In recent years, health care in Thailand has become an increasingly well-researched topic in the social sciences. This is because of the passage in 2001 under the Thaksin Shinawatra government of a universal health care bill, also known as the “30-baht cure all diseases program” (sam sip baht, raksa tuk rok). Under this bill, all citizens are able to access most forms of medical care with a co-pay of only 30 baht (about $0.80). This is a radical shift in health policy that has huge implications for the well-being of the poor. It is especially notable because it comes from a developing country with relatively limited resources, devoid of leftist political parties or influential labor unions. Despite extensive opposition, the 30-baht program has been effective, successful, and popular. Furthermore, it is seen as a model for advancing universal health care in other developing economies.Footnote ¹

The three books reviewed here are high-caliber studies that make valuable contributions to our understanding of the 30-baht health care program in Thailand. The fact that this program has attracted scholarly interest from scholars based in different disciplines—political science, sociology, and anthropology—is important. It moves the study of health care in developing countries away from technical literature emanating from public health schools and anchors it squarely in the social sciences. All three books employ concepts to frame their arguments, engage effectively with key methodologies of their disciplines, and display deep knowledge of and insight into Thailand. Read together, they provide a thought-provoking analysis of the origins, dynamics, and effects of health care reform in Thailand. In this review essay, I first draw out key analytical elements in the three books and then look individually at the main contributions of each.

The approach to the study of health care reform varies among the three books, although political scientist Illan Nam and sociologist Joseph Harris share much in common. Both Nam and Harris emphasize the macropolitical context within which the 30-baht program emerged and became institutionalized. For both authors, the period of democratization in the 1990s and 2000s was crucial to the eventual passage and implementation of universal health care. Furthermore, Nam and Harris emphasize social actors as key to the success of health care reform. For Nam, these are “solidarity coalitions,” while for Harris, these are “professional movements.” Knowledge, networks, ideas, and embeddedness in the state are central to the effectiveness of these solidarity coalitions and professional movements.

Importantly, the analytical focus of Nam and Harris on social actors, especially physician-bureaucrats, diverges sharply from a contrasting explanation for the implementation of the 30-baht program: electoral rules. This other position, advanced most forcefully by Joel Selway, claims that Thailand's 1997 constitution ushered in new electoral rules that strengthened party organization and identity. This, in turn, pushed parties to take seriously programmatic policies, including universal health care.Footnote ² An extremely insightful and productive debate in the Journal of East Asian Studies lays out very crisply the analytical elements of these dueling positions.Footnote ³ Precisely by contrasting Nam and Harris's social actors argument with an institutionalist one by Selway can we see the value-added of “solidarity coalitions” and “professional movements.” Most significant here are Nam and Harris's push to document how grinding, painstaking work by social actors ultimately influenced parties and shaped policy outcomes.

By contrast, and reflective of the ethnographic nature of anthropology, Bo Kyeong Seo's book takes a very different approach to the 30-baht program. Instead of rooting her study in macro structures, such as regimes, coalitions, or movements, Seo illustrates the lives of individuals and the way they seek and cope with medical interventions in a district hospital in northern Thailand following the implementation of the 30-baht program. Her study probes closely the thoughts, anxieties, meanings, and values that vulnerable individuals hold and express when engaging with the health system.

Concepts are key to the arguments of all three works. Nam's “solidarity coalitions,” Harris's “professional movements,” and Seo's idea of “elicitation” all play pivotal roles in structuring analysis of health care. Nam and Harris work with a causal ontology in mind, arguing that solidarity coalitions or professional movements are of vital importance in explaining the passage and implementation of health care reform. Seo, on the other hand, works with the concept of “elicitation”—the idea that action, meaning, and moral relations are generated when individuals elicit medical needs. Elicitation is the “pull” that draws medical care to a vulnerable individual and thereby develops a dynamic of meaning and relational entanglement. The concept of elicitation may not have been conceived as a causal variable, but, as I will argue here, in practice, it is causal.

