Installing the right medical facilities to take care of a sick family member at home could cost nearly the entire fortune for a household of six people. In the centre of Bangkok's commercial Lumpini area, the shabby-looking house of the Jan-urai family stands amid the Bon Kai community, a slum adjacent to the high-end Polo Club where the wealthy Bangkok elite gather for sporting events.
The slum is surrounded by construction sites for high-rise condominiums and mall complexes. It is a stark picture of the worlds of the rich and poor colliding -- a place where Mercedes-Benz cars can be seen gliding by garbage-collecting rickshaws in the same blink.
Early last year, the Jan-urai family discovered that Chan Jan-urai, the household's 69-year-old father of four, had stage 3 chronic kidney disease. His daughter Duangduen Seang-usa quit her job immediately to look after her father.
Chan had registered for the Universal care Coverage scheme (UHC). To reduce travel costs from home to the hospital, Duangduen received Continuous Ambulatory Peritoneal Dialysis (CAPD) training from the doctor overseeing her father's case. This way, she could perform CAPD on her father from home.
During CAPD, a liquid called dialysate is placed in the patient's abdomen through a catheter. The dialysate extracts wastes, chemicals and extra fluid from his blood through the peritoneum, or abdominal lining. The process must be completed at least four times a day.
The treatment requires pristine hygiene conditions. But Chan's house is located in a dense slum where poor hygiene is a big problem, among others that the family is facing right now.
setting sights: World Health Organisation director-general Tedros Adhanom examines the eyes of an elderly woman at Phra Jen community in Pathumwan district of Bangkok on his visit to Thailand. PHOTO: Pawat Laopaisarntaksin
"We used to take [Chan] to a hospital by taxi every day for CAPD, but it cost us more than we could afford," said Ms Daungduen.
"Each of our family members earn enough to get by on a day-to-day basis, but some of us can still hardly survive. We had to borrow 30,000 baht from a relative to build a closed room with air conditioning for our father."
But it is not only the room that is costing the family. Other costs include medical supplies such as the catheter and bandages, alongside electricity bills.
The treatment and dialysis fluid is fortunately free thanks to the state-provided UHC.
But Ms Daungduen can barely afford to feed herself nowadays. The rest of the family helps cover her living costs, with the exception of her mother who is suffering from severe back pain.
When Tedros Adhanom, director-general of the World Health Organisation (WHO), visited the Jan-urai family early this month on his official visit to Thailand, he asked Duangduen what type of scenario she would be facing if she did not have the UHC to help her father out.
"We could only wait for his death," she answered.
UHC was introduced in Thailand in 2002, initiated by a prominent doctor, Sanguan Nitayarumphong, who sold the idea to former prime minister Thaksin Shinawatra.
UHC now covers 75% of the Thai population -- around 48 million people. The rest of the population is covered either by the Social Security Scheme or Civil Servant Health Welfare.
Based on capitation payment system, UHC holds the government responsible for providing affordable health care to Thai citizens. It has also reduced catastrophe health expenditure by four times since its introduction.
Although the UHC has saved many lives, there are still obstacles standing in the way of Thai citizens' access to health care. Ms Daungduen's family offers an example of this stark reality.
"I think that even if we have free access to health care, people do not all get equal opportunities," she said.
The unequal access is most manifest in the case of informal and low-paid workers. While they can access free treatment from UHC, their long hours of work do not give them a sufficient income, often forcing them to work overtime. This can unknowingly expose them to long-term health risks such as stress, and alcohol or smoking addictions.
A visit to the hospital means the loss of a whole day's worth of income. Some workers told Spectrum that going to the hospital would waste time and their chances of earning more money. Instead, they prefer to drop by a clinic or drugstore nearby their workplaces.
Those working in agriculture face a different set of risks, dealing with daily exposure to dangerous chemicals. Major companies and agribusinesses profit from the contribution of these workers who put their health at risk while getting by on meagre pay.
Given these conditions, it comes as no surprise that the top 20% earn 10 times more than the bottom 20% in Thailand, according to the Office of the National Economic and Social Development Board. Seven million people live in poverty despite steady GDP growth.
"The majority of health and wellbeing determinants come from outside of the health sector itself," said Public Health Minister Piyasakol Sakolsatayadorn, adding that success of the Thai healthcare system can be owed to factors such as public investment in education, infrastructure, women's empowerment, and safe access to water and sanitation services.
Sangnim Lee from the National Centre for Global Health and Medicine in Japan said during a side meeting at the Prince Mahidol Award Conference 2018 this month that "a perspective of social and economic development must be taken into account to assure that people can afford healthcare schemes" -- either by insurance- or tax-based plans, she indicated.
