An Angkorian perspective on complexity
By Maryam Bigdeli, Alliance for Health Policy and Systems Research
Jayavarman VII, King of the Khmer Empire during the XIIth century ordered the construction of 102 ‘halls of diseaselessness’ (arogyasala) (Jan Ovesen and Ing-Britt Trankel 2010). These ‘hospitals’ existed since the reign of Yashovarman I but it is Jayavarman VII who is credited for increasing their number and taking instrumental decisions for making sure they delivered effective services. He staffed the hospitals with people who each had a specific task, ordered that the treatments were to be delivered to all four castes of the Empire without distinction; he provided some personal resources to make this happen but also called for donation from a long list of patrons. Last but not least, the King ordered farmers to produce and supply the hospitals with medicinal substances for free three times a year (Jan Ovesen and Ing-Britt Trankel 2010).
In fact, the most powerful ruler of the Khmer Empire had figured out a pretty decent universal health coverage agenda. He built facilities, solved the question of equitable access by enrolling the entire population in his scheme, had a human resource plan, a benefit package in which, in his great wisdom, he included medicines. Not just in theory, let me stress that: he took care of production, supply and financing.
Of course the story doesn’t tell whether the patients were satisfied or whether the medicines were quality assured. Ayurvedic medicine was practiced by doctors both competent and reputable and who lived afar: that served as evidence for medicines selection. Nobody dared to look at the difference in utilization between quintiles -or how do you call that when there are four castes? He didn’t care about adherence too much, wasn’t going to give himself a headache over patients records or health workers retention nor did he experience the torments of sleepless nights when someone would raise the issue of sustainability.
Jayavarman VII was people centered enough for “he suffered the illnesses of his subjects more than his own; because it is the pain of the public that is the pain of kings rather than their own pain.”. But obviously he didn’t have to deal with a very complex health system where mosquitoes competed with salt as threats to his people’s health, where random unlicensed healers would run clinics in their house at dusk, or where the peasants who grew medicinal plants had shareholders to be accountable to. More importantly he didn’t have any annoying health policy or health system researcher to trouble him with interesting yet sometimes slightly irreverent research questions.
Or maybe he did, as he is standing as an enlightened monarch.
But surely, these researchers they didn’t have a space where they could voice their research questions and devise on methods to investigate. They didn’t have an opportunity to share their results with their peers, they didn’t have access to the reputable scholars who published in whatever was the Health Policy and Planning of those times; nor did they have access to open-minded and knowledgeable decision makers, ready to bridge the gap of research and policy. They didn’t have Cape Town or a Third Global Health System Research Symposium. Not even a hashtag under which they could rally. In short, they weren’t as lucky as we are!
