An Assessment of the National Health Security Scheme: Governance and Management Perspectives

Abstract

Thailand has maintained a commitment to the universal coverage (UC) scheme for over 20 years, with the National Health Security Office (NHSO) playing a central role in driving its implementation and service delivery. Although various organizations have monitored and evaluated Thailand’s UC, research has largely focused on health outcomes and access to care, whereas assessments of the NHSO’s governance remain relatively unexplored. This study thus aimed to evaluate the NHSO’s governance, including its management of the National Health Security Fund. This evaluation applied the principal–agent theory to analyze power dynamics and accountability within the UC system. The assessment was guided by the “3E” framework: execution (practical implementation), evidence (evidence-based decision-making), and efficiency (operational performance). Key data sources included official documents, meeting records, research studies, and NHSO databases, complemented by in-depth interviews with experts and representatives from stakeholder organizations in the UC system. The findings offer insight into policy performance along with concrete recommendations for improving the governance and management of Thailand’s UC system. The evaluation of NHSO’s governance revealed that the current governance structure contradicted the intent of Sections 14 and 15 of the National Health Security Act, which emphasize checks and balances and inclusive participation. Members of both the National Health Security Board and the Quality and Standards Control Board have consecutively rotated across multiple terms, with some members concurrently serving on more than three subcommittees. This led to role overlaps between policymakers (principals) and implementers (agents), especially when individuals held dual roles at the central and regional levels. To prevent concentration of power, the study recommends introducing legal safeguards, including mandatory breaks after two consecutive terms when rotating between the main boards, limiting each member to no more than two concurrent subcommittees, and reconsidering the appointment of central board members to regional subcommittees.