While Thailand does not yet require engagement with social determinants in healthy policy decision-making, UHC lacks a template for improving the quality of health care and reducing the overload of patients in hospitals as many can come to hospitals without invoking medical fees.
The scheme will face challenges brought on by Thailand's growing ageing population. Its budget has already tripled over a decade from 56 billion baht in 2003 to 166 billion baht last year.
According to the World Bank, 11% of the Thai population, or around 7.5 million people, were 65 years or older in 2016, compared to the 5% in 1995. By 2040, it is projected that over a quarter of the population, or 17 million people, will be 65 years or older. Together with China, Thailand has the highest number of elderly people of any developing country in the Asia-Pacific region.
This will send ripple effects across the Thai economy, including shortages in the working population, and an increased need for caretakers for the elderly.
check-up: Mr Tedros speaks with staff and patients at a health centre in Lumpini sub-district. photo: Pawat Laopaisarntaksin
Thailand has yet to implement a pension scheme for retirees.
The health of elderly people will be affected if they do not have well-paying jobs, proper living conditions and access to healthcare services -- UHC cannot cover all these conditions.
On his visit to Thailand, Dr Adhanom said that UHC had left a good impression on him in terms of its ability to "break financial barriers" and "involve community" in the healthcare system. Still, he noted, Thailand will need to fight for better equality in healthcare services.
In a meeting with Prime Minister Gen Prayut Chan-o-cha, he stated that that the country's leader knows the details of the UHC in and out, and will do what is in the best interests of Thais.
However, how this will specifically manifest and if social determinants will play a role in reform remain to be seen.
Over its 15 years of being up-and-running, UHC has been subject to fierce debate over its financial challenges and politically polarising effects.
The scheme has come under attack by conservative groups who have called the scheme "bad populism".
Proposals that have been discussed include the introduction of co-payments to UHC, rather than the tax-funded model, and confining the eligibility of UHC holders to only poor citizens.
These might serve as credible alternatives to a future healthcare system under the current military government, which has markedly upped spending on weapons and propaganda.
Over the years, Gen Prayut has spoken to reporters, accusing UHC of being a financial burden to the government. He also mulled the idea of extending UHC only to the poor.
Patronisation has been raised as one way of solving social issues and offering opportunities to disadvantaged demographics.
However, the healthcare sector has developed to assure its reach will extend to all citizens.
Nonetheless, patronisation remains a part of Thai culture with its practice of merit-making. These dynamics have incited controversy related to dealings in the healthcare sector.
At the end of last year, public health officials and government leaders threw support behind a campaign by rock star Artiwara "Toon" Kongmalai, who ran 2,191km from Yala's Betong to Chiang Rai's Mae Sai to raise money for 11 hospitals to purchase medical equipment.
The public was perplexed by scenes of health officials collecting donations from their inner circle towards the campaign -- the people paid to uphold quality, accessible health care.
Perhaps more ironically, 17% of the 1.3 billion baht donated went to Phramongkutklao Hospital, a wealthy, military-owned institution, near Victory Monument in Bangkok.
The campaign's share of donations were distributed according to the size of hospitals and number of patient beds in each of the 11 hospitals, meaning that bigger hospitals -- those that can pay for public relations and access big donors -- can seize more funds.
The smaller, rural hospitals that mainly serve the poor get left behind.
It is unlikely that a small hospital offering free treatment to families such as the Jan-urais can access this type of financial support.
While Toon's campaign focused on purchasing medical equipment as the solution to solving access to healthcare services, moves like these are only temporary fixes to the broader systematic issue of social inequality.
The push for the government to implement a healthcare plan applicable to all was eclipsed by the success of one man who raised more than a billion baht of donations.
The implementation of UHC has been part of a global push, recently seen in several countries, especially those with low- to middle-income status.
For example, Kenya's government has announced UHC as part of its priority policy. Last year, Madagascar's government council passed a decree establishing a national health solidarity fund as part of its UHC efforts. On Feb 1, India announced a national healthcare scheme to offer free services to half a billion of its poorest citizens.
Although Thailand has successfully initiated UHC, it is still in a transition period to improve its system.
"Investing in human capital is one of the primary investments to eliminate poverty," Tim Evans, senior director of the World Bank group's Health, Nutrition and Population Practices, was quoted as saying.
To invest in people's survival, such as improving health care access, can make "very handsome" returns to society.
Fixing problems in the healthcare system will require a more holistic engagement with different social factors, from improving the education system to ensuring fairer working conditions for lower-income labourers.
Together, these should add up to a picture of health.
