"Weaving the stars and moon over the sky to make mats for the poor."
The above poem is quoted in the book, "On the path toward universal healthcare", written by Doctor Sa-nguan Nitayarumphong. The book talks about his experience in public health circles, showing that you can succeed in pushing for difficult goals that people see as impossible. To make it possible you need to have determination, hope, and dreams.
It is truly like that. In Thailand today, although the name Sa-nguan Nitayarumphong may not be a name that majority of people are familiar with, in this country there is nobody that has never heard of the ‘30 baht universal healthcare project'.
Doctor Sa-nguan Nitayarumphong, or Doc Sa-nguan, to those that knew him well, was an entrepreneur who succeeded in making universal healthcare possible in this country. Most recently, he served a second term as Secretary General of the National Health Security Office.
However, this is just a small part of his life and thought.
Doctor Sa-nguan Nitayarumphong was born on 18 March 1952 in a Chinese family in Bangkok. He was the youngest of the six siblings in the family.
After finishing his upper-secondary school from Triam Udomsuksa School, he passed the entrance exam to study in the Faculty of Medicine, Mahidol University. As a student activist prior to the 14 October incident, he was involved in rural development camps where he experienced the life of the poor, something he had never witnessed before. On one occasion, he came across a family which earned less than 20 baht.
During his university time, Doctor Sa-nguan enjoyed reading the Social Science Journal, People's Economics, and Maharat newspaper, which exposed him to the condition of rural society which was totally in contrast with the urban lifestyle. Apart from that, he was the editor of the Mahidol Journal, in Mahidol University.
Recognition of Rural Doctor Award
Dr. Sa-nguan graduated in 1977 and started working at Wachira Hospital in Bangkok for one year. After the 6 October 1976 incident, there was great political awareness among the students. Fresh graduates from nursing, pharmacy, dentistry, and medical faculties all wanted to work in rural areas although those areas remained underdeveloped in terms of the infrastructure. The social atmosphere was very energetic, and there were high sense of social responsibility.
Dr. Sa-nguan later was chosen to work in the rural doctor program at Rasi Salai District in Si Sa Ket Province. As a doctor working in a rural area, he experienced the disparity, in terms of issues relating to convenience, entertainment, and levels of prosperity and deprivation, between urban and rural areas.
However, Dr. Sa-nguan once explained that this period was a time of great happiness. Apart from enjoying good teamwork during his time there, Dr. Sa-nguan and the villagers became close. He said he was touched with the warmth and goodwill he received from them.
"If doctors could play a bigger role in working in the rural areas, the villagers would be given a better spread of services. This is different from in the past, where all medical services were situated in urban areas. But the negative part is the villagers will become less dependent on themselves. In the past, they had traditional knowledge. By becoming more reliant on modern medicine, they might abandon good things in their localities."
The Path toward Universal Healthcare
Although many say that the success in universal healthcare is largely due Dr. Sa-nguan since he had been campaigning for this, he himself never took the credit or boasted that it was his personal accomplishment alone, but often said that it was not his personal idea but was what many people wanted.
"When we watch movies, we always see those that need to sell their land and cattle to pay for medical costs. We never know that people in the rural area really face this kind of experience. In the past, although there were assistance programmes for low-income families, they still were not confident or felt shame about using the services. They usually would try to find money to pay for the costs. There was a case where a patient could not find any money but gave me edible beetles instead."
Doctor Sa-nguan said that in Thailand there are two societies. One is urban society; another is rural society. There are major dissimilarities between the two. Thus, a healthy society should be where all can live in equity, with both happiness and sorrow, and caring for one another. The rich help the poor, those that are strong help those that are unwell. This concept had become an inspiration and basic principle from which many people started to develop the healthcare system in Thailand.
The universal healthcare project started amidst many obstacles and friction. In the past, Thailand had few healthcare projects. For example, there was a project which focused on assisting the poor which later expanded to the old and children. However, this kind of project could not be implemented universally; the genuine poor were left out. Apart from that, by having different kinds of projects it decreased the effectiveness of each one. There was a study which questioned if the national budget could cover separate projects. At last, the common solution which all campaigned for was to improve the healthcare system so that it would be more effective, universal, and not too extravagant. This is the background of the universal healthcare system.
This project later was known as 30 baht health scheme. It was the name which a political group saw as appropriate since it would reassure the patients that once they come to use the service, all people will pay the same rate and get full treatment and care. It is a system where everyone has to pay a small amount, at least to show that all share the cost, and in the same way will lessen the obstacles for the patients that are to use the service.
When the universal healthcare project was initiated, it created both positive and negative impacts. On the positive side, it was an initiative to reform the healthcare system and budget to one that is people-centred based as opposed to hospital-based.
On the negative side, although there was reform of the system in the early stage, but the support system was not created. Therefore, after the 30 baht project had been popularised by a political party, there were expectations from the patients. As the support system was not created, it led to disappointment and subsequent problems.
Another major problem was that hospital staff were afraid that there would be no funds for the hospital to function, since the health budget, which in the past was allocated according to the size of the hospital, was now allocated by a head count.
However, although there have been negative feelings toward the change, no one can deny the basic principle of equity for people in the society, which is different from the idea of philanthropy for the poor which is how many would misunderstood it. Therefore, we need to make improvements, and try to understand and to handle the negative perceptions toward the Thai healthcare system. This is what we need to work together on.
Doctor Sa-nguan Nitayarumphong was a doctor that paid attention to "building good heath" rather than "fixing health". It means that he wanted the people to be healthy. Therefore the healthcare system needs to be effective, not by trying to attract more patients so that more money will be received. This thinking is contradictory to the code of conduct of doctors.
Budget allocation per patient, which is the program that the universal healthcare supports, is a system that promotes the idea that if the people are healthy, doctors will benefit. However, if there are more patients coming to the hospitals, the budget will increase. Therefore if there are programmes to make people healthy and protect themselves from diseases and illness, unnecessary costs can be reduced, which will be a long term benefit to society.
Doctor Sa-nguan Nitayarumphong made tremendous efforts in fighting against the obstacles and campaigning for universal healthcare where everyone has access with equality and dignity. There is the saying that silent and headstrong people are persistent. Doctor Sa-Nguan continued repeating this idea for ten years to push for an effective universal healthcare which all can access equally.
Ubekkha (equanimity) is a Buddhist principle which is most difficult. Ubekkha does not mean to be inattentive, to stop, or to be indifferent. But ubekkha means doing what you want to do in a persistent manner. It means having confidence that whether it is successful or not, you will continue. You will not give up, but you will not expect that you must be successful.
Dr Sa-nguan Nitayarumphong, widely credited as one of the initiators of universal healthcare in Thailand, passed away after a long illness on 18 January 2008, aged 55.
Translated by Pokpong Lawansiri