At a time when the united states remains the only industrialized

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1 Thailand Universal Coverage In The Land Of Smiles: Lessons From Thailand s 30 Baht Health Reforms Rapid coverage expansions and primary care financing reforms make this an attractive model for other middle-income countries. by David Hughes and Songkramchai Leethongdee ABSTRACT: Thailand became one of a handful of lower-middle-income countries providing universal health care coverage when it introduced reforms in Following the 2006 military coup, the coverage reforms are being reappraised by Thai policymakers. In this paper we take the opportunity to assess the program s achievements and problems. We describe the characteristics of the universal insurance program the 30 Baht Scheme and the purchaser-provider system that Thailand adopted. [Health Affairs 26, no. 4 (2007): ; /hlthaff ] At a time when the united states remains the only industrialized nation without universal health insurance coverage, the income threshold at which countries are achieving universal coverage is getting lower (Exhibit 1). Although there have been failures along the way, such as the stalled reforms in the Philippines, countries such as South Korea, Turkey, and Mexico have reorganized their health systems to provide care for all. In the category of lowermiddle-income countries, Thailand introduced reforms in 2001 that combined universal coverage with a relatively comprehensive benefit package. Recently, the national press of Thailand featured the reforms prominently, as commentators pondered the effects of the military coup that ousted Prime Minister Thaksin Shinawatra on 19 September Policymakers and academics have been weighing the achievements and shortcomings of the reforms and offering prescriptions for change. This paper assesses the balance sheet and considers what lessons the Thai reforms offer for the broader health policy community. Overview. Thailand s 30 baht treats all diseases project was largely the brain- David Hughes (D.Hughes@swansea.ac.uk) is a professor in the Institute of Health Research, Swansea University, in Swansea, Wales, and a visiting professor at Mahasarakham University in Maha Sarakham, Thailand. Songkramchai Leethongdee is an assistant professor in the Faculty of Public Health at Mahasarakham University and worked for the Thai Ministry of Public Health from 1997 to HEALTH AFFAIRS ~ Volume 26, Number DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 Country Studies EXHIBIT 1 Gross National Income (GNI) Per Capita Of Countries With Recent Universal Coverage Reforms, 2004 Country South Korea Mexico Turkey Thailand Philippines GNI ($US, World Bank atlas method) $14,000 6,790 3,750 2,490 1,170 World rank, this indicator SOURCE: Adapted from World Bank, 2006 World Development Indicators, Table 1.1: Size of the Economy, (accessed 3 October 2006). child of a group of reformers in the Ministry of Public Health (MoPH), who had long harbored ambitions for universal coverage. The central plank is a new public health insurance scheme that provides treatments within a defined benefit package to registered members for a copayment of 30 baht (US$0.80; 0.64 euro; and 0.43) per chargeable episode. 1 All members register with a contracting unit and receive a gold card entitling them to care in their home area. Elderly people, children, and poor people receive a special version of the registration card and pay no fee. Drugs prescribed are limited to those on a national list, some high-cost or chronic disease treatments are subject to cost ceilings, and there was initially no entitlement to antiretroviral therapy or hemodialysis (although these were later brought within the scheme). Treatment outside the area of registration is limited to accident and emergency care. Finance for the scheme comes mainly from public revenues paid to local contracting units on the basis of population. It has been calculated that less than 2 percent of total receipts come from copayments. 2 The reforms raised public health spending from about billion baht in to billion baht in , putting the first-year cost of reform at a modest US$175 million, including inflation. Previous coverage schemes. The 30 Baht Scheme filled the coverage gap left by the existing public health insurance schemes. 4 By the 1990s, Thailand was providing comprehensive health care to public servants and workers in larger enterprises though the Civil Servant Medical Benefit Scheme, the Social Security Scheme, and the Workmen s Compensation Scheme. About a fifth of the population was covered by a subsidized voluntary Health Card Scheme, which offered care to families for an annual fee of 500 baht (US$13.30; euro; 7.20). There was also a more restricted Medical Welfare Scheme for the poor and a Type B Exemption Scheme, which waived payments for the uninsured poor at the discretion of public health staff. The 30 Baht Scheme superseded the Health Card, Medical Welfare, and Type B Exemptionschemesandextendedcoveragetothewholeregisteredpopulation. Prior to the universal coverage reforms, the public schemes left almost 30 percent of the Thai people without coverage and a further 32 percent with only means-tested assistance under the Medical Welfare Scheme July/August 2007

