Health Care Delivery System Of Thailand Thailand officially is known as the Kingdom of Thailand ( "Land of the Free").

Thailand is the only Southeast Asian country never to have been occupied by any European or other foreign power, except during the war. Thai people form the large majority of Thailand's population, and most of them practice Theravada Buddhism. Other ethnic groups within the population include Chinese, Malays, and indigenous hill peoples, such as the Hmong and Karen. Thailand is known for its highly refined classical music and dance and for a wide range of folk arts. Traditionally based on agriculture, Thailand's economy began developing rapidly in the 1980s. People and Society Thailand has never been heavily populated. By the 1800s Thailand's population remained low at 2,000,000, and by 1950 it had risen to only 20,041,628. By 2000 the total population had increased to 61,163,833, giving a population density of 119 persons per sq. km. (309 per sq. mi.), still one of the lowest in Asia.

Economy Many different factors contributed to the rapid growth of Thailand's economy. Low wages, policy reforms that opened the economy more to trade, and careful economic management resulted in low inflation and a stable exchange rate. These factors encouraged domestic savings and investment and made the Thai economy an ideal host for foreign investment. Foreign and domestic investment caused manufacturing to grow rapidly, especially in labor-intensive, export-oriented industries, such as those producing clothing, footwear, electronics, and consumer appliances. Government. Thailand is a unitary state, in which the authority of the central government is superior to that of the country's provincial and municipal governments. However, in recent years pressure has increased for more devolution of power to the provinces and municipalities. PRIMARY HEALTH CARE IN THAILAND The problem of under-utilization of health centres and hospitals in rural Thailand led to the initiation of a pilot project on primary health care (PHC) in Sarapee District, Chiang Mai Province, in 1969. The project was designed mainly to extend various health services to cover a greater portion of the population in the area. The initial estimation for coverage of existing health services was below 20 per cent of the total population at that time. Recognizing that the health-service delivery structure was not covering all the health and medical demands of the community, the project organizers' strategy was to train people selected by the community to function as intermediaries between the peripheral tambon (community of villages) health officers and the community, adding to the existing health-service delivery on a voluntary basis. Evaluation of the pilot project revealed that there was increased coverage of the population with basic services. Since then, several pilot projects have been carried out in other parts of the country and the results have been satisfactory. Studies have also been done on various aspects of the volunteer service, such as the method of selection, the types of people who are best suited to perform health services on a volunteer basis, etc. The

experience gained from these studies led to the development of a nationwide programme of primary health care in 1977.

THE CONCEPT OF PHC IN THAILAND The concept of PHC in Thailand has been developed from the country's experience in solving the health problems of underserved people in the rural areas. The concept of community participation - consisting of the contribution of ideas, manpower, money, and materials by the community - is fundamental and provides the key to the success of the PHC programme. To educate a community to be self-reliant or self-supportive is another basic concept that the programme fosters. The Ministry of Public Health (MOPH) is aware that the strengthening of a health-services delivery system and development of a referral system is essential to support the PHC activities. In the National Seminar on Health for All by the Year 2000, conducted in December 1979, it was decided that primary health-care activities should comprise the following elements: (1) health education; (2) local endemic disease control; (3) maternal and child care, including family planning; (4) immunization against communicable diseases; (5) provision of essential drugs; (6) treatment of common diseases; (7) nutrition promotion; and (8) sanitation and safe water supply. Furthermore, the participants in the seminar felt that PHC activities could be changed according to community awareness of the problems to be solved. Because health is only one part of development, other aspects such as education, agriculture, community development, etc., should also be considered. OBJECTIVES OF THE PHC PROGRAMME The objectives of the programme, formulated on the basis of various concepts, were: 1. To expand the coverage of the health services, particularly among the underserved rural population, and to help the people help themselves. 2. To utilize community resources and encourage community participation in order to solve individual health problems, and eventually to establish self-help programmes at the village level. 3. To promote the dissemination of health information to local people, as well as to integrate all data that would reflect the needs and improve the health of the communities. 4. To make basic health services available, accessible, and acceptable to the people. 5. To promote better health for rural people as well as to enhance their awareness of health problems and problem-solving. PRIMARY HEALTH-CARE WORKERS Based on experience in Thailand, it is recognized that potential human resources exist in the community and are waiting to be mobilized. Two types of primary health-care workers have thus been developed: village health communicators (VHCs) and village health volunteers (VHVs), who promote rural health and other development efforts through an organized community. The VHCs are responsible for a cluster of 8 to 15 households, the VHVs for the whole village. The functions of VHCs are to impart health education (prevention and promotion), and to disseminate and obtain health information from the villagers. The VHVs

perform the same functions as VHCs, but also have the duty of caring for people who have had simple accidents or injuries and those with common diseases. Both VHCs and VHVs work on a voluntary basis. However, the government provides them with free medical services and a certificate when their training is completed. Other intangible incentives such as recognition from their peer group are also present.

