AGENCY FOR INTERNATIONAL DEVELOPMENT FOR AID USE ONLY WASHINGTON, 0- C. a253A I 294 BIBLIOGRAPHIC INPUT SHEET 1. SUBJECT NDOO-0000-G750

FICATION . del ivery--Thailand

2. TITLE AND SUBTITLE A look at programs to expand the rural health delivery system in Thailand

3. AUTHOR(S) Mol ldrem,Vivlkka 4. DOCUM'ENT DATE 5. NUMBER OF PAGES | 6. ARC NUMBER 1975J IH- . ISqp. I ARC

7. REFERENCE )RGANIZATION NAME AND ADDRESS AID/ASIA/USAID/Thailand

8. SUPPLEMENTARY NOTES (Sponsoring Organization# Publishers, Availability)

9. ABSTRACT

10. COTROL NUMBER 11. PRICE OF DOCUMENT

12. DESCRIPTORS 13. PROJECT NUMBER Project implementation Proj ec t s, 14. CONTRACT NUMBER uraes 4 CO T A T N M E Rural areas .AID/AS.IA/USAID/Thailand Thailand 15. TYPE OF DOCUMENT

AID 590-1 (4-74) A LOOK AT PROGRAMS

TO EXPAND THE RURAL HEALTH

DELIVERY SYSTEM IN THAILAND

by Vivikka Molldrem for USOM THAILAND March, 1975. PROJECTS RESEARCHED FOR THIS PAPERS

I. Phitsanulok Project: Division of Rural Health, MOPH/WHO 11. Saraphi Project: Chiang Mai University, School of Community Medicine/ MOPH. III. Non-Thai Project: Provincial Health Administration of Nakorn Ratchasima/ Division of Health Education, MOPH. IV. Malaria Volunteer Program: National Malaria Eradication Program, MOPH. V. Ramathibodi: Community Health Progrea at Bang Pa-In. VI. DEIDS: MOPH/APHA/USAID Washington. VII. Community Based Family Planning Services. VIII. Pilot Study on Expansion of the Government's Family Planning Services Using Village Volunteers: Public Health Administration Department, Faculty of Public Health, Mahidol University/National Family Planning Program, MOPH. IX. Chonburi Project: Chonburi Provincial Health Administra- tion/WHO. X. Accelerated Maternal and Child Health and Family Planning Services: UNFPA/WHO/UNICEF/National Family Planning Program, MOPH. XI. Community Development Workers as Family Planning Educators and Distributors: PPAT. XII. Tambon Paramedics as ramily Planning Educators and Distributors: PPAT. XIII. University Students Project: PPAT. XIV. ARD Mobile Medical Teams and Tambon Paramedics: ARD/Divisionof Rural Health, MOPH. XV. Family Planning Communication Development and Integrated Campaigns: UNFPA/National Family Planning Program MOPH. XVI. Mobile Vasectomy Units: PPAT. XVII. Use of Midwives to Inject Depo-Provera: National Family Planning Program, MOPH. CONTENTS Page Introduction 2 Existing Rural Health Services in Thailand 4 Table I: Per Capita Expenditures on Health Versus Ability to Pay, by Province 6 Table II: Existing and Targeted Health Center Infrastructure as of 1973. 11 Major Considerations in implementing a Program to Expand Rural Health Services 16 The Kinds of Health Projects Presently Underway in Rural Thailand 23 I. Village Volunteers 23 II. Cooperation with Village Indigenous Health Services and Village Level Programs of Other Ministries 32 III. Retraining and Redefinition of Duties of Existing Health Personnel 36 IV. New Categories of Health Personnel 39 V. Mobile Health Units 42 VI. Mass Media 46 - 2 -

INTRODUCTION

This report is based on information obtained from interviews with staff members of various health and family planning pilot projects as well as project proposals and other project documents. A great many people were most help­ ful in giving of their time to describe projects in which they are involved and to provide written materials about them. The Division of Health Planning in particular has been of great assistance in providing information both about individual projects and about the rural health sector in general. The report has attempted to present the information on all projects fairly; however, since most of it was received via word of mouth, it is possible that some statements may be inaccurate. Given the number of projects covered, minor inaccuracies about individual projects probably do not alter the broad generalizations significantly. The report is divided into three major sections. The first section describes the existing rural health services in Thailand, including national targets for development of the rural health infrastructure, financial and personnel constraints to meeting these targets, and a word on the private sector. The second section draws some conclusions as to the factors which should be considered before implementing any kind of project to expand services to rural areas, based on the experiences of the projects covered. The third section describes the ongoing and recently completed pilot projects to expand rural health and family planning services in Thailand, by broad classification of methods employed. Some generalizations are then made about important factors to be considered in utilizing each method, some typical costs involved, and possible impact. There is no one kind of project which provides the panacea for all rural Thailand's health problems, nor is there any one kind of project which is will probably be effective in all areas, without some modifications. Rather, combinations of various types of projects are more appropriate, the particular combinations depending on local conditions, such as village structure and ethnic background of villagers, quality of the network of transportation and communications, staff and infrastructure constraints of the rural health service, available financial resources, and special health problems of the area. -3-

If there is one message which runs throughout this report, it is the importance of the midwives and sanitarians working at the tambon level health centers. These are key personnel in almost every health project, if not directly in providing services then at least to lay the groundwork or provide follow-up. Projects cannot by-pass the tambon level health workers without setting up a duplicate structure at a high cost. Therefore the success of any project depends on the effectiveness of the bealth workers. First priority should be given to increasing their effectiveness through such means as improved supervision, retraining and motivational techniques. There are some ongoing pilot projects not researched for this report. For example, the Soong-Nern Project, the mobile family planning clinic of McCormick Hospital in Chiang Mai, and the parasite disease control prcject of Nakorn Sri Thammarat are among those not covereed. The attempt was made, however, to study as many projects as possible within each category of methods used, so that the generaliza­ tions made would apply to those projects not covered as well. Details of individual projects were written separately and are not included in the main body of this report, in order to minimize its length.

