Abstract
The transfer of Subdistrict Health Promoting Hospitals (SHPHs) to the Provincial
Administrative Organization (PAO), which bears responsibility for providing comprehensive primary
health care, including curative care, health promotion, disease prevention and control, and
rehabilitation. Adequate resources and budget allocations for service provision ensure that the
population receives comprehensive and equitable health services.
This mixed-methods study aimed to: (1) assess the efficiency of allocating outpatient (OP)
and health promotion and disease prevention (P&P) service expenditures among SHPHs transferred
to PAOs; (2) evaluate the cost–benefit of allocation models for SHPH expenditures under PAO
administration; (3) develop recommendations for expenditure allocation models for transferred
SHPHs; and (4) synthesize an optimal budgeting model to achieve the desired health promotion
outcomes for SHPHs under PAOs. The study included SHPHs registered as service units under the
National Health Security Board regulations within Contracting Units for Primary Care (CUPs) in fiscal
year 2024, based on the perspectives of service providers. Seven allocation models, as defined by
National Health Security Office (NHSO) resolutions, were examined across 2 provinces per model,
with 3 SHPHs per province (total = 42 SHPHs), plus comparison groups from 2 additional provinces
(6 SHPHs). In total, 48 SHPHs were assessed. Key findings are summarized below.
1. Efficiency of OP and P&P Expenditure Allocation: Unit costs tended to be higher in the
proportional (hospital per SHPH) allocation model, the per-capita model, and the model
allocating only P&P (with OP via CUP). Allocated budgets from the Bureau of the Budget
were sufficient to cover expenditures related to personnel, utilities, and supplies. The
remaining revolving funds in FY2024 were 1.63 times higher than in FY2023. For OP services,
the allocation models “equal allocation for all units” and “P&P allocation (OP via CUP)”
yielded the lowest cost per capita compared with other models. SHPHs implemented PP
capitation-based indicators but did not receive fee-schedule payments. For P&P feeschedule allocations, transferred SHPHs delivered services but data were not recorded in
HosXp or submitted to NHSO’s E-claim system, unlike non-transferred SHPHs.
2. Cost–benefit analysis of budget allocation models for SHPHs transferred to PAOs: For
OP services, the per-capita, SML-based, and equal-allocation models generally produced
negative CBA values (−0.06 to −0.40), reflecting reduced unit costs but increased allocated
budgets compared with non-transferred SHPHs. The exception was the model “allocation
via CUP / proportion between CUP: SHPH,” which yielded a positive CBA (9.33) due to
reductions in both unit costs and allocated budgets. For P&P services, cost–benefit
performance was generally superior to OP. The “equal allocation for all units” model
demonstrated the highest efficiency. Sensitivity analysis indicated that the “allocation via
CUP/proportion model” was the most sensitive to parameter variations, particularly OP
costs, whereas the per-capita, proportional of hospital per SHPHs, and SML-based models
were more stable. Based on benefit-cost ratios (BCR), the most efficient model for OP
services was “allocation via parent hospital,” with BCR = 2.47. For P&P services, the “P&P
allocation (OP via CUP)” model yielded the highest efficiency, with BCR = 3.70.
Overall, P&P services demonstrated greater cost-effectiveness and efficiency than OP
services, and the choice of allocation model played a critical role in economic performance.
Administrators should consider stability, cost-effectiveness, and operational feasibility in
decision-making, while ensuring continuous monitoring and evaluation when contextual or policy
changes occur. The SML-based allocation model should be considered the primary option due
to its operational stability and benefits across both OP and P&P services. As a secondary option,
the per-capita model offers fairness in resource distribution with low sensitivity across
parameters. Models to be avoided include the “allocation via CUP/proportion model” and the
“P&P allocation (OP via CUP)” model, given their high sensitivity and instability.
3. Recommendations for Expenditure Allocation for Transferred SHPHs:
First case: P&P budget allocated via CUP. Operations should comply with mutually agreed
arrangements concerning service delivery, resource allocation, performance recording, and
claiming procedures. Second case: P&P budget not allocated via CUP. PAO-affiliated service
units may procure quality services. For example, outsourcing laboratory service, or request
additional funding through the Tambon Health Fund via the District Health Board (DHB).
However, such outputs may not be recognized by NHSO and therefore cannot be claimed
through the E-claim system.
4. The optimal budget allocation model for achieving desirable health-promotion
outcomes among primary care units under the Provincial Administrative Organization:
The implementation begins with provincial-level policy mobilization through the Area Health
Board (AHB), ensuring alignment with national health indicators as well as locally relevant
indicators. This process adheres to the service standards mandated by the Primary Care Act,
covering the registration of service units, the assessment of primary care units, and the
management of basic service unit information within the National Health Security Office’s
Contracting Provider Profile (CPP) system. In addition, a comprehensive performance
response system is in place—from operational activities and data entry into the HDC system
to documentation through the E-Claim system—together with supervisory and monitoring
mechanisms capable of reflecting data recording and reimbursement outcomes. The
performance results are further incorporated into considerations for work performance
appraisal, thereby encouraging the attainment of desirable health-promotion outcomes.