3 Thailand Financing Reforms And The Broader Health Reform Agenda Rapid expansion of coverage. Although several generations of reformminded MoPH policymakers had sought to expand coverage, no government had been willing to foot the bill for major reform. The January 2001 election victory of the Thai Rak Thai (TRT) Party, on a populist program that included low-cost health care, opened the way for change. Despite advice from senior economists in favor of pilot programs and gradual implementation over three years, a powerful coalition formed that supported rapid nationwide implementation of universal coverage. MoPH reformers, who perceived a limited window of opportunity, lined up alongside TRT politicians, keen to make good on election promises, and civil-society groups. A pilot study already under way in six provinces in April 2001 was quickly relabeled as the first stage of implementation of the coverage reforms; fifteen additional provinces were brought on board in June 2001; and the scheme was extended to cover all provinces (except some Bangkok districts) by October The policy slogan of the reformers might have been: First achieve coverage. The 30 Baht Scheme extended the insured population from about twenty-five million (40 percent of the population) in 2001 to above fifty-nine million (95.5 percent) in Although the original policy design called for a single fund, the decision was made to delay merging the public insurance schemes. This meant thatuniversalcoveragedependedonapatchworkofthenewandoldschemes (Exhibit 2). Some early problems attracted media criticism, such as the absence of a provision to treat gold-card holders away from their home areas and claims that the 30 Baht Scheme provided lower-quality care than the traditional schemes. 7 However, the rapid expansion of coverage was widely seen as a major success. Policy formation process. Because of the rapid extension of coverage, many commentators regard the Thai case as an example of big bang reform. However, EXHIBIT 2 Coverage By Thailand s Public Health Insurance Schemes In 2004 Scheme Population covered (millions) Percent of population Under Health Security Schemes 30 Baht Scheme Social Security Scheme and Workmen s Compensation Scheme Civil Servant Medical Benefit Scheme a 8.2 a 4.5 a a 13.2 a 7.1 a Without public health insurance (unregistered/waiting to establish eligibility) Total SOURCE: Based on P. Jongudomsuk, ed., NHSO Annual Report 2004: Implementation of Universal Health Care Coverage (in Thai) (Nonthaburi: S.P.S. Printing Co. Ltd., 2004). NOTE: All data have been rounded. a Subcategory of Health Security Schemes. HEALTH AFFAIRS ~ Volume 26, Number

4 Country Studies the Thai reforms emerged out of a lengthy policy formation process that paid careful attention to international experiences, as well as to the patterns of economic incentives and costs associated with different funding models. 8 Although basic coverage was achieved remarkably quickly, the 30 baht project required a transformation of the resource allocation system that the reformers knew would take years to complete. This included the creation of a purchaser-provider split and a new system of capitation-based funding intended to strengthen primary care. Policymakers also needed to coordinate the reforms with cross-cutting legislative changes affecting the civil service and the relationship between central and local governments. The 1999 Decentralization Act mandated a larger role for local government in the decentralized administration of the health system and required that 35 percent of public finances be channeled to local governments by The 2002 National Health Security Act took account of this legislation and made provision for local purchasing agencies, which contained representatives from both health institutions and local governments. However, the details of local purchasing remained unclear, and policymakers recognized that further capacity building in local government would be necessary before this aspect of the reforms could be implemented. Thailand s Purchaser-Provider Split Two distinctive features of the Thai purchaser-provider system were the creation of a National Health Security Office (NHSO), as an autonomous purchasing agency separate from the MoPH, and the channeling of monies through a system of Contracting Units for Primary Care (CUPs). The first signaled that the Thai purchaser-provider split was intended to be more radical than, for example, the system in the British National Health Service, where both purchasers and providers are overseen by the central ministry. The second was innovative because the system did not rely on a local purchasing body to determine patterns of district services but gave this responsibility to a coordinating provider organization. The original policy intention had been that the money used by the MoPH to support public hospitals and the Medical Welfare and Health Card schemes would be transferred to the NHSO to fund the 30 Baht Scheme. At the same time, the NHSO would assume responsibility for purchasing care for the Civil Servant Medical Benefit Scheme. The NHSO would channel monies to local purchasing offices, either new entities or those associated with local government, which would then enter into contracts with contracting units on the provider side. MoPH policymakers believed that a major weakness of the existing Social Security Scheme had been that the choice of large hospitals as the main contractors had led to an excessive focus on secondary care. They decided that the new scheme would take a different direction and channel the bulk of universal coverage funds through contracting units closer to primary care: the CUPs. CUPsaslocalfundholders.One of the principal architects of the reforms, Sanguan Nitayarunphong, has described the CUP as a fund holder on the provider 1002 July/August 2007

