1. EDITOR'S INTRODUCTION
In 2011, Joel Selway, a political scientist, published an article in the journal World Politics arguing that the change in Thailand's electoral rules under the 1997 constitution led to the passage of the universal healthcare bill in that country (Selway Reference Selway2011). This article was subsequently refined and rearticulated in the context of a book, Coalitions of the Well-Being: How Electoral Rules and Ethnic Politics Shape Health Policy in Developing Countries (Cambridge University Press, Reference Selway2015). The book—a mixed methods comparison of seven developing democracies—argued that the interaction of ethnic salience and intermixing on the one hand, and electoral rules on the other, helps explain why some countries perform better in health than others. Common to both projects was a preoccupation with the power that electoral rules have to shape politicians’ behavior.
With respect to Thailand, Selway argued that the 1997 constitution provided incentives for political parties to transform themselves from weak organizations prone to fracturing and devoid of policy content to strong parties with independent internal mechanisms to evaluate and develop policies. The most successful of those parties was Thai Rak Thai (TRT), who were approached by members of the Ministry of Public Health (MOPH) regarding a universal healthcare policy based on a pilot scheme run in the mid-1990s in which participants paid a fixed and small co-pay for the treatment of any ailment. The most prominent member of the MOPH, Dr. Sanguan Nitayarampong, himself attributed the passage of what became known as the 30-baht to cure every disease policy, named after the co-pay, to the rise of responsible political parties (Nitayarampong Reference Nitayarampong2005, 85–87). Selway's approach was related to a broader body of literature that focused on the wider significance of the change in electoral rules in Thailand (Chambers Reference Chambers2005; Hicken Reference Hicken, Reynolds, Reilly and Ellis2005, Reference Hicken2006, Reference Hicken and Charles Schaffer2007; Kongkirati Reference Kongkirati2014). The underlying logic of this work was that differences in political outcomes following Thailand's transition to democratic rule could be traced to a fragmented party system, replaced quite dramatically by a more consolidated one following the constitutional reforms (Ockey Reference Ockey2003, Reference Ockey2005; Hicken 2009).
Approaching the same question from a different discipline, Joseph Harris, a political sociologist, published an article in the Journal of Health Politics, Policy and Law that pointed to the critical role played by a network of bureaucrats within the state who strategically mobilized resources in the bureaucracy, political parties, civil society, and international organizations to institutionalize universal health care in the face of broader professional dissent, political uncertainty, and international pressure (Harris Reference Harris2015). He contrasted this unusual “developmental capture” of state agencies by reformist bureaucrats who seek to promote broadly inclusive social policies of benefit to the wider populace with more traditional notions of “regulatory capture” involving interest groups who seek to weaken state regulation for private gain. Harris subsequently refined and rearticulated these arguments in the context of a larger book, Achieving Access: Professional Movements and the Politics of Health Universalism (Harris Reference Harris2017a) and a related article (Harris Reference Harris2017b).
Like Coalitions of the Well-Being, Achieving Access offered a major historical comparison—of three countries (Thailand, Brazil, and South Africa) in two different policy areas, AIDS treatment and universal healthcare. His book tackled two puzzles: (1) how and why resource-constrained countries make costly commitments to AIDS treatment and universal healthcare, and (2) why Thailand and Brazil have enjoyed relative success in these areas and South Africa, by contrast, achieved only incremental gains. Whereas conventional wisdom suggested that democracy empowers the masses, Harris’ book turned conventional wisdom on its head, showing how democratization empowered well-positioned elites, who subsequently had a major impact on politics. These “professional movements,” composed of elites from esteemed professions, drew upon their knowledge, networks, and state offices to institutionalize major social policies in the face of broader opposition from the profession of which they were a part and from conservative international organizations.
Harris's approach reflected not only a broader and more long-standing interest within sociology to social movements (McCarthy and Zald Reference McCarthy and Zald1977; McAdam Reference McAdam1982; Brown and Zavestoski Reference Brown and Zavestoski2005) and epistemic communities (Haas Reference Haas1992), but also a more sociological approach to Thailand's politics that took seriously the role of the professions (Larson Reference Larson1977; Starr Reference Starr1982; Freidson Reference Freidson1986; Abbott Reference Abbott1988) and state bureaucrats (Evans, Rueschemeyer and Skocpol Reference Evans, Rueschemeyer and Skocpol1985). Within the literature on Thai politics, Harris situated his contribution against three distinct strands of scholarship: foundational work on Thailand's bureaucratic polity (Riggs Reference Riggs1966); research that has sought to understand important networks that operate in Thai politics (Skinner Reference Skinner1957; Hewison Reference Hewison1989; McCargo Reference McCargo2005); and scholarship on medical activism that sought to broaden our understanding of the different interest groups involved in Thai politics (Cohen and Purcal Reference Cohen and Purcal1989; Bamber Reference Bamber and Hewison1997; Harris Reference Harris2014).
Central to both scholars’ stories is the case of Thailand and an explanation for what many regard as the industrializing world's most successful universal healthcare program. Which account is correct? In this article, the two authors respond to each other's arguments in a fruitful scholarly exchange. In what follows, Harris’ first reviews his movement-focused argument against Selway's institution-focused account. Selway then responds to these points, and finally Harris addresses Selway's counterarguments.
Stephan Haggard
2. HARRIS: WHY AN INSTITUTION-FOCUSED ACCOUNT IS INSUFFICIENT
I make two main arguments against Selway's institution-driven account. First, I posit that “while electoral rule changes did help produce more cohesive political parties with more coherent platforms, electoral rule changes fail to explain … how or why universal health care was chosen over other competing policy priorities at a time when the budget was already strained, following the Asian financial crisis” (Harris Reference Harris2015, 185). Second, I argue that “in a political context where politicians’ pledges had never amounted to much, they do not explain why the policy, once chosen, was actually implemented. If history is any guide, then we have good reason to expect that it should not have been” (Harris Reference Harris2015, 185). This account explains why the specific policy was chosen and then was institutionalized, first through implementation as a national pilot project and later enshrined in law.
