Dr.

Sanguan Nitayarumphong
and Public Healthcare Reform in
Thailand
Background
Name: Sanguan Nitayarumphong
Date of Birth: March 18, 1952
From a middle-income Thai-Chinese family
Education and Social Involvement
Highschool: Triam Udom Suksa High School (One of the best HS in Thailand).
Studied in Ramathibodi Medical School, Mahidol University to become a medical doctor. (1971
to 1977)

Thailand during that time:

◦ Authoritarian Rule
◦ Student-movement is active

Dr. Sanguan became socially active and joined various kinds of events.
◦ Chairman of the Academic Section of the Mahindol University Student Union (fourth-year)
◦ President of the Mahidol University Student Union (final year)
◦ Key leader in student movement against the military regime (1973 and 1976 demonstration)
Work and Social Involvement
Dr. Sanguan worked in a remote area in northeastern Thailand.
Rasi Salai Hospital in Si Sa Ket Province
Promoted acting director (1981-1982)

Initiated a proactive approach to public health care (an answer to prescription drug problem):
o Went directly to villages and communities to provide basic knowledge of disease prevention and use of
medicine.
o Established medicine fund for the local people.
o Began to operate a mobile medical unit.

Realization of Dr. Sanguan

o Inequality: Remote areas faced difficulties in accessing and receiving health care.
Achievements
•Promoted Director of Buayai Hospital in Nakhon Ratchasima Province. (1983)
•Selected Chairman of Rural Medical Doctors because of his good performance and work ethic at
Rasi Salai.
•Granted a granted a scholarship to pursue master’s degree in public health at the Institute
of Tropical Medicine in Antwerp, Belgium.
Return to Thailand
•Healthcare is inefficient
•People in remote areas receive low-quality public health care.
•There were weakness and limitation in terms of administration.

Dr. Sanguan launched an action research (1986-1988):

o In cooperation with his colleagues from Ministry of Public Health and other academic institutions.
o Aimed at examining and developing an efficient model of public healthcare system.
o Khun Han District in Si Sa Ket Province – experimental area for the research
Return to Thailand
1986- Dr. Sanguan was transferred to Bangkok

Main responsibility: to involve the public in public health care.

Key issue: top-down approach

Few years after…

o He was relocated to Planning Division
o Chance to observe and understand the overall picture of the Public Healthcare System in Thailand.
o Multiplicity of the problem.
Komol Keemthong Conference
Dr. Sanguan was selected as a keynote speaker
oDelivered a speech: ‘New Perspectives of the Thai Public Health System’
oPublic healthcare in Thailand needed reform: reform is unavoidable
oShortcomings and proposed alternatives
oHolistic approach
oAlleviation of poverty
Proposed Reforms
1. Primary health should be sufficient and cover all Thai people
2. The approach to public health care should focus on disease prevention rather than medical
treatment.
3. Public healthcare should be more decentralized with greater involvement from local
governments and the public
4. Management of public health system should involve cooperation from other related sectors
Sampran Forum
Dr. Sanguan was the chairman of the Rural Medical Doctors Network.
 1986, it organized “Sampran Forum”, with Dr. Prawase Wasi.
 Its creation was brought by several issues in Public Health Care System and the work of rural medical
doctors.
 Conducted monthly at Rose Garden Resort in Sampan District in Nakhon Pathom Province.

People involved in Sampran Forum

 Several famous doctors have also been active in the forum
 Think tanks from Ministry of Public Health – role: gathering information for drafting the National Health
Security Act as well as initiating and managing National Health Security Office.
Social Security Office
Before being the Deputy Permanent Secretary of Ministry of Public Health

Was also member of preparation committee for the establishment of Social Security Office.

Working in the committee would provide him experience and contribute to his ideas about
public health care reform.

He was invited Prof. Nikhom Jantarawithoon, who had initiated a campaign for Social Security
Act. In a time where social security is a relatively new concept.
Social Security Office
ISSUE: management of hospitals that provided public health services for social security subscribers
◦ Minister of the Interior wanted the ministry to build manage these hospitals.
◦ Working committee believed that public health hospitals should be able to provide services and building
hospitals for the project is unnecessary.

Functions of Social Security Office (Management Approach)

o As a regulator.
o Provide guidelines for public and private hospitals.
o Monitoring the operations of these hospitals.

Dr. Sanguan’s participation in the Social Security Act and Social Security office gave him knowledge necessary
for public health care reform.
Triangle Can Move A Mountain
Principle
THREE MAIN ELEMENTS
Knowledge
◦ Thorough knowledge = extensive research

Social Movement/Support
◦ Important to differentiate between good and bad, what should and what should not be done.
◦ To make significant change social awareness and support must be established.

