On 31 January 2020, PSI Asia Pacific Trade Justice Coordinator, Susana Barria, and PSI Asia Pacific Communications Coordinator, Madelline Romero, joined Ponnyisa Wajcharaanunt, General Secretary of the Nurses Union of Thailand (NUOT) for a field visit to the Non-Sung district hospital and the Don Chomphu Primary Health Centre in the central part of Korat. This account is an output of the field visit. For more pictures, go here.

Edited by: Madelline Romero

At the time of our visit at the end of January 2020 at Isan region’s Non Sung District Hospital – a secondary hospital some 300 kms from the capital Bangkok – the region was closely monitoring a suspected novel coronavirus – COVID-19 – patient at a hospital in Nakhon Ratchasima, Thailand’s northeastern region’s biggest province.

Since the first diagnosis of the virus on a Thai person on January 20th, Thailand has seen the number of infections rise to 2,579 – the fourth highest in Southeast Asia, after Malaysia, Philippines, Indonesia – in mid-April.

While lauded globally as among the most prepared to deal with an epidemic – and perhaps rightfully so, as Thailand performs better than much of the sub-region, registering 1.5 percent deaths and nearly 50 percent recoveries as of mid-April – Thailand’s health system is also, as it stands, overburdened and understaffed – a common lament among the fewer than 10,000 regularly employed nurses at the public health system serving a population of 66.3 million.

The Nurses Union of Thailand (NUOT), a PSI affiliate, has been advocating the government for increased compensation for public nurses

Before the COVID-19 outbreak, at the Non Sung District Hospital alone, there were only 14 doctors and 70 regularly employed nurses attending to a population of 170,000. The World Health Organisation standard is 41.1 skilled health workers – physicians, nurses, midwives – per 10,000 population.

To augment capacity, the hospital had enlisted the services of another 11 nurses on a temporary contract basis. That helped, but not sufficiently. The ideal figure, according to hospital director Dr. Anupong Chaokhonchai would have been 28 doctors and 100 nurses working at a hospital that currently has 60 beds (and average 50 in-patients daily) and catering to the needs of around 500 outpatients each day.

The Nurses Union of Thailand (NUOT), a PSI affiliate, has been advocating the government for increased compensation for public nurses, which rightly reflect the level of their profession – should be at par with other ministries’ workers’ and officials’ compensation – and the personal risks that they face as they perform high-risk jobs.

The current pay structure, the union says, does not meet neither the Thai Nursing Council standard nor labour law requirements. They also call for incentive mechanisms that would stem the tide of movement to private hospitals which are known to offer better compensation than public ones.

With the COVID-19 pandemic, the shortcomings of the system is bound to take a toll on Thailand’s response to the disease. But can and will the government much admired around the world for its universal healthcare system provide much needed TLC to its overworked and undercompensated healthcare workers?

Initially named the 30-baht universal healthcare scheme, the establishment in 2002 of the national and public health insurance scheme has enabled the Thai government to provide healthcare coverage to most of its 66.3 million population, regardless of their financial circumstances.

The policy is composed of three different schemes with their own legal frameworks: civil servants’ medical benefit scheme, social security scheme, and the universal coverage scheme that alone covers 72% of the population[1]. Except for the social security scheme, financing is non-contributory, but financed by general taxation and covers a comprehensive benefit package with a few treatment exclusions. Public facilities administered by different ministries implement the universal health scheme. The majority of public facilities come under the Ministry of Public Health (MoPH).

While the private sector plays a significant role in healthcare, especially in the provision of primary care, the Thai public health system still provides most of healthcare services to the population, covering 81% of total hospital beds, 86% of outpatient visits, and 89% of hospital admissions nationally. With public primary health care for Thailand’s rural poor being weak, people are compelled to go to large hospitals for even basic care which leads to simple cases becoming more severe before they are addressed[2].

Despite this, positive outcomes have been reported: poor or low-income families no longer have to spend all their savings on medical treatment, or have to go bankrupt because of expensive medical bills. According to government data, the number of households facing catastrophic health expenditure declined from 7.1% in 1990 to 2.3% in 2017 and the number of families falling into poverty due to out-of-pocket medical payments also fell from 2.3% in 1990 to 0.2% in 2017[3].

Thailand faces an inequitable distribution of key health personnel resulting in shortages in rural areas.

Despite a general improvement of health outcome indicators at the national level, there are disparities among Thailand’s five regions[4]. The northeastern region – Isan – is the poorest in terms of per capita value addition as well as health indicators. Isan accounts for about 34% of population and 11.5% of GDP, but receives only 5.8% of government expenditures. The government expenditure for health follows a similar pattern.

Thailand faces an inequitable distribution of key health personnel resulting in shortages in rural areas, even for hospitals. The Isan region faces the worse shortages in doctors, dentists, pharmacists and nurses compared to the other regions[5]. The International Labour Organisation (ILO) estimates show that at least 41.1 skilled health workers per 10,000 population are necessary to provide essential services to all in need. According to the Global Health Observatory of the World Health Organisation, Thailand has 29.65 nursing and midwifery personnel per 10,000 population (in 2017)[6]. Isan has only 10.3 nurses for 10,000 population (in 2005). It is projected that, with the current pattern of health education, by 2032 there will be a widening of the shortage of nurses and midwives in Thailand.

