The Fiscal Sustainability of Thailand’s Universal Health Coverage System: Lessons from Comparative Analysis of the United Kingdom, Canada, and Indonesia

Parinya Wangdumrongwong

Authors

Parinya Wangdumrongwong School of Political Science , Sukhothai Thammathirat Open University

Keywords:

Universal Health Coverage (UHC), Fiscal Sustainability, Healthcare Financing, Comparative Health Systems, Strategic Purchasing, Thailand

Abstract

This study examines the fiscal sustainability challenges confronting Thailand’s Universal Health Coverage (UHC) system, which is facing increasing fiscal pressure frompopulation ageing, rising healthcare expenditures, and the growing costs of medical technologies. These challenges have contributed to accumulated financial deficits among a significant number of public hospitals. Employing a qualitative research approach based on documentary research and comparative policy analysis, the study compares healthcare financing systems in the United Kingdom, Canada, and Indonesia through the lens of fiscal sustainability.

The findings reveal that Thailand’s primary challenge stems from a structural imbalance between the growth of healthcare expenditures and available fiscal resources. Comparative analysis shows that the selected countries have adopted different institutional mechanisms to enhance healthcare sustainability, including strategic purchasing and health technology assessment in the United Kingdom, global budgeting and expenditure control in Canada, and referral management alongside diversified financing arrangements in Indonesia.

The study concludes that strengthening risk-adjusted resource allocation, enhancing strategic purchasing mechanisms, improving expenditure management, and diversifying healthcare financing sources are critical for ensuring the long-term fiscal sustainability
of Thailand’s UHC system while preserving equitable access to healthcare services. The findings provide policy-relevant insights for healthcare financing reform in Thailand and other middle-income countries facing similar fiscal challenges.

References

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, S., Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., & Khusun, H. (2019). Universal health coverage in Indonesia: Concept, progress, and challenges. The Lancet,

(10166), 75-102. https://doi.org/10.1016/S0140-6736(18)31647-7

Appleby, J., & Harrison, A. (2023). The NHS at 75: The state of health and social care funding in the UK. The King’s Fund.

Bureau of Health Insurance. (2024). Report on medical cost analysis of hospitals under the Officeof the Permanent Secretary, Ministry of Public Health for the fiscal year 2023-2024. Ministry of Public Health.

Canadian Institute for Health Information. (2023). National health expenditure trends, 2023. https://www.cihi.ca/en/national-health-expenditure-trends

Chucherd, T., & Puapairoj, P. (2020). Fiscal sustainability in Thailand: Challenges from an aging society. Bank of Thailand.

Department of Health and Social Care. (2022). Health and social care levy: Funding the NHS. https://www.gov.uk/government/publications/health-and-social-care-levy/healthand-social-care-levy

Hanvoravongchai, P. (2013). Health financing reform in Thailand: Toward universal coverage under fiscal constraints. World Bank. https://doi.org/10.1596/13297

Hiscock, J. (2021). Thailand’s universal health coverage: Successes and challenges. Global Health Institute.

Institute for Population and Social Research, Mahidol University, & International Health Policy Program. (2025). SAFE financing: Fiscal policy for Thailand’s health system in an era of change. https://ipsr.mahidol.ac.th/en/2025-12-11-safe-financing/

Johns Hopkins Center for Health Security & Nuclear Threat Initiative. (2021). Global Health Security Index 2021: Advancing collective action and accountability amid global crisis. https://www.ghsindex.org/report-model/

Legatum Institute. (2023). The Legatum Prosperity Index 2023: Thailand. https://index.prosperity.com/globe/thailand

Marchildon, G. P. (2013). Canada: Health system review. European Observatory on Health Systems and Policies.

Martin, D., Miller, A. P., Quesnel-Vallée, A., Caron, N. R., Vissandjée, B., & Marchildon, G. P. (2018). Canada’s universal health-care system: Achieving its potential. The Lancet, 391(10131), 1718-1735. https://doi.org/10.1016/S0140-6736(18)30181-8

Marzoeki, P., Tandon, A., Bi, X., & Pambudi, E. S. (2014). Universal health coverage for inclusive and sustainable development: Country summary report for Indonesia. World Bank Group. https://hdl.handle.net/10986/20726

Mulyani, S., & Gani, A. (2021). The sustainability of Jaminan Kesehatan Nasional (JKN) in the post-pandemic era. Universitas Indonesia Press.

National Health Security Office. (2024). Annual report 2023: Strengthening UHC for sustainable development. NHSO.

National Institute for Health and Care Excellence. (2021). NICE strategy 2021 to 2026: Dynamic, collaborative, excellent. NICE.

Prakongsai, P., Palmer, N., Uasuf, C., & Tangcharoensathien, V. (2009). The implications of benefit package design for equity in health financing: The case of Thailand’s Universal Coverage Scheme. Health Policy and Planning, 24(1), 1-13.

Social Security Administering Body for Health. (2023). Annual performance report: Managing the JKN fund. BPJS Kesehatan.

Sutherland, J. M., & Hellsten, E. (2017). Integrated health care in Canada: Restructuring payment mechanisms. C.D. Howe Institute.

Tangcharoensathien, V., Witthayapipopsakul, W., Panichkriangkrai, W., Patcharanarumol, W., & Mills, A. (2018). Health systems development in Thailand: A solid foundation for successful universal health coverage. The Lancet, 391(10126), 1205-1223. https://doi.org/10.1016/S0140-6736(18)30198-3

Thorlby, R., & Gardner, T. (2020). The NHS payment system: A guide to how money flows in the health service. The Health Foundation.

Wangthititheerakul, T., & Sirisunthon, S. (2025, October 17). Opening the “Gold Card” budget: Expenditures exceed income, leaving Ministry of Public Health hospitals 18 billion baht in the red. Policy Watch. http://policywatch.thaipbs.or.th/article/life-202

World Health Organization. (2010). The world health report: Health systems financing—The path to universal coverage. https://iris.who.int/handle/10665/44371

World Health Organization. (2021). Global spending on health: Rising to the challenges of the pandemic. WHO Press.