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Thailand's Health Care Plan Creates Challenges for Hospitals

Thailand's low cost health program, introduced in 2001, has won plenty of support among voters in recent years. But the plan has overburdened hospitals with debts, and hundreds of doctors are leaving the public health system because of rising work pressures.

Thailand's low-cost health program was born out of populist politics.

It was a key campaign platform for Thaksin Shinawatra's Thai Rak Thai party's victory in general elections in 2001, and it has proven popular with voters.

Known as the 30 baht plan because patients pay just 30 baht or about $0.75 per visit, the initiative has been a key to the party's popularity in rural provinces, where cost kept many from seeking hospital care.

And while the program has meant millions of Thais now can afford care, public hospitals and many doctors say the plan was poorly thought out and too hastily implemented. The result has been a huge debt burden for hospitals and doctors so overworked they are leaving the public system.

The program is immensely popular, and was a feature in the last general elections in early April.

This woman, standing before a crowd of 150,000 Thai Rak Thai supporters, extolled the virtues of the program. She spoke of how her sick father would have faced a hospital bill of $2,500, had it not been for the 30 baht plan.

But even discounting the political rhetoric, many Thais support the program.

Boonsong Wannakasikum, a mother of two, is one of the millions who see the plan as a vital safety net.

Boonsong says the hospitals would otherwise be too expensive for many if it were not for the 30-baht health program, where they would have to pay 500 baht or over $12 for a hospital visit. That is two days' income for him.

The program covers most basic illnesses, plus many expensive surgeries and treatments for AIDS and cancer. Almost 80 percent of Thailand's population of 62 million benefit from the plan.

But local health officials and doctors complain government funding for the program has fallen short. As a result, many hospitals have accumulated huge debts.

Dr. Cherdchoon Ariyasriwatana, a member of the Medical Council of Thailand, says that, although the government has increased subsidies, the money remains insufficient.

"I think that the increased amount of money is still not enough for the health care scheme," said Dr. Cherdchoon. "When we have a meeting all of the doctors and hospitals, government hospitals have said the same thing, that the money is not enough."

Siriaj Hospital, Thailand's oldest medical school, faces debts of around $13.5 million, because of the 30-baht program. Other major teaching hospitals have withdrawn from the plan to avoid the spiraling debt.

Viroj na Ranong is an economist with the independent think tank Thailand Development Research Institute. He says the government appears unlikely to help hospitals cut their debts.

"There have been attempts in the Ministry of Public Health to solve that problem, but I think it would not solve the problem - I mean for the old debt, they would not do anything about the old debt. What they are doing is to reallocate some of the budget for this fiscal year," he noted.

Viroj says hospital usage has risen nearly 50 percent under the program. Most hospitals do not have enough qualified staff to handle the increased load, resulting in long waits for treatment. Those waits are discouraging some from seeking treatment, no matter how inexpensive.

Dr. Cherdchoon says the added burden has fallen on the shoulders of doctors, especially in rural areas, where hospitals have historically been understaffed. Over the past four years more than two thousand doctors have resigned from state hospitals because of the heavy workload. She says doctors are forced to work 100 hours a week, often earning just over $400 a month.

"The burden is much more on the doctors' side, because when the government said that any people can come to the hospital anytime just paying sum sip baht, 30 baht, so the people don't take responsibility for their health. Minor illness or minor ailment they come to the hospital anytime they want," added Dr. Cherdchoon.

But Viroj says the institute's studies show there has been less abuse of the system than first feared.

"A lot of people say that the 30 baht scheme would lead to moral hazard, people will abuse the system. But I don't think we have seen any evidence so far. We found that some people who were afraid to go to the hospital because they might not be able to pay, some of these people finally go because of the 30-baht scheme, but they have a legitimate reason to be there," he added.

Viroj says it is likely that future governments will have to adjust the program. Perhaps it will be limited to the country's poorest citizens, or the fees will be raised slightly.

Thailand's 30 baht health program marked a major step toward universal health coverage to ensure a safety net for many who had been largely ignored in public health policy. But health care experts say future governments must find the balance between serving the public and building a long-term health strategy.