An old meme cropped up in a new place last week, triggering debates, disputes and differences of opinion over a decade-old question of whether the free state medical programme deserves more respect, called co-pay.
Weirdly, it took six weeks for the issue to bubble up to the top of the public's perception, but it then became one of the hottest topics of the week.
"Co-pay" is a fancy way of saying "pay". Under a co-payment system, you cough up baht when you go to the doctor or pharmacy and flash your card to get state-sponsored care. You pay that money up front, and the government calls it a "co-payment" to be sure it gets all the credit for your treatment or drugs.
The issue was raised a week after the May 22 military takeover at a meeting between bureaucrats of the Public Health Ministry and the National Council for Peace and Order (NCPO).
A Rohingya family take their child to Maesot General Hospital in Tak province. (Photo by Paritta Wangkiat)
The credit/blame for recommending that the public should resume paying for its treatment belongs, weirdly, to a doctor who has nothing to do with most medical and pharmaceutical treatments, Tawatchai Kamoltham, director-general of the Department for Development of Thai Traditional Medicine and Alternative Medicine. But Dr Tawatchai says he was concerned that most people don't respect or even support medicine, health services and - worst of all - the government departments that provide today's nationwide health services. If they pay, they'll soon respect it.
While the issue seemed to shock consumers and the media, it's a pretty hoary subject. Remember? Co-pay first came from Lord Voldemort na Dubai when he brought in the country's first helpful upgrade of the public health system since Prince Mahidol Adulyadej of Songkhla. It was called the 30 baht health system because every user had to pony up that amount to use it.
Few people called it co-pay, but it was. The desert fox explained that his populist programme could provide free medical care for all, but a modest co-payment would ... well, here is Dr Tawatchai in July, 2014, saying exactly what the exile said in 2001.
Having to make a co-payment makes people think twice before they use the system, thereby reducing the number of patients who just want to complain to a doctor. It gives the programme itself respect that no free medical care could command. A co-payment means many people will take care of themselves better, so that they do not have to pay for trivial health events. And of course it puts money into medical care that relieves the burden to public coffers.
The populist medical care programme begun in 2001 caused huge debate and scepticism, more if anything than the recent rice-pledging disaster. But because it worked, the 30 baht health scheme became identified with the world’s only fugitive ex-prime minister. So when a military regime and the then the Democrat Party took over government after 2006, the 30 baht co-payment disappeared, the programme was re-jiggered and it became, in large part, free.
Dr Tawatchai, who has plenty of support within the health bureaucracy, wants to bring back co-payments — so long as they aren't the toxic 30 baht, and so long as the reasoning used is his, not the identical justification by the plan's originator back in 2001.
A huge public and media backlash erupted last week, not so much against a payment system per se as in the secretive manner it was brought up for discussion. Apiwat Kwangkaew, a well-known activist on health issues, suggested that if the Public Health Ministry bureaucrats want co-payments, they should institute a five-year pilot system to test the idea, for ministry employees only.
As is their wont, the civil servants refused to take credit for wanting to charge the country a reported 300 baht per visit under a new co-payment scheme. They need the money because the current system is losing money and putting small, rural hospitals and health centres at a disadvantage. Rather than fix that system, it would be easier to start demanding 300 baht per visit to the doctor, hospital or pharmacy.
But a debate over co-payments will only be honest if it acknowledges that the officials involved are deeply hypocritical, which is probably to say political. Not even two years ago, when the Yingluck Shinawatra government re-started the 30 baht co-payment for strictly political and aggrandising reasons, the Public Health Ministry officials responded with statements and reasoning exactly the opposite of their stance today.
In September, 2012, health officials told the media that hospitals should refuse to collect the co-payments. The government claimed co-payments meant rural hospitals could provide more services, but that was untrue. And, "It's the fundamental right of people to receive health services from the government."
The intrusion of politics into this issue only ensures that the public will never get the facts about co-payments from either health professionals or their representatives.
A co-payment of 30 baht never seemed onerous, and roused no opposition among health users. The deconstructionists of 2006 and of 2009 thought that "free" was an alternative to cause forgetfulness about the unfortunate days of 2001 to 2005. Today's neo-deconstructionists, however, are talking real money, since 300 baht is a day's wages to low-echelon workers and, realistically, the equivalent of two or three days of work to a rural farmer.
The very programme that heavily promoted equality and egalitarianism in medical care, making heart bypasses and cancer treatment available to the very poorest Thais, is now looking to price itself back into the class system of health care, all over co-pay.