Selway convincingly argues that electoral rule changes succeeded in effecting more programmatic political party campaign platforms. However, electoral rule changes, while important, cannot explain Thailand's universal coverage policy alone. Programmatic campaign platforms need not have led a political party, like TRT, to make universal healthcare its flagship campaign policy. Indeed, any number of social or economic policies might have been the top policy the party campaigned on. And indeed, had the party followed its own polling, this is actually what would have happened. This is ultimately why an account of Thailand's universal coverage cannot stop at electoral reform. It says nothing about how such an unlikely policy got there amid an otherwise unsupportive political context. Electoral reform changes are therefore insufficient for explaining Thailand's universal coverage policy.
My account of the role that the professional movement of Rural Doctors played in the policy process is therefore critical for explaining how and why it was chosen at such an improbable moment, as well as why it was actually implemented. This latter point is actually an important, if underappreciated, one because Selway's account assumes that parties with programmatic platforms will implement the policies on their platform. Yet, Thailand's past history does not suggest this. And key Rural Doctors in the ministry actually sensed reluctance that TRT would actually follow through once in office, allowing the medical profession to mobilize against it. Understanding how popular it would be, they therefore implemented it as a “national pilot project,” first in six provinces, which led MPs to clamor for implementation next in their provinces and effectively forced TRT to follow through. This is one of the most remarkable elements of the story of Thailand's universal coverage policy and one of the least appreciated aspects of its politics—and one that reformers in other countries might do well to emulate.
Aside from these two critical points raised in my original article (Harris Reference Harris2015), I raise one other key point in my book: that the agenda for the constitutional reform that led to the necessary electoral rule changes was itself set by the patriarch of the RDM. Prawase Wasi originally wrote to caretaker Prime Minister Anand Panyarachun in 1992, suggesting the need to change the constitution (Wasi Reference Wasi and McCargo2002). Later, as Chairman of the Democracy Development Committee, Prawase Wasi recommended a new constitution be drafted (Wasi Reference Wasi and McCargo2002). More generally, the RDM played an important role in the transition to democracy in 1992, having created the Health Assembly for Democracy and the electoral watchdog, PollWatch (Bamber Reference Bamber and Hewison1997), alongside new watchdog agencies that would come into being after the new constitution was put in place, including the Electoral Commission, the National Human Rights Commission, and the National Anti-Corruption Commission (McCargo Reference McCargo2003).
The larger point here is that the agenda-setting actions of a professional movement was itself a major reason why a constitutional reform that led to such important electoral changes happened in the first place. The implications of this are significant, since it suggests “no movement, no electoral reform”, which in turn would mean no political parties with more programmatic campaign platforms. This connects to the broader theme of my book that turns conventional wisdom about democratization on its head, that democratization not only empowers the masses, but empowers well positioned movements of elites from esteemed professions. In Thailand, the elites who were advantaged by democratization also played an important role in ushering in democratization and the changes in the rules of the game that accompanied it.
Far from being “compliant” actors, these actors actually had more power in the post-1997 environment, and they used that power strategically to advance a developmental project (Selway Reference Selway2011, 196). In their drive for universal coverage, the Rural Doctors would additionally go on to finance and mobilize a civil society campaign to press parliament to consider universal coverage, which took advantage of provisions in that new constitution. The larger point here again is that we cannot stop at electoral reform alone as an explanation. The role of actors involved in the reform has to be interrogated.
3. SELWAY: RESPONSE AND CRITIQUES
In this section, I first respond to Harris’ critiques of my institutional argument by conceding to the role of the RDM in the inspiration behind healthcare reform in Thailand. On Harris’ second point about implementation, however, I take issue, and argue that TRT undertook numerous steps to ensure the policy's implementation independent of professional influence. At some point, it becomes difficult to distinguish between the two actors’ role in implementation as they harmoniously worked toward the same goal. Yet this synergy illustrates the very internal party transformations I argue were critical to supporting the onset of this momentous policy. Lastly, I argue that the role of the RDM in electoral reform is overstated.
INSPIRATION
Harris’ insightful addition of “well-positioned professional elites” as a crucial set of actors for the introduction of UHC in Thailand is a welcome and important part of the story. Indeed, I interviewed several members of the RDM and my field notes offer plenty of evidence in favor of Harris’ argument. I did not ascribe inspiration to the movement in my work, but highlighted the role of a key member of the RDM, Dr. Sanguan Nitayarampong, who had piloted a 70-baht scheme in the 1990s, the pre-cursor to TRT's 30-baht policy. It was he who approached Thaksin, as he had other political parties in the 2001 (and previous) elections. Harris is to be congratulated for such a careful piece of research and for introducing a set of actors often overlooked in Political Science.
IMPLEMENTATION
Harris’ account also shows how the RDM played a part in the implementation of the program. Dr. Sanguan had been appointed as the first secretary general of the National Health Security Office (NHSO), but Harris highlights the RDM's role in much more detail, elegantly laying out their involvement in rolling out a national pilot program in the first year. However, Harris oversells the role of these professional movements in the implementation of UHC, or rather undersells the role of TRT.
Harris argues that electoral reform made no guarantee of implementation. He states that programmatic platforms are not guaranteed to be implemented, and references “Thailand's past history” as evidence. Two things are incorrect about this point. First, the fact that Thailand's past history saw no implementation of UHC is exactly the theoretical expectation generated by electoral rule theory. Second, that same theory also expects that policies would be less programmatic before electoral reform. My research actually found that policies were nothing like what we would label as programmatic prior to electoral reform in Thailand, and mostly consisted of broad platitudes taken from the National Economic and Social Development Board's (NESDB) Five-Year plans. Notably, the RDM was pushing for UHC in that same period with no success.
But Harris is correct that implementation is important. And if he was right that implementation only came about due to further RDM efforts following the 2001 elections, we would rightly question the role of transformed political parties with independent internal mechanisms to evaluate and develop policies. It is thus a key task of the empirical evidence to show TRT's role in the implementation. Harris argues that members of the RDM “sensed reluctance” in the governing party, pushing for a national pilot program in 2001 to tie TRT's hands.
TRT's reluctance is over-stated, however. We know that TRT's featuring of the “30 baht to cure all diseases” came very late in their campaigning. Harris states, moreover, that initial TRT polling suggested healthcare wasn't a priority. But once TRT decided to put it at the center of their campaign, it was accompanied by more detail than any other health platform in Thailand's electoral history, right down to a detailed plan for financing. The policy was an immediate hit with the electorate. If there was any chance that TRT would not implement the policy after the elections, why go to so much trouble? And once they realized how energized voters were about the idea, did they even consider reneging on their central campaign platform?
