Ministry's power trip bad for people's health

Ministry's power trip bad for people's health

The universal healthcare system has not only brought praise, it has brought medical care throughout the country - but it means the Ministry of Public Health loses power. (File photo)
The universal healthcare system has not only brought praise, it has brought medical care throughout the country - but it means the Ministry of Public Health loses power. (File photo)

If it ain't broke, don't fix it. Public health authorities are not paying heed to these cautionary words however, because their plan to fix the National Health Security Act is not about how to better serve the 49 million people under universal healthcare coverage. It's about their own power.

The much-praised universal healthcare system has put Thailand on the world map. But for the Public Health Ministry, it means losing old power. So what is there to be happy about?

Before, the Public Health Ministry controlled all public health budgets. Not anymore though, after the 30-baht universal healthcare coverage, the policy platform that gave Thaksin Shinawatra a landslide election victory in 2001.

Sanitsuda Ekachai is former editorial pages editor, Bangkok Post.

Under the 2002 National Health Security Act, the universal healthcare budget is run by the National Health Security Office (NHSO). Apart from allocating the budget according to population density under the principle of equity, the NHSO also manages the purchases of medicines and medical equipment since bulk purchases for all hospitals in the country are more cost efficient. The purchasing system is also more transparent because civil society and patients groups have a say in the decisions.

The ministry's resentment over the loss of budget control and power is understandable. Considering that the current budget for universal healthcare coverage is 147 billion baht -- repeat, 147 billion baht -- it's even more understandable why the Public Health Ministry wants to take over the system.

Why now? Because their past attempts under civilian governments had all failed. Under electoral democracy, patients and civil society groups could freely resist efforts to tamper with the system. Politicians were also afraid to lose their voters. Military rule has changed the game.

Since the 2014 coup d'etat, the military-backed bureaucracy has been using its power to bring back unpopular policies to serve corporate profits in all fronts -- from forest eviction of the poor, free-wheeling mining, to environmentally destructive megaprojects such as dams, coal-fired power plants and deep-sea ports -- by resorting to the military to suppress opposition.

Of course, the Public Health Ministry would not want to miss the train. If not now, they know they cannot retrieve old power under the electoral democratic system.

This just provides more proof of how coups are bad for our health.

Of course, the public health technocrats need to justify changes. And they've got the most powerful supporter. In 2015, Prime Minister Prayut Chan-o-cha slammed the universal healthcare system as a populist policy that was not sustainable. This was followed by witch-hunting investigations against the NHSO that finally froze public health services.

The public uproar ended with the prime minister having to use his absolute power under Section 44, now a daily cure-all under military rule, to order the NHSO to continue its operations. But the mess did not end there.

A committee was immediately set up to amend the 2002 National Health Security Act, creating more controversies. They surround the ministry's proposals to make the patients partially pay for their medical treatment, to take over the NHSO's purchasing authority, to increase the representation of state authorities in the universal healthcare board, and to stop hospitals from using their universal healthcare budget to pay for health personnel salaries' and other hospital expenditure.

The proponents claim that co-payment will save the increasingly expensive system from going bankrupt, that the NHSO does not have legal authority to buy medicines, that the board membership must be readjusted, and that it is illegal for hospitals to use the universal healthcare budget for other purposes. These arguments are deceptive at best.

First thing first -- the co-payment system. The underlying assumption here is that universal healthcare, otherwise called the gold card system, is breaking the bank, so people should contribute. This reasoning is flawed on many fronts.

For starters, the per head cost of the 147-billion-baht universal healthcare for 49 million people this year is currently at 3,109 baht. Meanwhile, the government spends 71 billion baht -- which is half of the gold card system budget -- for only about 5 million government officials and family members. That comes to 14,200 baht per head, or four times higher than what taxpayers get.

Talk about expensive and unsustainable. Yet, this is not of the government's concerns.

It's therefore maddening for ordinary citizens to listen to officials with healthcare privileges scolding them for not taking good care of their health because they can enjoy free medical treatment. The claims that universal healthcare is not sustainable also creates widespread resentment among the public given the military's spending spree on weaponry.

Although the government has tried to play down the co-payment proposal, there are valid grounds for concern. Previous constitutions clearly stated that free and equitable healthcare for all is a right. The present charter omits this rights clause; it simply states the poor are entitled to free healthcare.

Furthermore, the government launched the registration of the poor so they are eligible for state assistance. 14 million people did. Should co-payment become a reality, it's possible that only 14 million people would be able to get free healthcare. More than 35 million people will be left out.

It's also not clear how the proposed co-payment system will work. But fear of cost unpredictability and financial bankruptcy will surely prevent people from getting proper treatment. The co-payment system can also be easily distorted to favour those who can pay more while free treatment will be only for the destitute.

In sum, inequality, disparity and the people's suffering from unaffordable healthcare of the old days will return to haunt us.

Thanks to the public outcry, the government backed off, albeit temporarily. The committee in charge of amending the national health security law finally announced there will no co-payment at the point of service as feared, but the co-payment issue will not be dropped for possible future use.

Health activists and patient groups have tried to shoot down the committee's other proposals, but to no avail so far.

Letting the Public Health Ministry buy the medicines and medical equipment in a closed system will revive old corruption problems, they argue. Letting the Public Health Ministry play both roles as purchaser and provider of health services also fosters inefficiency.

Public health activists protest against the amendment to the National Health Security Act at a public hearings forum in Khon Kaen last month. JAKKRAPAN NATHANRI

The NHSO, meanwhile, needs to back their purchases with research. Bulk bargaining power also results in huge cost savings, inexpensive medicines, and more health services for people. And if the NHSO board is eventually dominated by health authorities as planned, it's certain that universal healthcare as we know it will be no more.

Community hospitals are also concerned with declining healthcare quality if their bosses in Bangkok have their way. At present, allowing state community hospitals to manage salaries and universal healthcare budget together creates flexibility and efficiency since different locales have different needs.

When the two budgets are strictly separate, the per head budget will be significantly less. The flexibility in budget management will be gone. The quality of healthcare services and reach will surely be affected.

Public Health technocrats keep insisting the law does not really allow such a practice. But if it works, and if they want to amend the health security law to make it better, why not make it legal?

It all boils down to the Public Health Ministry's power game to regain its old power. And they want to wrap up the game in their favour before the political game changes again.

The answer to officialdom's power game is people power.

Universal healthcare was possible thanks to electoral democracy. And through electoral democracy, it will continue to benefit people. The sooner the general election, the sooner people can use their voting power to keep what they see as a matter of life and death.

In a country ridden with glaring inequalities like Thailand, free healthcare systematically bridges the gap and helps keep a lid on the people's frustrations which may otherwise violently explode. If the ruling elites fail to realise this, the situation ahead will not be a pretty one.

Sanitsuda Ekachai

Former editorial pages editor

Sanitsuda Ekachai is a former editorial pages editor, Bangkok Post. She writes on human rights, gender, and Thai Buddhism.

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