Many people believe that if you want to change your fate, you should start by changing your name. Dr Sanguan Nitayarumphong does not think of himself as particularly superstitious, but he still believes a good way to de-politicise the Bt30 health scheme is perhaps to give it a new name.

"Perhaps, it should simply be known as the 'universal healthcare' scheme," said Sanguan, referring to his brainchild health security scheme that was adopted by Prime Minister Thaksin Shinawatra as a flagship policy of his Thai Rak Thai Party five years ago.

"Bt30 may not be the single flat-rate payment anymore. The scheme has to undergo a lot of adjustments for it to survive in the long run. It is known the quality of healthcare under the scheme has been compromised by financial constraints. People might still pay Bt30 if they go to neighbourhood hospitals for primary care, but if they go to big hospitals, they may have to pay Bt60 or even Bt100 in admission cases."

To build an equitable health security system for all Thais, no matter how much money they have in their pockets, has been Sanguan's dream since his medical student days some three decades ago. He was not alone, many doctors, academics, social and health activists shared his passion. Together they developed the scheme that landed in the hands of Thai Rak Thai party under the slogan "Bt30 for all treatment".

The scheme now covers some 48 million of the total 62 million population. Sanguan is now chief of the National Health Security Office set up to implement the scheme.

Ironically, although it was politics that gave birth to the scheme of his dreams, Sanguan is now seeking to de-politicise the project in order to help it survive the crumbling political situation.

The first priority is to find a more secure financial source for the scheme. Being part of the national budget system, as it is now, makes the scheme vulnerable to the government's control, Sanguan said. He also put forward the idea that the Bt1,000-billion annual sin tax from alcohol and tobacco, could be a viable alternative source of finance for the scheme.

"This way we wouldn't have to worry about which party forms the government or their policy priorities because money from tax will always be available to us," he said. "We are building this scheme so that it can be sustained to serve your children. Health security for citizens is a fundamental element of a civilised society."

But the sin tax proposal is not without controversy.

Thailand Development Research Institute's senior economist Dr Viroj Na Ranong said the amount of annual sin tax fluctuates depending on the economic situation. For example, during the 1997-98 economic crisis, consumption of luxury goods dropped and had a knock-on effect on the amount of sin tax collected by the government.

"Paying for healthcare with sin taxes may sound attractive, but I don't want to see expenses for public healthcare depending on fluctuating economic conditions," Viroj noted. "If the government agrees to allocate all the sin tax it collects to the health fund, that may be a good idea. But I don't think that will be the case because that would mean less money for the government for other budgets."

Nonetheless, Viroj agreed in principle with Sanguan that there should be a separate fund from a secure source to finance the national health security scheme.

"Financial shortage has been a big obstacle that has prevented the scheme from being implemented smoothly," he said. "The assumption that with increasing efficiency healthcare may not require a lot of money is true to a limited extent. Healthcare is not an activity that will generate high economic surpluses."

However, both Viroj and Sanguan are positive that the increase of capitation budget from Bt1,659 to Bt2,089 next year, if approved by the new Cabinet, will relieve financial burdens that have plagued the scheme since its inception in 2001.

Sanguan also suggested the exclusion of high-income earners from the scheme could help to relieve its financial burden. But more importantly, the exclusion would help allay criticisms that the scheme diverts resources that may otherwise be more vital for the poor, in order to support the rich.

"We may consider exempting high-income people, say those who earn more than Bt10 million a year, from the scheme," Sanguan said. "That will cut about 5-10 per cent of people from the scheme coverage. From our studies, these people seldom use our health service anyway."

In the next phase of the universal healthcare scheme, with or without the Thai Rak Thai government, Sanguan sees himself striving to introduce radical reforms in Thailand's healthcare system to improve efficiency.

"The [Thai Rak Thai] government gave the scheme less money than it requires hoping to use financial constraints to force cuts in order to improve efficiency. But the policy to force the reform was not clear. We have only achieved 30-40 per cent of the required reforms in the past five years. A lot more still needs to be done."

The first article was printed last Friday.

Nantiya Tangwisutijit

The Nation