TRT's commitment began by bringing in a healthcare expert, Dr. Surapong Suebwonglee, to spearhead the details of the program. Surapong was not a member of the RDM, yet it was he who devised the 30-baht co-pay after extensive research. He also took charge of the details of financing the new scheme. Surapong differed from Dr. Sanguan, who remained non-partisan, in becoming part of the internal structure of the party.Footnote 1 The final policy that TRT went forward with was a party-adjusted version of Dr. Sanguan's pilot program.
Within four months of the election, the government had rolled out the program in six provinces, and in all 76 by the end of the year. Was this to combat TRT reluctance? Such a widespread pilot program would have required the cooperation of the Prime Minister, Thaksin Shinawatra, a strong-minded leader who would have stopped it without hesitation if he had deemed it against the party's (or his) interests. Additionally, it would also require the cooperation of the Health Minister, Sudarat Keyuraphan. Herself a capable administrator, handpicked not for her health expertise, but for her ability to get things done, Sudarat took seniority over even Dr. Surapong, who was appointed Deputy Health Minister.Footnote 2 She ran the day-to-day affairs of the ministry, and hand-picked the permanent secretary. If Harris is suggesting that the RDA rolled out a pilot program without Thaksin or Sudarat having any say in the final decision, or any part in the implementation, then that is overstated.
My field interviews collectively suggested that both Thaksin and Sudarat were committed to UHC, even if they had different priorities and lacked a full understanding of healthcare. It may have been the RDM who pushed for the pilot program, I have no evidence to suggest otherwise, but I do have evidence suggesting that both Thaksin and Sudarat wanted the 30-baht scheme implemented quickly. Dr. Viroj Tangcharoensathien, a key member of the RDM who was referencing his first meeting with Thaksin on March 17, 2001—just a couple of months after the election—stated that “he [Thaksin] and Sudarat wanted things done quickly. We said to do it gradually, but he said no, in six months’ time. See, Thaksin has to respond to electoral votes. So, the MOPH capacity had to ‘scale up’ very quickly, especially at the operational level.” A different interpretation of the pilot program, then, is that it was suggested and pushed by the RDM, but that Thaksin and Sudarat quickly agreed, seeing it as an opportunity to get things moving.
Dr. Sanguan also states that the charge for the MOPH to implement the 30-Baht program came “immediately” following the election. He specifically names Sudarat as one of four people that led the implementation effort. And then uses the pronoun “we” to reference the rolling out of the program—from six provinces in April to fifteen two months later, to all seventy-six provinces within one year. Moreover, Dr. Sanguan doesn't refer to the initial six provinces as a pilot program (Nitayarampong 2006, 94).
Indeed, it is not clear that TRT needed any extra impetus from the RDM, or to be locked in by a pilot program, even in the first year following the elections. Everybody was holding TRT accountable: the media, opposition parties, and the public at large. Indeed, a key feature of parliamentary systems is their ability to hold politicians accountable for policy promises—a reason parties made no promises prior to electoral reform. TRT's huge electoral success, largely reliant on the popularity of the 30-baht scheme, had already tied their hands. Fail to implement UHC, and there is a much lower chance of TRT being returned to government in 2005 in a landslide. Dr. Viroj's insightful statement seems to agree that responding to votes was the key incentive for TRT.
4. HARRIS: RESPONDING TO SELWAY'S CLAIMS
Selway argues that I oversell the role of professional movements in the implementation of UHC, or at least undersell the role of TRT, ignoring important policy-making choices made by the party. Selway makes a strong case and raises some important points. However, I believe that the evidence suggests a different interpretation. In this section, I address each of his criticisms and offer a few additional points that distinguish our perspectives.
pOPULARITY VS. lOCK-IN eFFECT
In his discussion of the policy's inspiration, Selway acknowledges that the professional movement was responsible for the content of TRT's health policy amid numerous possible alternatives. However, he states that, more than anything, it was the policy's own popularity, rather than the national pilot project, that so greatly tied TRT's hands. Yet, great popularity also sometimes allows parties the luxury of backtracking on promises or, as I describe in the book, to do unthinkable things like entertain dissident science on AIDS, which led to the death of over 330,000 people in ANC-led South Africa. More than popularity, what prevents politicians from backtracking is if citizens have already had a taste of the benefits, a phenomenon political scientist Paul Pierson calls, “lock-in effect” (Pierson Reference Pierson1993). This explains why, when TRT wavered at a crucial moment, physician-civil servants associated with the RDA felt such a need to move forward so rapidly in order to ensure that the program was institutionalized. Otherwise, why implement such a sweeping program in less than a year before the policy became law?
THE DISPOSITION OF TRT ELITES IN POLICY IMPLEMENTATION
Second, Selway points to evidence that suggests that Sudarat and Thaksin supported early implementation of the program and did not need their hands tied. Indeed, the meeting Selway references was an important one, and Dr. Viroj is a highly credible source. But as the ministry's highest-ranking civil servant (and someone Selway notes was “hand-picked” by Sudarat and outranked Dr. Viroj), Dr. Mongkol na Songkhla would have been privy to ongoing discussions by senior TRT officials regarding health policy. Thus, we might also regard the reluctance reported by Mongkol as highly credible evidence (and he was not the only Rural Doctor to report this either) (interview, former Permanent Secretary, May 12, Reference Na Songkhla2009).
More broadly, the most compelling evidence of TRT's actual disposition towards the program was its actions with respect to funding. For a policy that was the central plank of the party's campaign platform, TRT demonstrated a shockingly weak financial commitment to the fledgling new policy. The reform was essentially done within the existing cost envelope, and TRT tried hard to hold the line on spending in the years that followed. One would have expected a party that was really serious about delivering substantial new benefits to the rural populace to allocate substantial new funding to do so. We don't see that, and here it's also worth remembering that the 30-baht program was not TRT's only populist program. That is to say that the party's reputation hinged on more than just that of the 30-baht program alone. If they did not deliver on that program, there were still other populist programs on which they might hang their hat.