SELECTION OF PRIMARY HEALTH-CARE WORKERS (VHVS AND VHCS) To prevent a high drop-out rate for PHC workers, proper procedures for selection are critical. Community preparation prior to selection is necessary. A simplified house-tohouse survey proved suitable for identifying the right people. TRAINING OF PHC WORKERS An informal five-day training course for VHCs, covering the use of self-instruction modules, health problem identification, team working, etc., is organized by subdistrict health personnel. The 35 self-instruction modules for VHCs cover curative, preventive, and promotive measures. The VHCs are expected to be able to disseminate such knowledge and gather information from villagers. VHVs obtain 17 additional modules on simple curative care and are trained for an additional two weeks. When the programme was first implemented nationally in 1981, a training scheme extending from the central MOPH to the peripheral level was developed (fig. 1) The central trainers are staff members of the MOPH trained in the principles of teaching and learning, using 7 modules on self-teaching and learning. These trainers then developed simplified modules for training the provincial and district trainers and became involved in curriculum planning and training of VHCs and VHVs. The provincial/district trainers consisted of provincial health staff from the training section and one staff member from each district health office. This team was responsible for training tambon health personnel to conduct the training of VHCs and VHVs.

Project Highlight: Health Care Reform Project - Thailand In Thailand the Department of Public Health is assisting the Thai government in a reform process of the health care delivery system. This is done in close collaboration with a number of former ICHD-participants and with former collaborators of the Ayutthaya action-research project, which had run its course in 1996. The need for reform was identified starting from the following observations. Thai society is in a period of very rapid evolution. The booming economy is transforming Thailand into an industrial rather than an agricultural country, but this has a number of side effects which need to be carefully managed. Specifically, the

danger of evolving into a two-tier kind of society, in which the gap between rich and poor is widening, is very real. Health care is becoming increasingly technologyoriented and partly commercialised, among other things in the wake of a wildly expanding private-for-profit sector. Although the Thai government has always implemented a policy aiming at maximum coverage and access to essential health care, a substantial portion of the population is still not covered by any form of health insurance. The ever rising cost of health care is of increasing concern to the public and to policy makers. The Thai health care reform focuses on four general concerns: equity, quality, efficiency and social accountability. The reform project aims to specify these concepts in accordance with Thai reality and to translate them into outputs in the fields of legislation (regulation of health care delivery and social security), institutional development for training, planning and monitoring of change, and the building of technically efficient, integrated health care delivery systems, accessible to all, focusing on primary medical care backed up with effective referral hospitals. Such integrated systems are being developed in five provinces in different parts of the country.

At an international workshop on Health Care Reform; at the Frontier of Research and Policy Decisions, held in Korat (Thailand) in January 1996, an exchange of experience and insights has been brought about, drawing on the experience of several countries in different continents. Presently, in implementing the reform process in Thailand, inputs in the form of technical assistance are provided in the fields of system management, development of primary medical care (developing the concept of family physicians), quality assurance at first contact and referral level, and health economics. The ITMs Department of Public Health is providing this technical assistance in close collaboration with the London School of Hygiene and Tropical Medicine, with the Lothian Health Board and Edinburgh University (Scotland), and with the Thai government and universities in Bangkok and in the provinces. The project is cofinanced by the European Union (DG I) until 1999. Implications for health promotion strategy Concerning health promotion as a process of enabling people to increase control over, and to improve, their health, and to reorient of health services was considered a meansfor health promotion action. Experiences from the development of the health care system in Thailand could draw many recommendations for reorientation of the healthcare system to support health promotion as follows: 1) The health care system should not limit its role to effectively provide only P&P services but should also empower people to take care of their own health. Reorientation of the health care system as well as retraining health personnel are needed to augment this essential role. Primary health care could be considered as a core strategy for this reorientation and the first step is to rethink the roles of people in health and health-service provision. 2) Universal access to P&P services should be guaranteed as a basic right of people because of its positive externality effect and its cost effectiveness. Access to P&P services could affect not only the health of individuals but also the health of people in the community. 3) The health care system needs to be reoriented in order to favour universal accessto P&P services. These include the following: Minimizing physical barriers by improving the coverage plan. This could be done by using an administrative area approach or a catchment population approach. The administrative area approach could lead to maldistribution of health facilities if there are different population sizes at the same level of the administrative area; the catchment population approach is preferred in thiscase.

