fiscal and financial disciplines on budget preparation, administration, budget control, evaluation and reporting.

The State Fiscal and Financial Disciplines Act B.E. 2561 (2018) provides the basis for fiscal disciplines regulation, operation of state finance and budget, internal auditing and internal control.

The Government Procurement and Supplies Management Act B.E. 2560 (2017), also called the Procurement Act, establishes uniform policies and procedures for the purchase of goods and hire of work by government agencies.

The Annual Budget Act states that the government operates a top-down budgeting approach following high-level, longterm strategies through annual budgets to reflect policy and expenditure priorities.

Under the Procurement Act, three main procurement methods must be used, in accordance with the conditions stipulated.

1) General invitation method: A government agency may invite general entities that have the qualifications specified by the government agency to submit a proposal.

2) Selection method: A government agency may invite at least three particular entities that have the qualifications specified by the government agency to submit a proposal, unless there are fewer than three entities that meet the qualifications.

3) Specific method: A government agency may invite one specific entity that has the qualifications specified by the government agency to submit a proposal, or to directly negotiate a price matter that has a small budget.

Generally, healthcare procurement and tendering processes must comply with general government procurement and tendering processes.

The Ministry of Public Health (MOPH) sets the maximum procurement price, called median price, for each drug identified under the Median Pricing. If sellers or manufacturers cannot offer median priced drugs, biologicals, supplies, appliances, and equipment at the stipulated median price or lower, they cannot participate in bidding nor selling them to government hospitals or the MOPH’s Departments.

Central procurement is done for special items from the National Essential Medicines List (including high-cost medicines, antiretrovirals and antituberculosis, dialysate solution and antidote). Regional and hospital procurement is done for general essential medicines. 

The National Health Security Office (NHSO) manages contractual agreements with the Ministry of Public Health and private hospitals.

All stakeholders are responsible to obligations from the terms and contractual agreements outlined in corresponding national laws and regulations, such as the National Health Security Act and Social Security Act.

There are no clear benchmarks nor incentives based on performance of hospitals or health facilities.

The three UHC schemes have different beneficiaries, reimbursement systems and service conditions. These do not have clear mechanisms of output-based incentives such as performance-based financing.

However, there are policy conversations and academic advice on value-based healthcare to optimise cost and outcomes, increase transparency and accountability for health outcomes and manage risks among stakeholders. System reform is required to develop performance measurements that are based on the value of each hospital discharge — using a performance improvement framework that creates value for patients as measured by the outcomes achieved rather than by inputs or volume of services delivered.

There is no clear performance assessment process, but hospitals must be evaluated through a standard and well-established accreditation system such as the Thailand Hospital Indicator Program (THIP). The Healthcare Accreditation Institute (Public Organisation) is responsible for setting standards for all hospitals (public and private).

The National Health Security Office (NHSO) has a registration mechanism with a set of criteria for hospitals to join the Universal Coverage Scheme. The public hospitals have well-defined and well-established mechanisms for quality assessment, but the private hospitals have also improved. Provider performance is randomly checked and evaluated through regular audits on finance and service data.

Provider performance is randomly checked and evaluated through regular audits on finance and service data.

The Healthcare Accreditation Institute, beyond setting standards for providers, is responsible for certifying the quality of service of all public and private hospitals.

The National Health Security Office (NHSO) and Ministry of Public Health (MOPH) have expert support from academic research units for systems-level analysis.

For example, the MOPH collaborates with the Health Intervention and Technology Assessment Program (HITAP) and International Health Policy Program, Thailand (IHPP), Health Insurance System Research Office (HISRO) and Health Systems Research Institute (HSRI) among others on system-level analysis.

The National Health Security Office (NHSO) has microdata on medical treatments and reimbursements which reflect cost and efficiency.

The ICT Center of the Ministry of Public Health (MOPH) has a health management information system which collects activities, resources and costs of the health services delivered from MOPH hospitals and health centers.

Both the Ministry of Public Health (MOPH) and the National Health Security Office (NHSO) use evidence-based research and theoretical concepts on health system performance to inform policymaking decisions. However, whether to implement policy recommendations from the NHSO or MOPH depends on policymakers at the national or subnational levels.

There is no clear evaluation system for the Social Security Scheme (SSS) or Civil Servant Medical Benefit Scheme (CSMBS) to inform policy.

Only the National Health Security Office (NHSO) uses set indicators to monitor and evaluate purchasing decisions. These are as follows:

1) Coverage:
Measuring Universal Health Care population coverage (99.58% in 2022).

2) Units of healthcare services delivery:
The number of hospitals by classification (hospital service levels such as primary, first-level secondary, mid-level secondary, high-level secondary, and tertiary) and affiliations (ministries or government agencies they are affiliated with).

3) Number and percentage of services received by members:
This covers outpatient and inpatient treatments; HIV patients receiving antiviral medicine; chronic kidney disease, diabetes and high-blood pressure, and chronic depressive disorder patients receiving treatments; and population receiving health promotion and prevention services.

4) Seamless care:
Indicators include primary care services anywhere; integrated information system for inpatient services; Cancer Anywhere (Telehealth, Telepharmacy, Home Chemotherapy, and integrated databases); changing primary care delivery through mobile applications.