Given this context, it is critical to understand exactly who it was that pushed implementing the policy as a pilot project in six provinces in April, less than four months after the election and less than one month after the Government House meeting. According to Surapong, it was Mongkol—a Rural Doctor—who came up with this idea; neither Surapong, nor Sudarat, had imagined doing that so soon (interview, former Deputy Health Minister March 13, 2009). And we know too that he was driven, at least in part, by concern that TRT would not follow through if they waited. However, once the policy was implemented and benefits began being delivered to constituents, lock-in took hold, and the rest is history. If there was reluctance, then implementation so early after election tied their hands. TRT could (and did) keep investment in the program at lower levels than one would expect for such a program, but repealing it outright became improbable if not impossible.
Selway also suggests that roll-out of a national pilot project would require the cooperation of the Health Minister, Sudarat Keyuraphan. While it's true that rollout would require cooperation of the Health Minister, Selway's point that Sudarat was not picked for her health expertise is critical here. As I mention in the concluding chapter of my book, next to the human brain, there are simply few things more complicated than health reform and health system dynamics. And Sudarat knew next to nothing about health! A focus on Sudarat does not appreciate who was doing the real work in the health ministry related to the UHC program. The fact is that TRT assigned its chief health policy adviser, Surapong Suebwonglee, who was not only a medical doctor but former director and assistant dean of the School of Hospital Administration at Ramathibodi Medical School, in addition to being the one who introduced Thaksin to the physician-bureaucrats who conceived of the policy, to oversee the policy's implementation as Deputy Health Minister. Surapong was viewed not only as competent and able to oversee such a complex reform process, but as a former employee of Shinawatra enterprises, he held Thaksin's personal trust. Selway overstates Sudarat's role and value in the implementation process. In actual practice, she was little more than a figurehead at the time and was viewed in some quarters with contempt for her lack of knowledge of health.
How we characterize Surapong is also vital in the interpretation of whether we credit the RDM or TRT with the policy's implementation. Selway states that political parties controlled senior appointments at the ministry but that at times it becomes hard to distinguish between TRT and the RDM. I agree with him on this point, but this is also why it is so important to understand the different identities and commitments held by the key actors involved and what makes the professional movements story so compelling. By digging deep, we see who was really behind the policies and how and why policies unfolded the way they did. Indeed, TRT did control some senior appointments, but the party's most important senior appointment was Surapong who himself was deeply enmeshed in and part of the Rural Doctors’ network! While he was TRT's health point person, he was also a confidante of Dr. Sanguan and the other Rural Doctors with whom he had ties going back to the 1970s and was former editor of the Bulletin of the Rural Doctors’ Society. In fact, at a recent ten-year anniversary of Dr. Sanguan's death, he was the person chosen to be the keynote speaker. Moreover, he was one of the more radical of the Rural Doctors having been a leader in the student movement who was forced to go into hiding in the forest with the communist insurgency after the 1976 coup (along with another TRT executive, Dr. Prommin Lertsuradej, Dr. Mongkol na Songkhla, who served as Permanent Secretary, nominated two other Rural Doctors, Dr. Suwit Wibulpolprasert and Dr. Sanguan Nitayaramphong as Deputy Permanent Secretaries. Holding these high-level positions certainly helped to increase the influence of the movement, but the RDM also held durable positions of influence in and around the ministry and contributed to the reform from a variety of positions. This speaks directly to Selway's second point about who actually did the work overseeing the implementation process.
Finally, I would simply note that it is surprising to me that what is probably the most notable aspect of the most celebrated universal healthcare reform in the industrializing world had gone virtually unnoticed by other scholars before I drew attention to it. The rollout of a national pilot project before the reform became law was a remarkable political strategy—one that deserved more scholarly attention and one that reformers in other countries could learn from. I suspect the greater focus and attention I paid to it highlights the way in which different disciplinary orientations and theoretical concerns can lead us to train our attention on certain things (like electoral rules) and overlook other important dynamics and mechanisms that otherwise deserve interrogation. I certainly did not key into the role that electoral rules played in Thailand's story the same way that Selway, a political scientist, did in his account and therefore did not capture some of the insights he shares in his article and his very valuable comparative book project.
5. SELWAY: HARRIS IGNORES IMPORTANT TRT POLICY CHOICES REGARDING IMPLEMENTATION
Harris raises an interesting point on the financing of the 30-baht program. The healthcare personnel I interviewed in 2006–07 across the board felt that the program required more funding to reach its full potential. That this was a criticism of TRT from the beginning is not inconsistent with the party being committed to UHC, however. Naturally, the party had other objectives and other programs they wanted to finance. TRT implemented several policies designed to get the rural consumer base back into the economy. The social safety net of UHC was just one component. But we should not confuse a different set of priorities with a lack of commitment. Indeed, TRT made several policy choices that demonstrated their commitment to UHC:
1. Personnel appointments over UHC's implementation. I have already mentioned the appointing of Sudarat Keyuraphan as Health Minister along with Dr. Surapong as Deputy Health Minister. Sudarat was not liked by key members of the MOPH, and they did cite her lack of health expertise. But Thaksin put her there precisely because he did not want to have the policy slowed down by the bureaucracy. She was a blunt tool in pushing the program forward, often when the ministry wanted to more carefully deliberate certain points. In addition, TRT appointed Dr. Sanguan as the founding Secretary General of the newly created National Health Security Office (NHSO). As Harris points out, other members of the RDM were appointed to senior positions within the MOPH. In short, at some point it becomes hard to distinguish between TRT and the RDM. But this is exactly my point about how political parties in Thailand transformed to become programmatic. They take professionals on board, into their own ranks. In the case of health policy, we should be seeing doctors and public health professionals joining political parties, helping them evaluate competing policy suggestions from the bureaucracy and professional organizations, and ultimately creating their own, even if they are more rushed and less well thought out than the relevant bureaucracy would like.
2. Leadership over the implementation process. Thaksin's management style was a key feature of his leadership as Prime Minister. He preferred a centralized “CEO-style” approach, in which he could actively oversee the implementation of his most important policies. His planning and strategizing meetings with senior party figures in the first year of his tenure became dubbed the “War Room” committee, invoking images of a Churchill-like leader perched over a map during war-time Britain, directing the professionals (in Churchill's case generals of the armed forces). It is clear from interviews with members of this committee and with junior party members on the back benches that the 30-baht policy was important to Thaksin and the party. Again, my interviews did not detect the same reluctance in TRT's implementation of the 30-baht scheme in the year following the elections.