Minimizing financial barriers by using general tax revenues from the central government or local governments. Provider payment for P&P services should be performance-related and an appropriate information system needs to be established to monitor provider performance in delivering P&P services. 4) Although integration of health service delivery is preferable, a vertical structure still has some roles to play in the provision of P&P services, especially in these circumstances: - An emergency situation needs a rapid response; - A situation of low prevalence of health problems; - Basic health care infrastructure is not operating properly. 5) P&P services are best delivered by a primary care provider. A primary care provider can deliver most health services comprehensively. Its location close to the community also facilitates its interaction with the community and creates mutual understanding and close collaboration between the primary care provider and the community. 6) Health centres and district hospitals are the main public primary care providers in Thailand. The health centre needs to be further strengthened in order to increase acceptability to the people. More investment is needed to improve the capability of health centre personnel as well as the physical infrastructure of the health centre. 7) A private health care provider could participate in the provision of personal P&P services if an appropriate financial incentive is arranged. Involvement of private health care providers in the provision of P&P services could improve service coverage, especially in urban areas, and could shift public investment to other places where the needs are greater. 8) It is rather difficult to empower people by using the bureaucratic structure and the topdown approach. Working with people in a horizontal approach such as a partnership is recommended, and this would facilitate the learning process of each others, and also create a sense of ownership The Image of the Thai Health System The current National Economic and Social Development Plan specifies the vision of desirable Thai Society that it is a strong society with a balance of three aspects, i.e. society of quality, wisdom/learning, and Unity / solicitude. Thus, health as part of society has to be strong and balanced in such three aspects. A proactive health system that emphasizes health promotion of the people, in parallel with a satisfactory health insurance system, so that the people will have access to health care that is solicitous and of good quality when necessary; whereas all sectors of society at all levels have potential and participate in the creation and management of the health system according to the sufficiency economy philosophy, through learning and utilization of Thai and international wisdom in a wellinformed manner, so as to make Thai society survive in a self-reliance and healthy manner in the global society that is interconnected and extensively influential to each other.

Vision of Peoples Health Development All Thai citizens have security to live a happy life in a healthy condition, with access to health care in an equitable manner, in a family, community and society that is self-sufficient in terms of health, with potential, learning and participation in managing health problems, using international and Thai wisdom in a well-informed manner. Source: National Health Development Plan under the 9th National Economic and Social Development Plan (2002-2006).

Core Mission: Mobilization of resources from the entire society for promoting health (all for health) The 9th National Health Development Plan focuses on the mobilization of resources from the entire society for promoting health by creating health consciousness in all sectors of society, and providing an opportunity for them all to participate and use their potential in the development process to make a healthy society.

Strategies and Tactics for Health Development Development Strategies To achieve the objectives and targets of health development that will lead further to achieving the desirable image of Thai society and health system, the following seven development strategies have been formulated and used during the 9th Plan Period Strategy 1: Development of management system for health Strategy 2: Development of health security and service quality Strategy 3: Development of basic factors for good health and health promotion Strategy 4: Development of peoples health behaviours and potential as well as strength of civic groups for health Strategy 5: Development of health knowledge and technology Strategy 6: Management of human resources for health Strategy 7: Development of countrys competitiveness in health Development Tactics For the above strategies, the following tactics have been specified. Strategy 1: Development of management system for health 1) Revise the management system leading to good governance. (1) Establish the management, information, and budgeting systems according to the results-based approach ( 2) Adopt the management approach emphasizing the proactive health development concept 3) Coordinate and enhance partnerships and networking with domestic and international agencies (4) Reorienting the role from being operators to supervisors and supporters 2) Develop and create a checks-and-balances mechanism in society. (1) Campaign on consciousness, values, ethics, and principles (2) Develop a mechanism of checks and balances (3) Support counter-corruption efforts by: - Revising rules and regulations that will minimize the use of personal judgement - Setting up guidelines for actions against corruption - Raising public awareness against corruption 3) Revise relevant laws. (1) Revise relevant laws that will support the management system (2) Serve as a core agency in pushing for the legislation of the National Health Act and the Health Promotion Foundation Act (enacted in 2001) (3) Develop guidelines for the decentralization of powers Strategy 2: Development of health security and service quality 1) Support the development of health insurance systems including the payment systems so that they all are efficient and uniform, with clear legal measures. 2) Develop primary care facilities in both urban and rural areas with a good-network involving