5 Thailand side: A primary care provider is entrusted [with] the main provision of comprehensive care for their registered population. 9 Each CUP serves the population of a local health district, for which it receives capitation-based funding. The CUPs use their funds to support local service units and pay for referrals. Nitayarunphong argued that the main advantages of the approach are (1) greater responsiveness as a result of the closeness of the decisionmakers to the local population and (2) cost containment via CUP gatekeeping of referrals to larger hospitals. Referrals are reimbursed through diagnosis-related group (DRG) based payments to provincial and tertiary hospitals, reflecting volumes and case-mix, and adjusted according to the relative weights pertaining to particular hospitals. CUPs are required to employ specified numbers of professional staff and provide comprehensive care within thirty minutes travel time of the registered population, which includes both hospital and community services. Most CUPs were expected to be in the public sector, but accredited private providers could gain CUP status if they were able to offer the full range of required services, including health promotion and disease prevention. Objections to the CUP plan. Many aspects of this plan proved to be highly controversial. Conservative elements in the MoPH fought a successful rear-guard action to slow implementation and delay passing control of the reforms to the NHSO. The 30 baht project was more than just another insurance scheme because it fundamentally changed the way funds were channeled to public hospitals. The system of block grants from the MoPH to hospitals ceased and was replaced by a new capitation-based funding stream that went to the CUPs. The MoPH won two key concessions: (1) that it would oversee the implementation of the reforms through an initial transitional period ending in May 2006 and (2) that in the interim it would disburse the universal coverage budget via the provincial health offices, bypassing the NHSO. This meant that right from the start, the system lacked a strong local purchaser. The provincial offices continued as supervisory bodies in the line of command from the MoPH to the provider units and simultaneously acted as local health insurance offices. The de facto responsibility for providing comprehensive district health services lay with the CUPs, creating the unusual situation in a purchaserprovider system that coordination depended on a body on the provider side. National and provincial health offices. The NHSO began operations in late 2002, but initially its responsibilities under the 30 Baht Scheme were limited mainly to purchasing high-cost care and accident and emergency services. The NHSO quickly designated the provincial health offices as its local branches, but much of the steering of the emergent system continued to come from the MoPH, which was controlling the main universal coverage budget. However, there were disagreements within the MoPH about how much control the provincial offices should have over local-level spending of the budget. Faced with a logjam, policymakers decided to allow provincial offices two important areas of discretion. They could decide (1) whethertoholdasalaryfundattheprovincialofficeorallowthecupstopaysalaries directly, and also (2) which funding model to use at the local level. Some prov- HEALTH AFFAIRS ~ Volume 26, Number

6 Country Studies inces passed on the bulk of the universal coverage budget to the CUPs under the socalled inclusive model; others used an exclusive model whereby the provincial office itself held a fund for inpatient activity. Under both models, the provincial offices created a clearinghouse to channel the inpatient fund, or the inpatient component of the CUP budget, to hospitals in line with the referrals coming from the CUPs. Capitation to reduce health spending inequities. Capitation funding was a radical departure intended to reduce the historical geographic inequalities in spending patterns that had bedeviled the Thai health system. Much of the medical workforce and hospital facilities were concentrated in the Central Region and a few large urban centers, while the rural South, North, and Northeast Regions were underserved in relation to their populations. The reforms used finance to try to engineer a reallocation of resources. A system in which money followed patients empowered rural hospitals and primary care units to recruit extra professional staff in line with local populations while forcing capitation-losing urban