3. Policy communication with the general public. One way in which TRT revolutionized Thai politics was in its ability to communicate policy with the Thai public. They did this in two ways. First, TRT engaged in policy marketing, with catchy names for every policy. More importantly, but less emphasized is TRT's behind-the-scenes polling of the general public about specific features of their policies as well as ways to present them. This polling provided support for these policies, often labeled as populist by political opponents, enabling TRT to dare the opposition to defy the will of the people. Thus, public support was essential to the implementation of the policy.
4. Power restructuring in the MOPH. Perhaps the most important part of UHC's implementation was the creation of a separate institution to handle the budget. Most of the health budget was now redirected to the new National Health Security Office (NHSO). Whose idea was this? If that of the Rural Doctors, how did they pressure TRT into doing this? Though the precise source of the NHSO's creation was not something I investigated in my field interviews, the theme of bypassing opposition within the MOPH was. Such opposition by other, competing “well-positioned elites” in the MOPH, was drastically reduced through the creation of a new institution to handle UHC's budget. Regardless of whose idea it was—and my sense from the interviews was that this was Thaksin's idea, which gels well with his centralized, CEO-style leadership—the NHSO was seen as a party-run institution. Dr. Piya Netrawichien stated that the NHSO “was associated with TRT … Basically, the MOPH's power dropped. Ninety percent of the budget was transferred to the NHSO. The MOPH used to send money directly to the hospitals, but now the NHSO was in charge of distribution.”Footnote 3
These examples demonstrate a party committed to UHC, but also aware of the broader political environment needed to implement it for the long-term.
A final point I re-make here about implementation is one I make in the article and book, regarding the actions of the Democrat Party in healthcare during their tenure as the leading coalition partner in government during 1997–2001. I show that the Democrats drastically increased healthcare funding of two major programs: Free Medical Services for the Poor (FMSP) and Voluntary Health Card (VHC) programs. These programs were championed by other constituencies within the MOPH, and the Democrats were not responsive to the RDM. Thus, even though their vision and approach to universal coverage was different,Footnote 4 they pushed in that direction and were major players in policy implementation.
SPURIOUS OR MEDIATING VARIABLE?
Harris’ final critique of my institutional argument is that the RDA had been pressing for constitutional reform for years before 1997. There are a couple of possible implications of this, if it is true. The most damaging would be a completely spurious relationship between electoral rules and change in healthcare policy. That they happened fairly simultaneously, and were originated by the same set of actors, does not mean that one caused the other. I don't think Harris is arguing this. He seems to accept the idea that electoral reform and political parties, as Dr. Sanguan (2005) himself noted in his own account of the scheme's implementation, was a necessary (though insufficient) condition of UHC's implementation. But what if electoral reform was, in the first place, part of a long-term scheme by the RDM to implement UHC? That, in turn, might mean that the internal transformations I observed in TRT were actually driven by the RDM. Perhaps they aimed to take over a political party? At any rate, it assigns much less agency to TRT politicians than I afforded them. This last point seems a new argument by Harris, one that would require a remarkable amount of foresight on the part of the RDM.
In my previous work, I pushed against a similar idea that the 1997 Financial Crisis had led to both electoral reform and demand for healthcare. While conceding that this was the case, I maintained that you still needed electoral reform in order to get UHC. In addition to the careful process tracing of my account, I examined two scenarios. The first was an additional observable implication of electoral theory: that smaller parties likely to dissolve by the next elections would not respond to the incentives of the new electoral rules. This is a crucial test because, if it was simply demand for healthcare generated by the Crisis that mattered, these small parties should have been responsive. I show, however, that in the interim period of 1997–2001, two smaller governing coalition parties that even held the posts of health minister and deputy health minister showed no interest in health reform. It was the larger coalition partner, the Democrat Party, largely seen as the party most likely to benefit from the new rules at the time, that responded by expanding the two existing schemes.Footnote 5 Applied to Harris’ current argument, would we have seen the Democrat Party engaging in such dramatic policy reform that pushed in the direction of universal coverage given that the RDM was unable to penetrate that party?
The most likely implication of Harris’ final critique is one of endogeneity between two right-handside (causal) variables, suggesting the need for a more complex mediating-variable model. In statistical terms, we would require a two-stage estimation of reform efforts by bureaucrats on electoral reform, and then a second estimation of electoral reform on healthcare policy. This is considerably less damaging to my theory that institutions matter. Indeed, Harris seems to concede that electoral reform mattered, just that it doesn't tell the whole story. In turn, I concede that, yes, the Rural Doctors mattered, but that I was not focusing on that part of the story. Or, to put it another way, perhaps Harris’ account is about the first stage of the mediating model and mine is about the second stage. But Harris certainly has something to say about the second stage, arguing that even with electoral reform you don't get UHC without the RDM continuing to push. I have already conceded that the RDM played a part in implementation, but maintain strongly that TRT did too, and that at some point the two sets of actors’ aims are so unified in their aims that it is impossible, and futile, to differentiate who did more.
Let me briefly deal with the charge that without the RDM you don't get electoral reform. I find Harris’ argument—“that the professional movement was itself a major reason why a constitutional reform that led to such important electoral changes happened in the first place”—vastly overstated. How central was the RDM to electoral reform? It is true that Prawase Wasi was an influential figure. It is true that he was part of the RDM. But could electoral reform have happened without him or the RDM? Accounts of the 1997 constitutional reforms reference a plethora of civil society organizations in existence in Thailand during this period (McCargo Reference McCargo2002), and all of them pushed toward constitutional reform in some way. Indeed, the 1997 Thai Constitution has been hailed as one of the most progressive constitutions in the history of the world. Thus, it was a product of a much larger societal movement, not the Rural Doctors’ movement in particular.
In sum, I agree with Harris’ later point that “we cannot stop at electoral reform alone as an explanation.” That is the thing I learned most from his account, and I am sure that there are additional factors that both of us overlooked. At the very least, however, this scholarly interaction has led me to moderate my earlier theoretical claim as follows: conditional on the efforts of the Rural Doctors, and specifically their pilot programs in the 1990s, the 1997 electoral reforms resulted in the governing Thai political party, TRT, developing and implementing universal healthcare, the 30-baht scheme.