The methodologies that structure these books are central to their larger analytical strengths. Nam and Harris work squarely within the comparative method of political science and sociology, comparing and contrasting cases to develop theory and explain outcomes. Harris picks his three cases especially well: Thailand (the positive case), Brazil (the positive to middling case), and South Africa (the negative case) are among the most unequal in the world, have weak institutions amid high levels of clientelism, and are recent democratizers. Although Harris's area knowledge is most evident for Thailand, the choice of three countries from different world regions is a notable effort to broaden the comparative map, very much in line with an important social science initiative known as comparative area studies.Footnote ⁴ Nam compares two democratizing countries, South Korea and Thailand, that are also from different (albeit more proximate) areas—East Asia and Southeast Asia. South Korea and Thailand are both positive cases of health care reform, but in different areas of health equity. Although both cases are positive, nuanced differences between the two enable contrasts in outcomes as well.

Seo's study is not comparative in a strict macro sense. It zeros in on one local site—a district hospital in Chiang Mai—and engages deeply with its medical staff, as well as with patients, particularly Shan women from Burma. The study is rooted in understanding the lives of individuals who struggle to improve their health, to care for their sick children, and to survive in the informal economy. This can only be gained through careful ethnographic fieldwork. Yet, a close reading of the book also reveals micro comparisons being articulated, particularly in the moving narratives of the Shan women.

In Democratizing Health Care, Illan Nam has written a superb comparative analysis of initiatives to reform health care in Thailand and South Korea following both countries’ turn toward democracy. Thailand and South Korea were both successful in reforming the health care system, although in different ways. In Thailand, reformists succeeded in expanding access to health care, but not in unifying the different insurance schemes. In South Korea, activists were able to create a single-payer fund, but they were unable to reduce out-of-pocket costs. Thus, both cases reflect positive outcomes of reform, but in different aspects of health equity. Thailand, however, is a somewhat more successful case than Korea given its more sweeping package of changes.

Nam's theoretical contribution pivots especially on the concept of solidarity coalitions. These are coalitions composed of societal and state actors, imbued with knowledge and strategic capacities who seek to accomplish a concerted goal. In Thailand, the key actors coming together were progressive physician-bureaucrats from the Ministry of Public Health and a plethora of NGOs. Unlike social movements, solidarity coalitions are temporary and do not necessarily build organizational structures in their wake. Such coalitions are crucial for bringing together different actors’ unique skills, thereby strengthening and expanding networks for reform; setting out a wider agenda that can shape government action; and ensuring accountability of public programs.

Solidarity coalitions are especially important in countries like Thailand and South Korea because they can serve as stand-ins for weak political parties that in other countries would play the central role in advancing social reform. In Thailand and South Korea, parties have historically been ideologically vacuous, organizationally feckless, and weakly institutionalized.Footnote ⁵ This has meant that—unlike, for example, Western Europe—leftist parties have not arisen to take up the mantle of social reform, including that of universal health care.

Solidarity coalitions, Nam shows, did not come out of nowhere. They emerged from the brief but momentous window of democratization in the mid-1970s, when Thailand was rife with ideas and initiatives for social justice and equity. During this period, students, workers, and peasants mobilized for radical change. This was also a period when leftist parties gained a foothold in parliament only to end up quickly destroyed through relentless violence unleashed by right-wing groups.

It was during these turbulent years that a group of medical doctors started mobilizing for greater attention for the poor. These doctors would be the individuals spearheading the move for universal health care, which would culminate in the 30-baht program under Thaksin. In the 1970s, they sought to raise awareness about the plight of the rural poor by forming the Rural Doctors Society and urging doctors to work in villages in the north and northeast. The Rural Doctors Society, as well as the later Sampran Forum (an informal think tank for discussing ideas for health reform), so ably documented by both Nam and Harris, became the foundation and launching pad through which progressive doctors would move toward deep social change. As progressive doctors slowly gained positions of authority in the Ministry of Public Health their identity as Rural Doctors was central to their ability to strategize, organize, and corral resources for reform.