hospitals to reduce staff. Theinitialpaymentwassetat1,202bahtperinsuredmemberin ,inline with a proposal put forward by MoPH experts, despite a competing proposal that estimated the required per capita payment at 1,482 2,397 baht. 10 Despitesomecriticism from independent commentators, the 1,202 baht figure was regarded by insiders as adequate if the new policy was implemented ruthlessly, in the sense of imposing reduced budgets on previously overfunded public hospitals. This purchaser-provider system quickly led to micro and macro allocation problems, which resulted in a major change in the financing method in 2002 that largely undermined the reforms redistributive impact. The micro problem, especially apparent in rural areas such as the Northeast Region, concerned the way the CUPs distributed money within the local health care system; the macro problem concerned the impact of the reforms on capitation-losing regions and centers. Retreat From Radical Policies The problem with CUPs in rural areas was that they rapidly came under the control of physician-directors of communityhospitals,whothenusedtheirpower to allocate resources according to their own priorities. 11 In the reformed system, each CUP had to include both hospital and community services. Because health centers had no medical staff and relied on community hospitals doctors to provide clinics, these hospitals quickly emerged as the dominant players and almost all CUP board chairs were hospital directors. Secondary and tertiary care hospitals depended on referrals from local service units for their share of universal coverage funding, channeled to them via DRG-based payments from CUPs. Unfortunately, in Year 1, many community hospitals, particularly in the Northeast Region, held onto patients to retain the capitation-based income that would have been reduced by the cost of referrals or delayed-referral payments. Provincial and tertiary hospitals received less money than expected. The power of the community hospitals also affected primary care services. In many rural areas, health centers, pri July/August 2007

7 Thailand mary care units (PCUs), and district health offices found that monies they had expected to receive were retained for community hospitals projects. At the macro level, capitation funding left many of the larger hospitals, particularly teaching and supertertiary hospitals in the Bangkok Metropolitan Authority area, in deficit. Many could not cover salary costs yet were unwilling to allow the workforce movements that architects of the reforms had envisaged. By November 2001, twenty-nine provinces had made requests for help from the MoPH Contingency Fund and received support totaling 3.2 billion baht. 12 What the policymakers might not have anticipated was the power of the professional groups affected by this change to mobilize support and influence ministry decisionmakers. The combination of the redistributive effect of capitation funding at the national level and the referral and allocation problems at the CUP level in rural areas provoked a backlash in the upper ranks of the medical profession and policy adjustments in the MoPH. In , the problems were addressed by creating a central contingency fund, over and above the universal coverage budget. Additionally, as mentioned above, provincial health offices were given the option of choosing to hold both the salary budget and the inpatient budget for the province centrally, thus helping safeguard the position of larger provincial hospitals by guaranteeing their funding. In , under a new, more conservative permanent secretary, the MoPH decided that the salary budget would be held and disbursed at the national level, and provinces were also required to use the exclusive model and separate out the inpatient budget from the universal coverage funds paid to CUPs. These changes reduced the impact of capitation-based funding. At the national level, much of the funding lost by larger hospitals in the Central Region was restored by redirecting the salary budget. At the provincial level, exclusive funding strengthened the position of the larger provincial hospitals, whose funding now bypassed the CUPs. Rural community hospitals that had initially been cash-rich found in Year 2 that their allocations were dramatically cut. The idea of a major movement of doctors and nurses from overserved to underserved areas, as staff followed money, disappeared from the policy discourse. During the transitional period with the MoPH as purchaser, this pattern continued. Larger hospitals were protected from the full impact of capitation funding through top-slicing of the budgets for salaries and inpatient activity, although they still suffered because of general underfunding of the new scheme. In each of the fiscal years from 2001 to 2006, the capitation payment agreed upon by government fell short of the figure requested by MoPH or NHSO experts (for example, 1,308 baht versus 1,447 baht in FY 2004; 1,396 versus 1,510 in FY 2005; and 1,396 versus 1,800 in FY 2006). 13 The problem was accentuated because promised funds were often not allocated in full, especially at the CUP level. In the Northeast, community hospitals, PCUs, and health centers mostly received very limited funding, which affected their ability to develop health promotion and disease prevention projects. The aim of building the capacity of rural PCUs to offer close to the HEALTH AFFAIRS ~ Volume 26, Number