6. HARRIS: RESPONDING TO SELWAY'S COMMENTS ON TRT POLICY CHOICES
As we have already debated the issues of personnel appointments and leadership over implementation extensively, here I will take up the role played by TRT in other policy choices related to communications with the public and restructuring within MOPH.
First, I agree with Selway that TRT had a powerful messaging and polling apparatus. But I think it worth emphasizing, again, that it was the doctors who put the idea there in the first place, in spite of what the findings from TRT's polling apparatus said. In my book, I show that it was Surapong who invited the doctors to present their ideas to Thaksin, and their idea of universal coverage replaced what had actually come up as much more important priorities in TRT's own polls. Thaksin deserves credit for seeing the electoral value that the policy might hold and repackaging it in a way that voters could appreciate as the “30 baht to cure every disease” program, although Surapong played an important role in determining the amount of the co-pay (Thaksin had originally suggested 20 baht). This was incidentally less a product of research than Selway suggests, though you'll have to read my book to learn the whole story.
On the second point, the restructuring of power and the separation of the purchasing of healthcare services from provision, it may have been that the interests of leading figures in the ministry and TRT were aligned, since it stood to improve the efficiency of healthcare, something that was of special interest to TRT, which did not want to commit any additional money to the enterprise (the capitation rate was relatively static for the first few years). It also stood to improve the transparency of healthcare operations, which was of particular interest to the RDM, who had forced one health minister out on corruption charges previously and would play a role in ousting another later who sought to privilege commercial interests over people's lives. However, I find the notion that it was Thaksin's idea implausible, particularly since debates over the “purchaser–provider split” in health reform have a long history around the globe. This may have been something that Thaksin would have had some reasons to agree with fiscally, but there was a clear technocratic basis for this decision, one that the doctors, many of whom were educated in Britain, where the original purchaser–provider split happened, would have had a clear position on.
I want to make two final points. First, Selway contends that I vastly overstate the role of the professional movement in the process of constitutional reform that led to the electoral reforms. While it's true that a plethora of civil society organizations were engaged around the time of the drafting process for the so-called “People's Constitution” in 1997, it was an elite-led process, and the powerful role that the patriarch of the RDM played in setting the agenda for substantive constitutional reform in the first place is clear and unambiguous. And other doctors from the movement were also involved in reform process, including through their contributions to democratization vis-à-vis the Health Assembly for Democracy and PollWatch, which other scholars have already documented. Had these agenda-setting actions not happened, it's not clear who or what would have moved Thailand's political process in the direction of meaningful constitutional reform. Certainly, the Democrats who were in power at the time were not invested in substantive political reform. And while the changes that were ultimately wrought from this process may not have been part of a decades-long strategy for UHC by the Rural Doctors, the important point is that they certainly took advantage of a variety of opportunities in the new environment that they themselves had a hand in creating once those changes were made, from putting UHC on the agenda of TRT to financing and mobilizing a civil society petition campaign for UHC under new provisions in the constitution.
Finally, Selway also argues that electoral rule changes help explain the Democrats’ support for expansion of two state health insurance programs later, the Voluntary Health Card and the means-tested Low Income Card (Selway Reference Selway2011, 177). I do not subscribe to this reading of the political situation, the incentives that pressed Democrats to respond the way they did, nor for their reasons for doing so. Selway argues that the core of the Democrats’ party platform was to cover all Thais through the expansion of the VHC program. Yet, the Democrats had actually resisted repeated calls by the RDM over the years for universal healthcare. It was only the Asian financial crisis that forced them to expand these two residual and somewhat limited welfare programs when they did. But amid the dramatic consequences of the Asian financial crisis, even this modest expansion left it vulnerable in the 2001 elections, and citizens at that time frequently associated the party with the IMF.
When universal healthcare finally became part of their platform in the prelude to the 2001 elections, it was something the party embraced reluctantly, and only after TRT had made it an issue in the election. Indeed, the Rural Doctors who had originally envisioned achieving universal healthcare by expanding these programs gave up on that approach because they realized that expansion of a voluntary program could never achieve universal healthcare (Harris Reference Harris2017a, 54). And public statements by party leaders at the time provide clear evidence of how they really felt about the policy. Expansion of the VHC program following the Asian financial crisis still required low and middle income Thais to make a significant outlay (500 baht) for somewhat limited coverage for one year. This is all to say that it was much more in line ideologically with the principles that guided the Democrat Party: avoid investment in the kind of universalistic social democratic policy commitments that might cost a lot, and keep spending growth limited to short-term increases in residual programs. Yet, even the participatory health reform associated with the Democrats (which was ironically spearheaded by elites in the RDM) languished for many years and was not passed until 2007. To close, to the extent that the Democrats were responding to anything, they were responding to the economic crisis in 1997 and not the electoral reforms. And if expansion of funding for the state's two residual health insurance programs post-1997 reflected anything programmatic, it was the Democrats’ same old program, just souped up slightly given the crisis.
7. SELWAY: RESPONDING TO HARRIS’ COUNTERARGUMENTS AND CRITICISM
OUTSTANDING DISAGREEMENTS
To summarize, Harris and I still disagree on some points. Harris argues that the pilot program was entirely driven by the RDM to ensure policy lock-in. I agree that it was instrumental in creating a lock-in effect. However, it is not clear to me (a) that it was the sole reason the program survived (though I could be convinced on this point), and (b) that the lock-in was to prevent TRT specifically from reneging, rather than a tactic developed by the RDA that TRT elites, equally eager to see through their signature campaign promise, jumped on. I just don't see enough evidence presented by Harris on either front. Given that TRT and the Rural Doctors’ aims were so closely aligned, who is to say that TRT did not allow the pilot program to go ahead precisely to create the same lock-in effect in order to withstand criticism they were getting from the more fiscally conservative Democrats? Although I did not pursue this line of inquiry specifically, my interview notes reveal an active War Room committee—even in the first year—that was dedicated to implementing the pilot program, and at least one key member of the RDM stating two months after the election that Thaksin and Sudarat were almost too eager to get UHC implemented.