Nam highlights that the progressive movement that succeeded in putting universal health care onto the political agenda not only has its roots in the democratic movement—and leftist ideals—of the 1970s. Even more importantly, Nam argues that the solidarity coalition that succeeded in executing its vision of universal health care has also ensured that the ideals of the progressive left are firmly anchored in the polity. Thus, Nam points out that ideals of justice and equity can get a hold in the state without leftist parties. This is an extremely valuable insight because it puts the successful initiatives of the progressive physician-bureaucrats in a wider ambit. Comparisons with the left's achievments in Europe will always lead one to be pessimistic about the possibilities for change in developing countries. Yet, Nam shows that social reform can be initiated, sustained, and above all institutionalized without strong leftist parties.

Joseph Harris's Achieving Access not only provides a richly documented narrative of Thailand's move toward universal health care, but also puts Thailand's experience in comparison with successful efforts in Brazil, and failures in South Africa. Furthermore, Achieving Access takes on both the politics and policy of universal access, as well as that of the cost of drugs for HIV/AIDS. Harris therefore has structured comparisons of three countries as well as of two policy areas. The country cases position themselves similarly on both policy areas. Thailand has done well not just in universal coverage, but also in lowering the cost of medicines for HIV/AIDS. Brazil has done relatively well in both areas (although less so than Thailand), while South Africa has done poorly across both areas.

The centerpiece of Harris's book is the emphasis on “professional movements” made up of doctors, pharmacists, bureaucrats, and lawyers. Harris shows clearly how professionals in the fields of medicine and law built extensive networks, furthered, or drew on specialized knowledge, and used their ranked positions in the state to open up access to care, as well as to lower the price of medicines for HIV/AIDS. Achieving Access is at its best in its narrative of the process through which professional movements developed their agenda, mobilized, and built allies on the way to successful reform. Harris's command of a very gripping narrative demonstrates deep knowledge of the key individuals and institutions involved in the push for equitable health care.

What bears emphasizing about these professional movements is that, although they are elites in society, they were marginal in their relative fields and had to push hard against strong currents in order to succeed. The progressive doctors at the heart of the 30-baht program were by no means in the mainstream of the medical profession and as debate heated up in parliament over the universal health care bill, conservative doctors sought to defeat the bill. However, the combination of ranked positions in the bureaucracy, support from Thaksin and the Thai Rak Thai Party, as well as significant momentum from civil society allies, eventually ensured passage of the bill.

This knowledge of the intricate details of the Thai case allows Harris to draw out valuable insights that should have larger theoretical resonance. Two are worth highlighting. First, Harris notes that the professional movements in Thailand had to push against international organizations, especially the World Bank, that were opponents of universal health care. Yet, these progressive doctors then used medical awards and other international forums to draw international actors into their reformist agendas. Second, Harris argues that a crucial step in institutionalizing the 30-baht program was the push to implement it as a pilot project before it had been made into law. This “lock-in” effect that was purposely pushed by the permanent minister of the Ministry of Public Health was crucial in preempting any possible delay or opposition. Both insights point to strategic action by the professional movement that had deep implications for successful reform.

In Achieving Access, just like in Democratizing Health Care, democratization is framed as the wider canvas within which to situate movements for reform. Without democratization, professional movements would not have had the space within which to advance social change. Although ultimately it is professional movements that bring together the necessary elements to drive through deep reform, democracy appears as a necessary condition for these movements to operate.

Yet, there are a few questions that arise from the way in which Harris's study engages with democratization. The variable that is actually pinpointed in explaining South Africa's failures in advancing equitable health care reforms is the lack of competition in the postapartheid democratic system. Because the African National Congress had no significant rivals, it was not impelled to seek reform in health care. By contrast, in Thailand and Brazil, the fluid political system created incentives for politicians to see health care reform as politically useful and therefore to work with professional movements. But, if it is the extent of competition within democracy that creates incentives for reform, then it is less democratization that matters for reform, as much as competition of some form.

This brings one to an interesting twist in Thailand's ability to sustain universal health care despite entrenched opposition. After the 2006 coup, the military regime appointed Mongkol na Songkhla as minister of health. Hailing from an illustrious family, Mongkol was a key member of the Rural Doctors Society, as well as a forceful proponent of compulsory licensing of patents for HIV/AIDS drugs. Ironically, the generals who led the 2006 coup elevated a progressive doctor-bureaucrat to the Ministry of Public Health, in effect providing the 30-baht program with a staunch defender deep inside the cabinet. At the point when the 30-baht program seemed in peril, the dictatorship kept it on its legs, well aware that Mongkol was an experienced and highly skilled progressive bureaucrat. Perhaps then, it is competition broadly understood—such as competition for legitimacy between democratic and military forces—that matters even more than democratization.