intermediate- and high-level healthcare facilities. 3) Develop healthcare facilities so that their qualities are in accordance with the Thai or international standards. 4) Promote the use of herbal medicines and Thai traditional medicine in public and private healthcare facilities. 5) Develop the emergency medical service system at the national and provincial levels, with regional/general hospitals serving as the centres. 6) Set up a system for foreign workers to have access to health insurance with premium payments. Strategy 3: Development of basic factors for good health and health promotion 1) Push for the adoption of provisions on health promotion, prevention/control of health problems, and development of basic factors in the national health development law, including the setting up of a mechanism, policy, measure and process for health promotion at the national level in a holistic manner according to the changes in economic, social and political situations. 2) Develop a system or network for the surveillance, prevention/control, and monitoring of health problems according to the changing situations. 3) Promote the knowledge, ethics, and responsibility of the private sector, particularly the operators in the manufacturing sector, to be conscious of the quality of their products and responsible for the health and environmental impacts of their operations. 4) Develop the health information system so that it is up to date and links to other relevant agencies, provide an opportunity for other individuals or agencies to easily access and use the information, and promote a mechanism for the dissemination of correct information to target population on a timely basis as necessary. Strategy 4: Development of people,s health behaviours and potential as well as strength of civic groups for health 1) Create the values for society members to emphasize and realize the importance of health consciousness and healthy lifestyle, based on the self-reliance and self-care principles, and develop the potential related to the building of knowledge, standards, technology and innovation, involving all sectors concerned, for the promotion of learning process in health. 2) Promote/develop the private sector, especially operators of the manufacturing sector to be conscious of the quality of their products and responsible for the health and environmental impacts of their operations. 3) Create opportunities for learning and developing healthy life-skills at the individual, family, community and societal levels. 4) Develop the environmental factors that will facilitate health behaviour development at the individual, family, community and institutional levels. 5) Develop systems/mechanisms and partnerships/networks of public participation in health development. 6) Develop a quality and efficient information system as well as a community health surveillance system. 7) Develop the potential of communities for health promotion, disease prevention/control, health rehabilitation, and consumer protection, using local wisdom and appropriate technology. Strategy 5: Development of health knowledge and technology 1) Develop the technical management system for health research that will help technical officers and researchers in their efforts in building the body of knowledge in health in various disciplines in terms of

both quantity and quality. 2) Assess the potential of agencies under the MoPH in conducting research studies on health promotion as a whole. 3) Create a mechanism for technical officers and researchers to adhere to the ethical principles in doing research, particularly the system for monitoring research on humans. 4) Place a particular emphasis on the creation and coordination of participation of all domestic and international health partners in all sectors in developing the research system as well as researchers and research work. 5) Promote the creation of management decision-making on the basis of information and knowledge related to health that can be verified. 6) Promote the strengthening of the system for controlling, monitoring, and assessing the research achievements and results utilization. 7) Support/push for the establishment of an autonomous/flexible agency that will help to set up a system/mechanism for the management of knowledge and wisdom for health in a fullcycle manner. 8) Develop a system for the dissemination of research information or findings and body of knowledge so that it is convenient for the public to have access to and use such information or knowledge. Strategy 6: Management of human resources for health 1) Establish an agency or a ministerial/central committee to be responsible for monitoring and setting up mechanisms, criteria, principles, and conditions for developing policies and plans on the production, development, and management of health workforce, possibly by merging health workforce agencies under the MoPH according to the national health manpower policies. 2) Establish and develop a central database of health workforce of the MoPH in such a way that it is of good quality, accurate and up to date, covering all agencies concerned, and having linkages with all other central and local databases; a core agency should be set up for this purpose and another agency or a private firm may be contracted to collect and process the data. 3) Support the production of health personnel so that the categories, quantities, qualities, and specific qualifications are consistent with the needs and necessity for the health service system reform of the country. 4) Revise the personnel management system so that it is more flexible and efficient, including: - Performance assessment system - Incentive and compensation system - Utilization and distribution system consistent with the needs and for problem-solving in each locality - Personnel (in-service) development system in response to the decentralization policy - Monitoring and assessment system that is transparent and accountable. 5) Develop a personnel development plan aimed at raising the knowledge, capability, skills, righteousness, morality, attitudes, and values for service provision consistent with continuous health service system development efforts. 6) Create and support the building of new knowledge as well as technology suitable for the changing health problems and situations. 7) Provide technical advice to agencies and healthcare facilities in the heath system as well as to the communities and localities.

Strategy 7: Development of countrys competitiveness in health 1) Develop the personnel potential to be capable of supporting system operations in an efficient manner. 2) Develop an organization, working system, and information system with work standards in support of the production of health products. 3) Promote and provide technical support related to the production technology to enhance the capacity for the production of health products for import substitution. 4) Establish partnerships and networks for cooperation in the operations for enhancing export efficiency. 5) Develop and assure the quality of health products and health services according to the international standards and those of trading partners.