One possible reason for the differences in our interviews is perhaps a classic case of credit claiming. Both the RDM and TRT would like to claim primary responsibility for such a landmark policy. So how do we adjudicate? I am not sure we can, or what purchase we get from doing so. Every indicator seems to signal that they both stood to gain from its implementation and that they worked closely together. Ultimately, I remain convinced that TRT were serious about implementing the 30-baht scheme in the year following the election; it was the one campaign promise that Thai voters were most energized by, and it was a momentous achievement that matched the ambition of the most successful party to date, not to mention the ego of their leader, Thaksin Shinawatra.
Second, we weight the influence of TRT in the policy's implementation differently, especially in the first year. I maintain that Sudarat was more than just a figurehead and was seen as a highly capable administrator; that Thaksin had put her there to make sure the policy was implemented. But I agree she was helped in these efforts by Surapong, who had health-specific knowledge and networks. We still disagree on the nature of Surapong's contribution, and as such a pivotal figure he deserves one final response from me. I learned from Harris that Surapong had some history with the Rural Doctors that had not come across in my field interviews. It is not clear if he still considered himself part of the Rural Doctor movement at the time of UC's implementation—Surapong had worked for Thaksin in the private sector, a far cry from the public-service driven ethos of the RDM—but even if he was, how much does it matter?
A major theoretical point I make in my book is that electoral reform caused Thai political parties to fundamentally transform their internal organizational structure in order to have independent capabilities to formulate programmatic policies. Hiring a health expert would have been a necessary part of that transformation. And Surapong filled that description to the tee, taking on a clearly different role than Sanguan or other members of the RDM. Surapong was, at his core, a party man. Yes, he relied on his ideological leanings from his time in the RDM. Yes, he leveraged those contacts, introducing the Rural Doctors to Thaksin; but did he do so because, like Thaksin, he had the interests of the party in mind? What this question comes down to is how to characterize Surapong's contributions; was he an ideologically driven Rural Doctor still, or a TRT-elite party figure with the success of the party in mind? He seems to be somewhere in the middle, and for my theory that is fine. Parties need to bring in policy experts in order to transform. They certainly weren't doing that before electoral reform. The Democrats had their equivalent in Burunaj Samutharaks. These individuals were crucial to the parties’ internal transformation, signaling a large shift from the past.
8. CONCLUSION
The classic exchange in the field of Southeast Asian Studies between Samuel Popkin and James Scott in the 1970s sought to explain why Southeast Asian peasants revolted against their colonial masters. Scott's Moral Economy of the Peasant was countered by Popkin's The Rational Peasant, with the result being that Scott changed his views entirely and a decade later he penned the masterful Weapons of the Weak. This scholarly exchange is in the same vein of intellectual probing, and while it has not resulted in a wholesale abandonment of our initial arguments, it has certainly led to more appreciation of other factors and moderated our original claims. There are still outstanding disagreements that we leave unresolved. But these disagreements are much more about the weight of different factors at different time periods than they are about disproving the other completely. So, what general lessons can we take away from this scholarly exchange?
SELWAY: THEORETICAL SCOPE AND LEARNING FROM FIELD RESEARCH
This exchange has caused me to re-examine not only my previous evidence and the conclusions I drew, but the entire process of information gathering in the first place. Qualitative research designs are often criticized for their lack of transparency, especially those relying on field interviews wherein nuance, interpretation, and even what is recorded in the interview notes are so heavily subject to researcher bias. If Harris had a fixed idea on the role of professional bureaucrats it would be hard to independently evaluate his field research (and vice versa for my findings). Rarely do we get two researchers independently investigating a question so closely. I was not at all sensitive to the role of the RDM during my interview process, even having interviewed many of the same individuals, yet going back to my own field notes I was able to corroborate the centrality of their role.
My own investigations began with a clear theoretical framework. Electoral rules are a large part of the institutionalist literature in political science, but we know little about the precise mechanisms through which these relationships take place, or their scope conditions. As part of this larger debate, my motivating question was never the passage of universal healthcare specifically. This may not be obvious to the general reader, nor even to a scholar from a different discipline. After all, the title of my article is: “Electoral Reform and Public Policy Outcomes in Thailand: The Politics of the 30-Baht Health Scheme.” This is not to say that the passage of UHC is not an important sub-question for me, but it is just that: a sub-question. To be more precise it is a single case, among several, that I use to test a more general question: how do different electoral systems affect public goods outcomes? Healthcare in Thailand was just one place and one policy area in which to test this theory, and I was conversing with a discipline that cared about that larger conversation. Indeed, the whole first paragraph of my World Politics article makes no mention of Thailand or healthcare. Even when I get to speaking about Thailand's healthcare, I use the more general concept of healthcare policy, rather than the passage of a specific policy, like UHC. This distinction is important because it completely changes the scope of the question. Harris was interested in the passage of that specific policy only, and during our discussions he asked me if, in hindsight, I would change the subtitle of the article. I would not. Perhaps this has to do with the disciplines each of us are plugged into and their norms and current conversations than any disingenuity on my behalf or nitpicking by Harris.
In terms of the larger body of evidence I presented, my focus spread to preventative care, promotion, the details of how the program was financed, how it was implemented in practice, as well as gauging actual outcomes. All those things had to align in my account. Changes in financing to other related programs, such as the Civil Servant Medical Benefits (CSMB) and the Social Security Insurance Program (SSIP) were also important because they represented large proportions of the population. Since the theory predicted that benefits should have accrued broadly to the population, these were essential causal process cases (or observations) to explore.Footnote 6 The nature of health policy in the 1997–2001 era was also an important case that broadens the scope beyond UHC.
This subtle difference in scope had implications for the way in which I conducted my field research—the questions I asked interviewees, the universe of interviewees whom I even wanted to interview in the first place. Scholars often go to the field having carefully examined a topic. My own journey involved extensive newspaper archival work and reading secondary accounts of the history of Thailand's healthcare, as well as the political system, including political parties and the bureaucracy. I had already narrowed down my explanation to the electoral rules, but I didn't know how they translated into policy change, or if I was just observing correlation. I needed to “soak and poke,” to use Fenno's (Reference Fenno1978) terminology, that is, immerse myself in the field. However, I still went into my interviews with a set of questions designed to understand the topic from a certain point of view. Of course, if interviewees had provided me answers that completely disconfirmed my original hunches, I would have had to completely re-think my theory.Footnote 7 However, what occurred was more along the lines of a quick confirmation and then an immersing in the details of the process.