One last point about democratization is worth noting. Harris claims that the prominence of professional elites following democratic transitions is unusual and counterintuitive. Here, he uses Europe's leftist parties and movements as the basis for comparison. However, with the exception of Europe, democratic change has often not empowered the “popular sector,” as much as strengthened political and social elites. Although working classes across the developing world have played important roles in tearing down autocratic regimes, once the dust settles, elites have often come out on top in many of these democratic transitions.

Compared with the books by Nam and Harris, Seo's Eliciting Care is the most grounded in the lives of the people affected by health care. Seo's work is distinguished by deep ethnography, moving storytelling, and empathy for the poor. Most of the individuals featured in Seo's book are Shan women—migrants from northern Burma who are searching for a better life in Thailand. As migrants from Burma, they are not eligible for Thailand's universal health care program. Yet, one of the most striking aspects of Seo's book is the fact that the doctors and nurses in the rural, district hospital she studied often sought to care for individuals whom they knew would be unable to pay their bill. In Eliciting Care, we thus gain insight into how universal health care plays out in everyday lives.

Structuring Seo's work is the concept of elicitation. Elicitation is defined as “generative capacities entailed in an embodied presence that can induce responsiveness in others and thus create contacts, linkages, and relations of care” (p. 13). By virtue of individuals with health needs appearing at a hospital they create a relation of elicitation between patient and medical staff that brings care to the fore. Seo writes, “care happens or fails depending on how well one's presence is seen, heard, felt, imagined, and called upon” (p. 15).

Although interesting, the concept of elicitation is problematic at both a theoretical and an empirical level. Theoretically, Seo constantly employs jargon to define or elaborate on elicitation, making the concept more confusing than necessary. Much of this elaboration of elicitation draws on quotes from other anthropologists and excessive abstractions that makes the concept murky and hard to pin down empirically.

Although one might think that causality is not central to the analytical thrust of Eliciting Care, Seo, in fact, makes a causal claim, even if implicitly: that the physical and symbolic act of presence creates a basis for elicitation, which leads to (causes) a medical response (effect). Yet, the problem is that there are numerous instances in the book in which patients make themselves “present,” but do not receive the appropriate medical intervention that they sought. Therefore, simply being present and “eliciting” does not generate a caring response. The empirical facts discussed do not match the conceptual abstraction.

What is more significant in explaining whether patients were given care is that the district hospital in which Seo was based appeared to be unique in its efforts to care for patients who could not pay their bills. In other hospitals discussed in Seo's book, migrant women were not always treated kindly. But in this district hospital, “they are inclined to consider all of them who are present in the ward as legitimate and deserving subjects of care” (p. 31). The concept of elicitation in terms of its causal effect of generating responsiveness matches perfectly the professional ethos of the hospital's medical staff in terms of their support for individuals without insurance. But it does not match other hospitals or primary health stations discussed in the book.

This leads one to ask, why was this hospital so remarkable in its sense of public purpose? One answer could be that the 30-baht program affected norms across some (but not all) public hospitals in Thailand by making them even more conscious of the need to care for marginalized peoples. In other words, did the 30-baht program have “spillover” effects in terms of shaping professional norms? Or is it more likely that this particular hospital always stood out in terms of its sense of professional ethics that predated the policy shift coming from Bangkok? Perhaps being far from the nerve centers of power, close to the border with Burma and with many migrant patients, this medical staff saw its mission differently from the concerns of other hospitals? Whatever the answer may be, more could have been done to dig deeper into the sources of this medical staff's willingness to care for the poor who cannot pay their bills.

While we can continue to debate the strength of concepts in these works, the overall contribution of these books is fundamentally clear. They have, above all, shown that taking actors seriously, both at the macro and micro level, is central to understanding the origins, processes, and meanings through which the groundbreaking 30-baht program has shaped Thailand's polity and society.