8 Country Studies home care remains largely unrealized. Because most qualified staff still work in hospitals, many PCUs are based there and differ little from outpatient clinics. Lessons For Other Countries The Thai experience demonstrates that basic access to health care for all is achievable in a middle-income country, although with question marks about sustainability and quality. It shows that even where headline big bang reforms bring immediate expansion of coverage, it can be difficult to sustain momentum by consolidating policy measures. Major financing reforms typically involve a series of phased changes that make heavy demands on state funding and require a long-term commitment to overcome opposition. Many commentators accept that underfunding and limited political will in the final years of Thai Rak Thai Party rule blunted the original objectives of the universal coverage reforms. Low budgets resulted in quality problems and double standards, which led in turn to loss of public confidence. Although unequal access was not a new phenomenon, the reforms had raised expectations that then proved difficult to satisfy. Risk of big bang reforms. One risk of big bang reforms in a developing nation is that system components, such as the purchaser-provider split, introduced in Western countries in a series of stepwise changes over many years, are compressed into an unrealistically short time span. Arguably, for example, the successful implementation of the British purchaser-provider system depended on underpinning management changes made following the so-called Griffiths reorganization nearly a decade earlier (named for the late Sir Roy Griffiths). Changing purchaserprovider relationships is more difficult in the Thai system, where old-style physician-administrators control the MoPH and hospitals and where there is still considerable cultural resistance to the concept of purchasing health care. Limitations of economic levers. Although economic levers have a part to play, the Thai experience demonstrates their limitations. It was overly optimistic to think that capitation funding alone could achieve a major redistribution of resources and staffing when resisted by the medical profession and sections of the administration. Largely because of the absence of checks on professional power, the present CUP system has resulted in problems of service coordination and resource allocation at the local level. Hopes of building incrementally by consolidating the existing insurance schemes into a single state scheme also proved unrealistic in the face of opposition from vested interests. It seems likely that a further round of radical reform will be necessary to achieve these goals, but this might be difficult against a background of political uncertainty and reform fatigue. Other challenges. The Thai reforms remain an attractive model for other middle-income countries because of the remarkably successful rollout of coverage and thecentralplacegiventoprimarycareinthefinancingsystem.thereformswereintroduced in a period of fiscal restraint, so that economy and efficiency were paramount concerns. Thus, the detail of the payment mechanisms in both primary and 1006 July/August 2007

9 Thailand secondary care will be useful to others. However, other countries should pay careful attention to the problems encountered in building on the initial reforms and the scale of the cultural change required. They should also consider the reasons why the Thai purchaser-provider split model has not performed well. It seems clear that a powerfulbodyontheprovidersideintheshapeofthecupneedstobematchedby a strong local purchasing body. The benefits of creating an independent national purchasing agency, in the shape of the NHSO, remain unproven. Others contemplating this approach should avoid the overlap in responsibilities between the MoPH and NHSO that caused tensions in the Thai system. Future Prospects And Uncertainties The NHSO assumed full responsibility for the administration of the 30 Baht Scheme in May 2006, and events now will determine whether the original policy aims of the universal coverage reforms are revived. It is unclear whether the NHSO, as an independent purchasing agency, has been adequately prepared to develop purchaser-provider contracting and how the purchasing function will be organized at the provincial level. There has been much discussion about a purchasing role for local government agencies, notably the subdistrict offices. The MoPH has experimented by allowing local government to allocate a portion of the health promotion and disease prevention budget, but local government agencies lack the capability to purchase inpatient and outpatient care. Initially, funding will be allocated to CUPs through local branches of the NHSO established in largerprovinces.onebigquestionwillbehowfarthemophisabletocontinueto control the disbursement of the central salary budget to favor the status quo. However, the coup introduced a further layer of uncertainty. The ruling military council claimed that it seized power to end a political impasse caused by government corruption, but some critics have alleged that it represents an urban elite opposed to redistributive policies such as the health reforms. 