My field research was invaluable to identifying the various causal process cases I use in my final analysis. Some of them were surprising. I had no expectation, for example, to talk about the Democrats and their response to the change in electoral rules. I figured they had lost the 2001 election precisely because they had failed to understand the new institutional environment. But I was wrong. The Democrats, who had overseen the passage of the constitution while in power, significantly increased their attention to healthcare policy. They had previously been the largest party in the parliament and had led the government coalition. Moreover, they had been one of the two largest parties throughout the 1990s, one of the three largest parties throughout the 1980s, and the most consistent party at the top over those two decades during an era in which parties fractured, dissolved, or merged with frequency.
I also did not expect to see such significant structural change in political parties. The successful parties had begun to transform themselves to look much more like their counterparts in Western democracies. No longer able to simply rely on the bureaucracy for policy direction, parties had to compete for new and innovative policies, ones that would align with the new institutional incentives, which had brought about the need for a strong national orientation.
But while there were unexpected empirical findings, the scope of my explanation was limited by my initial, theoretically driven question, which itself was perhaps narrowed by my disciplinary training, political science, and further by my subfield of training, institutions. It is thus no surprise to me that a sociologist whose own disciplinary training emphasized social movements, would find evidence along those lines. Indeed, I think Harris’ work has produced a more rounded explanation of the overall process. As I mentioned above, I have since reviewed my field notes from my interviews in Thailand, and many of the people I interviewed were from this network of bureaucrats that Harris identifies. Many of the other people I interviewed made some mention of these individuals and of the RDA specifically. It was the scope of my question and the goal of my research (theory testing) that precluded me from emphasizing their role.
HARRIS: A PRODUCTIVE SCHOLARLY ENGAGEMENT
While the debate here has really centered on the different perspectives we take towards specific issues like the role of the RDM in embedding the policy in the campaign platform of TRT and in policy implementation, it's worth noting that the more defining differences between us come from the very different contributions our respective books make: Selway's theoretical focus was arguably much broader than mine, being concerned with the role of electoral rules (and ethnicity) in public goods provision. In reading his book, I learned a great deal about how different kinds of electoral arrangements interact with ethnicity to produce distinctly different public goods outcomes in a wide range of countries. And it was obvious that countries seeking to improve the provision of public goods could benefit a lot from the insights of his research.
My work has been concerned with the role that professional movements play in expanding access to healthcare and medicine in countries engaged in processes of democratic deepening. To date, so much of the theory generated by the welfare state literature is grounded in the European and American experience, even though the political conditions in much of the rest of the world are substantially different. In that regard, building on the work of people like Joseph Wong and others, my work helps us to understand the sweeping role they play in the agenda-setting, policy adoption, implementation, and accountability phases of the policy process during “highly interactive moments” like democratic transition (Keck Reference Keck1992). Here we see them employ a number of remarkable political strategies, only a few of which have been discussed in the pages of this debate.
One major conclusion that we can take from this exchange is that institutional theories generate expectations about how institutions shape the incentives, capabilities, and behaviors of actors. In the Thai case, electoral reform increased the incentives for parties to develop, pass and implement programmatic policies. However, the case also highlights the fact that institutionalist explanations do not offer a theory of specific policy preferences. Absent other assumptions or information, an institutional theory has nothing to say about why policy makers might choose to pursue health care, education, or poverty alleviation policies—just that they should be more likely to pursue these policies generally, and in a more programmatic way under some conditions and less likely under others. We need a theory of policy preferences, or agenda setting, to get us to specific policy proposals and outcomes.
The theory I offer helps us understand where specific policy proposals come from, and why certain groups have more influence than others, although we cannot draw a straight line from interest group power and influence to policy outcomes, since interests and preferences are always filtered through political institutions. Those preferences and interests look very similar in 1996 and 2001, and yet we get very different outcomes. A theory of institutions therefore helps us to understand why the institutional environment was much more favorable for programmatic policies post-constitutional reform. In other words, we need both theories to help us understand why universal health care was adopted in Thailand in 2001.
I think both Selway's project and my own contribute to extending the literature in important ways in areas of the world that have been generally neglected by scholars. Yet, there remains precious little work by social scientists on health policy in the industrializing world more generally. Thus far, “health policy process” research is dominated principally by scholars from interdisciplinary schools of public health. While researchers working in this area have generated scholarship with important implications, these debates could be enriched substantially by theoretical engagement with literatures in sociology and political science. Given the substantive importance of the field and the extraordinarily rich opportunities for theory building and testing that exist within it, clearly much more needs to be done. So my hope is that these kinds of productive exchanges help to spur more serious research projects by social scientists on health policy in the industrializing world, as well as more scholarly interactions between researchers using different frameworks and approaches.
More broadly, this exchange has helped demonstrate how much scope there is for researchers to produce genuinely distinct and useful findings from the same case, particularly if the researchers come at the same problems with different disciplinary orientations and theoretical approaches. Indeed, the exchange illustrates the value of mobilizing our collective knowledge and thinking together about the issues in some way. And Selway and I are not the only social scientists to make valuable contributions using the Thai case (see, for example, the great and very different account by Nam Reference Nam2015). This is to say that even if imposter syndrome may begin to flex its grip in graduate school, hopefully it does not blind us to the genuinely unique and important insights that other approaches offer.
Another fruitful outcome of this exchange has been the way it has caused me to want to think more about the processes by which political parties incorporate (and assimilate) professionals and the role that assimilated professionals play in political parties. I think Selway makes a really important point, and in many ways, this focus runs counter to the general thrust of my own research, which has illustrated more how professionals penetrate political parties, carrying many of their existing identities and commitments with them. So it strikes me that this points to a very productive tension. An important line of future research might elaborate on the role of professionals in political parties and the extent to which incorporation of professionals actually professionalizes the parties themselves. Here we see that professionals don't just evaluate and develop policy. They sometimes play a broker role, connecting unlikely partners and collecting ideas from professionals outside parties. And even when they don't draw on their professional skills in determining the shape of policy, their professional credentials still do frequently play important legitimizing roles. There is clearly a great deal more work to be done.
CONFLICT OF INTEREST
Both authors declare no conflict of interest.