It can be expected that such a shortage will affect Isan disproportionately.

Hospital revenues fund hiring of contract staff

There are various revenue streams for public hospitals. One is government financing based on the size of the facility determined by the number of bed and sanctioned workforce. This is called “supply side logic.” Another is revenue from third parties, for example, the Universal Coverage Scheme (UCS) that pay hospitals based on the number of population that they have to provide services to (capitation-based), or, the Social Security Scheme (SSS), that pay hospitals based on the services that were actually provided in the facility (case-based). Both UCS and SSS follows the “demand-side logic.”

Capitation system such as the one followed by UCS does not take into account the varying levels of burden of disease among different populations, which is known to be higher in poorer areas such as Isan.

Since 2001, the Government of Thailand has maintained a policy of zero growth in the size of the civil service, including in the healthcare sector. The current funding for UCS is lower than 1% of the country’s GDP. But as hospitals faced a rising demand for services after the universal healthcare scheme had come into play, the need for more health personnel also increased. In order to cope with this situation, hospitals have been using their revenues from third parties to hire more staff, though on a temporary basis and without the same benefits and allowances provided to permanent employees who are considered civil servants.

As a result, the entire health workforce is overworked, with an increasing number among them having to face precarious employment. Health workers at the Non Sung district hospital explained that despite outpatient consultations being technically scheduled from 8AM to 4PM, the service often remains open until 10 in the night in order to respond to the demand.

“Each nurse in the hospital has to do overtime work around five times each month to deal with the workload. The union thinks that the ideal number of permanent nurses in the hospital would be closer to a 100, considering the work load,” said Poonyisa Wajcharaanunt, NUOT’s General Secretary.

Of the 70 nurses in the hospital, 11 are on short-term contracts. “The number of nurses on short-term contract is smaller now since the union had brought its demands to the management of the hospital, who then acted to have the contract nurses be given regular employment. Other hospitals in the province are probably in a worse situation.”

While NUOT has achieved a lot for public nurses in Thailand including for those working at the Non Sung hospital, there is still a lot to be done. Currently, the union is campaigning to increase the number of regular posts in public hospitals across the country. A statement of NUOT’s Demands for Nurses’ Rights includes a demand for “providing official positions for nurses as it is important to have adequate numbers of nurses in government hospitals especially in developing rural areas to care for poor patients.” The statement also stresses that: salaries need to be at par with professionals’ in other ministries; incentives, similar to the ones provided to doctors, dentists and pharmacists, must be provided in order to retain nurses; and allowances that account for the work related risks faced by nurses, as well as extra work, must be given.

Using hospital revenues to hire personnel was meant to be a temporary coping measure. While an increase in the demand for health services has forced public hospitals to also increase its nurse workforce – albeit with temporary staff – the MoPH is hesitant to offer regular employment. Putting these precarious workers into the regular government staff will not only ensure decent work among those that literally work to make universal health coverage possible, but will also add to the very sustainability of delivering universal healthcare. Plus, doing so would make Thailand even more ready to deal with disease outbreaks when nurses become the most sought-after healthcare workers as we’re seeing in the COVID-19 global pandemic.

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[1] https://www.who.int/bulletin/volumes/97/6/18-223693/en/

[2] https://www.newmandala.org/primary-health-care-and-the-rural-poor-in-thailand/

[3] https://www.bangkokpost.com/opinion/opinion/1811469/populist-uhc-now-a-feather-in-thailands-cap

[4] The five regions are Central, Southern, Northern, North-eastern and the Bangkok Region.

[5] Attitudes toward working in rural areas of Thai medical, dental and pharmacy new graduates in 2012: A cross-sectional survey, 2013, and Nonglak Pagaiya and Thinakorn Noree, Thailand’s Health Workforce: A Review of Challenges and Experiences, HNP Discussion Paper, November 2009 and Ruangratanatrai W, et al., Equity in health personnel financing after Universal Coverage: evidence from Thai Ministry of Public Health's hospitals from 2008-2012, 2015.

[6] https://www.who.int/data/gho/data/indicators

References

Pagaiya N. and Noree T., Thailand’s Health Workforce: A Review of Challenges and Experiences, HNP Discussion Paper, November 2009

Pagaiya N. et al., Forecasting imbalances of human resources for health in the Thailand health service system: application of a health demand method, Human Resources for Health, 2019.

Ruangratanatrai W, et al., Equity in health personnel financing after Universal Coverage: evidence from Thai Ministry of Public Health's hospitals from 2008-2012, Human Resources for Health, 2015

Tangcharoensathien V. et al., Health workforce contributions to health system development: a platform for universal health coverage, Bulletin og the World Health Organsiation, 2013

Thammatacharee N. et al., Attitudes toward working in rural areas of Thai medical, dental and pharmacy new graduates in 2012: A cross-sectional survey, 2013, https://www.researchgate.net/publication/258034466_Attitudes_toward_working_in_rural_areas_of_Thai_medical_dental_and_pharmacy_new_graduates_in_2012_A_cross-sectional_survey