Abstract
This study was mixed-methods design to estimate cost of public health services from the
provider’s perspective. The budget allocation models between the Contracting Unit for Primary care:
(CUP) and the network of health service unit include Chaloem Phra Kiat 60 Years Nawamin
Maharachini Health Center and Tambon Health Promoting Hospital (THPH) were compared between
before and after transferred to the Provincial Administrative Organizations (PAO) in fiscal year of
2022 and 2023, respectively. There were 7 studied budget allocation models. Two provinces for
each model and another province that budget allocation model has not been defined yet were
purposively selected into this study lead to the total number of studied provinces become 15. Three
THPHs per province were recruited to this study. There were 45 THPH in total.
Results: 1) The situation and comparison of the proportion of the allocation of public health
service expenses to the THPH transferred to PAO (before and after the transfer) There was a variety
of presentations of information to the Local Health Committees (LHCs), both in the form of a
subcommittee and in the form of a committee. Most of them adhered to the allocation model as
it was allocated before the transfer, along with using information from past allocations as a criterion
for allocation. The National Health Security Fund's public health service expenses are allocated as
a monetary value, medicines and medical supplies, and equipment, including payment as a fixed
cost, depending on the agreement of each province. In the allocation of outpatient health service
fees, most do not pay in cash based on the results of services provided at the THPH. As for health
service fees for health promotion and prevention (P&P), most are allocated in monetary value based
on number of outputs of public health services, or the P&P Fee schedule. Nonetheless, the P&P
Capitation is not allocated in cash. However, the rehabilitation fund and the fund for patients
specially caring for palliative patients, which are the joint funding between hospital and THPH has
begun to be considered.
2) Comparison of unit costs of public health services of THPH transferred to PAO (before and
after transfer). In 2022, before the transfer, the median unit cost using activity-base costing approach
of the medical treatment by physicians cost center was 34.67 baht and the medical treatment by
non-physicians cost center was 113.38 baht. In 2023, after the transfer, the median unit cost using
activity-base costing approach of the medical treatment by physicians cost center was 29.95 baht
and the medical treatment by non-physicians cost center was 135.12 baht. The reason of increasing
in the unit cost might be because the average number of outputs of public health services were
decreased from before the transfer (fiscal year 2022).
When comparing the maintenance expenses (personnel, utilities, and material procurement)
with the money supported by the Department of Local Administration (DLA) in fiscal year 2 023 ,
it was found that most of the transferred THPH had spent more maintenance expense than the
money supported by DLA. This is because the money was used to hire personnel and pay various
fixed costs (previously, this money was received from the host hospital). When comparing the
balance in the maintenance expense account at the end of the fiscal year before and after the
transfer, it was found that after the transfer, all THPH had a higher number of balances than before
the transfer. Overall, in fiscal year 2023, the average number of balances in the maintenance expense
account of 45 THPH was 53,545,969.99 baht, or twice as much as before the transfer (27,637,584.41
baht).
3) Results of analysis of cost per capita of expenses for general outpatient services (OP) and
expenses for health promotion and disease prevention services (P&P) of THPH transferred to
provincial administrative organizations (before and after transfer). The unit cost of outpatient service
includes 2 cost centers: the medical treatment by physicians cost center and the medical treatment
by non-physicians cost center. The unit cost unit of health promotion and disease prevention
activities (P&P) is estimated from health promotion and disease prevention activities according to
the announcement of the NHSO in 2023, totaling 134 activities.
The empirical cost data for estimating the direct costs comes from interviews the healthcare
personnel, query the medical records, and accounting data, material use, equipment registers, and
buildings. The indirect cost was obtained from the full cost data of the THPH and hospital. The
average unit cost of outpatient services treated by physicians in 2022 and 2023 were 786.3 and 175.1
baht, respectively. While the average unit cost of outpatient services treated by non-physician in
2022 and 2023 were 266.6 baht and 1,189.7 baht, respectively. For the unit cost of health promotion
and disease prevention activities (P&P), when compared to 2022, there were 45 activities whose
costs decreased in 2023 (47.37 percent), while there were 27 activities whose costs increased (28.42
percent).
4) The policy recommendation, that is, the allocation model for public health service
expenses to THPH that are transferred to the PAO should go through the financial sub-committee
with an equal proportion of representatives from the Ministry of Public Health (MOPH) and the PAO.
Three options are proposed: 1) Allocation through the CUP of the Ministry of Public Health, 2)
Allocation through a CUP outside the Ministry of Public Health but working together with the CUP of
the Ministry of Public Health, 3) Allocation through a CUP outside the Ministry of Public Health
without working together with the Ministry of Public Health, such as the PAO having its own hospitals.
However, these proposals are not final information for each CUP's decision. In the case that
the provinces can reach an agreement, they should proceed according to the agreement. As for the
provinces that cannot consider, they can submit a proposal to allocate 80 percent of the sub-district
hospitals and 20 percent of the CUP. In addition, consideration should be given to direct allocation
to both THPHs that are not transferred and those are transferred before 2023 to avoid inequality
and not affect the overall performance of primary care public health care.