Political Support Decision

◦ Politicians – key drivers of policy change.
◦ Ergo, political affiliations are crucial
Triangle Can Move A Mountain
Principle
This idea was accepted by Dr. Sanguan.
He used these three principles when he was campaigning for public health care reform.
Knowledge – Public Health Care Reform
•Dr. Sanguan and his colleagues conducted studies and experiments on public healthcare system
• To gain general knowledge on Thai Public Healthcare System
• To examine its efficiency
• To develop an appropriate reform

• He invited professors in economics and public health

• To share expertise on financial issues involving public health care
Ayutthaya Project – An Experiment
•A pilot universal healthcare project in Ayutthaya Province
•In this project participants were obliged to pay flat rate fee of 70 bath (112.65 php) for all
medical treatment received from any hospitals or community healthcare center.
•This model proved to be workable since there are existing budget allocations for community and
hospitals.
Social Movement/Support
•Change will not occur if campaigns were launched only by academics and medical practitioners.
•Dr. Sanguan approached key person in several NGOs to gather support.
•The key people arranged meeting among themselves.
•This meeting resulted to the recognition of the potential benefits of the draft.
•NGO members became key supporters in pushing for the National Universal Coverage Act.
Political Support – “30 baht treats all
disease”
•Dr. Sanguan recognized that he must embrace political affiliation in order for the draft to pass.
•He propose his ideas to several political parties (Democrat, Chart Thai, Seritham, and New
Aspiration).
•Through arrangement with Dr. Suraphong, he met with Thaksin Shinawatra, leader of Thai Rak
That Party, and proposed his idea of universal coverage.
•Thaksin accepted the idea and attached it to the party’s manifesto.
•Thaksin pointed out that public might not understand the phrase “Universal Health Coverage”,
so he suggested a more attractive slogan “30 baht treats all diseases.”
Landslide Victory – Thai Rak Thai Party
(TRT)
•Thaksin Shinawtra became prime minister after the landslide victory of TRT Party.
•TRT managed to secure the majority in the House of Representatives.
•Victory of TRT = quick implementation of the party’s manifesto, including the “30 baht treats all
diseases”.
•Issues prior to the implementation:
• Fragmented funding
• Healthcare disparities

◦ Objective of the universal coverage policy

◦ To ensure universal coverage
◦ Creation of standardize and sustainable system
Implementation Timeline
•April 2001- Initial Phase
• Pilot program was tested in six provices of Phayao, Pathum Thani, Yasothon, Samut Sakhon, Nakhon
Sawan, and Yala.

◦June 2001- number of pilot provinces gad increased to 21

◦October 2001- all provinces, except Bangkok.
◦April 2002- 45 million (out of 64 million) people across the country has been covered by the
scheme.
National Health Security Act of 2002
•Passed by the House of Representatives in May 2002
•Ratified by the Senate in August 2002.
•Requirement of the National Health Security Act of 2002
• Creation of National Health Security Office- an autonomous body in charge of the universal coverage
• National Health Security Board
• Constituted to design the universal coverage program
• To provide direction to manage the scheme and ensure standardized health care for all Thais
• National Committee for Quality Accreditation
• Constituted to deal with quality control
Avoiding Politics
•Dr. Sanguan was approached by the Prime Minister and the Minister of Public Health
•He was given the choice of being appointed as first Secretary General of NHSO or becoming an
Assistant to the Minister of Public Health.
•Dr. Sanguan decided to be secretary general in order for him to distant himself from politics.
• Toughest pressure for him was to raise public awareness that the NHSO was not a political instrument to
be used to deliver government’s populist policies.
• His responsibility – to steer the NHSO to the right direction
• Dr. Sanguan noted that this is one the hardest challenge that he faced, to keep NHSO away
from the political influences.
Lessons to be Learned
•Triangle Can Move a Mountain Principle
•Building solid knowledge base through student activities, field research, and post-graduate
studies.
•Working with nongovernmental organizations
•Never stop meeting and talking with politicians
Six Abilities of a Phronetic Leader
Dr. Sanguan can be identified as having all six abilities of a phronetic leader.
1. Ability to set good goals and make judgements on goodness
2. Ability to perceive reality as it is
3. Ability to create “Ba”
4. Ability to articulate essence into a narrative
5. Ability to exercise political power to realize the story
6. Ability to foster phronesis in others
The Ability to Set Good Goals and Make
Judgements on Goodness
•Commitment to establish healthcare equality
•Involvement in rural development activities
•Initiating innovative project (e.g. mobile medical unit)
•Motivation to improve accessibility of medical services
•Endeavored to reform the healthcare system
Ability to Perceive Reality as It Is

•Dr. Sanguan understood the challenges faced by the rural communities

• He form a medical unit

•Understanding the Thai healthcare system

• Formulation of healthcare reform proposals

◦ Acknowledged that political affiliations underpinned successful policy changes

Ability to create “Ba”

•Creation of “teamwork culture”

• In Rasi Salai Hospital
• During the inception of NHSO

• Hiring a chef to cater to the hospital staff

• Spending time together over meals (team building)
Ability to Articulate Essence into a Narrative

•Able to communicate in a way that everyone can comprehend

• Able to give the local knowledge on disease prevention and proper use of medicine.
• Dr. Sanguan and his team were able to simplify the issues and communicate effectively with rural
people.
Ability to Exercise Political Power to Realize the Story
•Ideological influence over his colleagues
•Despite condemnation of the universal health coverage proposal, he managed to explain its
complexity to his fellow professionals.
Ability to Foster Phronesis in Others

•Dr. Sanguan was able to foster his ideology and work ethic among his “dream team”
•Some of its members were able to assume influential positions
 Other Characteristics
•Compassion and Empathy
•Perseverance
•Flexibility
 “Hindi ko po kinakailangang mahalal bilang isang senador,
sapagkat sapat na po upang (na) ako ay magtaguyod at
tumulong sa pagbabantay sa kapakanan ng bansa” – Geremy
Geroy