14 Yet the huge public popularity of the 30 baht project would make any early termination of universal coverage politically infeasible. In the general election of 2005, opposition parties that in 2001 opposed the reforms on grounds of affordability promised to rescue the scheme from what they portrayed as its cynical exploitation by the TRT Party. Both the incoming interim prime minister and the MoPH have stated that the policy will continue, though with the possibility of changes. The appointment of the former MoPH permanent secretary Mongkol Na Songkhla, who led the reforms in , as minister of public health appears to signal that pro-reformists are in the ascendancy. Since his appointment, Songkhla has announced his wish to abolish the 30 baht copayment and consider widening treatment eligibility beyond patients district of residence. 15 The Thai government has appointed expert advisory committees in ten key policy areas, including one on the universal coverage reforms, chaired by the prominent economist Ammar Siamwala. This will reexamine financing arrangements and issues such as the relationship be- HEALTH AFFAIRS ~ Volume 26, Number

10 Country Studies tween the MoPH and NHSO. In the immediate future, the Thai Constitution will be rewritten, which suggests that any major legislative changes in social policy will be about two years away. By then we should know whether Thailand s universal coverage reforms will be given a new policy direction or quietly downgraded. This research was supported in part by a Leverhulme Trust Study Abroad Fellowship and a grant from the British Academy to David Hughes. NOTES 1. A. Towse, A. Mills, and V. Tangcharoensathien, Learning from Thailand s Health Reforms, British Medical Journal 328, no (2004): ; and S. Pannarunothai, D. Patmasiriwat, and S. Srithamrongsawat, Universal Health Coverage in Thailand: Ideas for Reform and Policy Struggling, Health Policy 68, no. 1 (2004): V. Tangcharoensathien et al., Co-payments in the Universal Coverage Scheme: A Policy Analysis (in Thai) (Nonthaburi: Health System Research Institute, 2005). 3. Ministry of Public Health, Health Resources Report 2004 (in Thai) (Nonthaburi: Bureau of Health Policy and Strategy, MoPH, 2004). 4. V. NaRanong et al., The Monitoring and Evaluation of Universal Health Coverage in Thailand, First Phase 2001/02 (in Thai) (Nonthaburi: Health Systems Research Institute, MoPH, 2002). 5. S. Wibulpolprasert, ed., Thailand Health Profile (in Thai) (Bangkok: Express Transportation Organisation Press, 2005). 6. Ibid.;andP.Jongudomsuk,ed.,NHSO Annual Report 2004: Implementation of Universal Health Care Coverage (in Thai) (Nonthaburi: S.P.S. Printing Co. Ltd., 2004). 7. See C. Suraratdecha, S. Saithanu, and V. Tangcharoensathien, Is Universal Coverage a Solution for Disparities in Health Care? Findings from Three Low-Income Provinces in Thailand, Health Policy 73, no. 3 (2005): S. Nitayarumphong, ed., Health CareReform: AttheFrontier of Research andpolicydecisions (Nonthaburi: Office of Health Care Reform, MoPH, 1997); S. Nitayarumphong and A. Mills, eds., Achieving Universal Coverage of Health Care (Nonthaburi: Office of Health Care Reform, MoPH, 1998); V. Tangcharoensathien, S. Wibulpholprasert, and S. Nitayaramphong, Knowledge-Based Changes to Health Systems: The Thai Experience in Policy Development, Bulletin of the World Health Organization 82, no. 10 (2004): ; P. Pramualratana and S. Wibulpholprasert, eds., Health Insurance Systems in Thailand (Nonthaburi: Health Systems Research Institute, MoPH, 2002); and V. Tangcharoensathien, A. Supachutikul, and J. Lertiendumrong, The Social Security Scheme in Thailand: What Lessons Can Be Drawn? Social Science and Medicine 48, no. 7 (1999): S.Nitayarumphong, Annex8:AchievingUniversalCoverageofHealthCareinThailandthroughthe30 Bahts Scheme, in Social Health Insurance: Selected Case Studies from Asia and the Pacific, WHO Regional Publication, SEARO Series, no. 42, ed. World Health Organization, Regional Office for South East Asia (New Delhi:WHO,2005). 10. S. Pannarunothai, D. Patmasiriwat, and S. Srithamrongsawat, Universal Health Coverage in Thailand: Options and Feasibility (in Thai) (Nonthaburi: Health Care Reform Project, MoPH, 2000). 11. Our account of the micro allocation problem is based mainly on our own research, involving fifteen interviews with policymakers in Bangkok and 124 interviews and three focus groups with administrators and professionals in three Northeast provinces. 12. Nitayarumphong, Annex V. Leesmidt et al., Assessment of the Purchasing Functions in the Thai Universal Coverage Scheme for Health Care (Nonthaburi: International Health Policy Program, MoPH, 2005). 14. Because of media censorship, these critical voices are excluded from the mainstream press but have been mentioned by pro-government commentators. See C. Saengpassa, Burning Issue: A Pot That Threatens to Boil Over, Nation, 13 October A. Treerutkuarkul, Health Ministry Sets New Policy: 30-Baht Treatment to Be Made Free, Bangkok Post, 13 October July/August 2007