There is some terminology, not always consistent in English, which should be clarified here.Throughout the report, "health worker" will refer to goveriunent midwives and sanitarians. "Midwife" always means government midwife. Indigenous midwives are so specified. Province refers to the Changwat, district to the amphur, village to the muban. The terms "first class health center" and "second class health center" are consistently used, although these terms are now being replaced by "Primary Medical and Health Sub-Center" and "Secondary Medical and Health Sub-Center". Finally, the initials FP and MCH ara often used to signify family planning and maternal and child health, respectively. - 4 -

Existing Rural Health Services in Thailand

The Ministry of Public Health (MOPH) provides the bulk of the government's rural health services. For FY 1975, the MOPH has appropriations of 1,547.4 million baht, about the same percentage of the total RTG budget that it has received for the last eight years (three percent). The total alloca­ tion to the provincial health service, including operating and capital costs, amounts to about 89 percent of the total budget. There are as yet no indications that rural health will become a higher priority of the Thai government in the next few years, although all of the political parties elected recently included rural health on their party platforms. In fact, some members of the Country Health Programming Team (WHO Assessment Team) voiced concern that the poor in municipa­ lities have been neglected in the past and that they should receive top priority in the future. Since 1971 the budget of the MOPH has fallen in real terms despite slight increases in money terms so that the real increase in the 1975 budget of close of fifteen percent leaves the Ministry at about the same position it was in during 1971. This means that staff increases and higher levels of construction can only be financed at the expense of other programs, by consolidation of programs, or by more efficient operation. In 1975, several of the specialized programs registered real declines, disease control, school health, and maternal and child health among them. On the other hand, 18,220,000 baht have been appropriated as counter­ part fund for health projects, including 13 million baht for "medical volunteers".

In terms of how the budget is allocated to the provinces, Table I may provide some insights. Table I compares provincial ability to pay for its own health services with MOPH expenditures and non-MOPH health expenditures, per capitized. MOPH expendi­ tures are further separated into expenditures on improvement of provincial hospitals (capital costs) and expenditures on provincial and district health administration plus improvement and expansion of health centers. While the latter includes both operating costs and construction costs, it is impossible to separate the two because provinces have mixed them in their reporting. The difference between the sum of these two columns and total MOPH expenditures is accounted for by the - 5 ­

various special health programs (communicable disease control, school health, family planning, etc.). Column 1, percent of employment outside of agriculture, is meant to give a rough measure of comparative wealth of the provinces. Columns 1, 2, 4, and 5 are expressed in terms of both amount and rank order among provinces. It will be noted that Column 1 is derived from 1970 data, while the other columns are derived from both 1973 expenditures and 1972 population. In all cases, these were the most recent figures available, and it is assumed that for this rough ranking, changes which occurred between the years involved would not significantly affect the results. Although no strong correlation between wealth and health expenditures is apparent, many of the "poorer" provinces of the Northeast and North also rank low in MOPH expenditures, and some of the "wealthier" provinces of the Central Plains and South rank qute high. Thus a province's financial need does not appear to be a particular priority for additional MOPH funding. There may be some substitution effect in ARD provinces, however, where ARD paramedic and Mobile Medical Team projects substitute for MOPH expenditures, but this does not show up in Column 5, non-MOPH expenditures. In non-MOPH expenditures as in MOPH expenditures, there is a fairly wide variation within regions of per capita health expenditures. No strong correlation between non-MOPH health expenditures and either wealth or MOPH expenditures is apparent. Small provinces in terms of population seem to fare relatively well in MOPH expenditures. There is probably a minimum expenditure per province, regardless of size, required to operate a provincial hospital and a minimal level of health service.

It is interesting that in the majority of cases, per capita expenditure on improvement of provincial hospitals is as high as or higher than other MOPH expenditures. Since provin­ cial hospitals are found in the province capital cities, normally the largest cities in the provinces, this may indicate that priority is skewed towards the urban population. It also indicates that medical services have priority over general health services. TABLE I Per Capita Expenditures on Health Versus Ability to Pay, by Provinc (1) (2) (3) (4) (5) Percent of Per Capita Per capita MPH Nn-budgeted Etloymnat Per Capita MOPH Expendi- Expenditures on per capita outside Total MOPH tures on Provincial and Expenditures agricultureg penditure2Mqprovwesnt District Health (revenues from (1970) 1973 of Provincial Adm. & laprove- hospitals & Hospital mnt &Expansion4 health centers Regioni and Prvince 1973of Health Centers contributions, 1973 1973 etc5 1973

egionl % Rank Baht Rank Baht Baht Rank Baht Rank Bangkok (Pbra Nakhon) 91.67 1 1.02 67 0.00 1.01 67 na x Sarab ri 27.98 12 20.92 13 15.78 4.02 51 19.92 3 Ayutthaya 37.89 9 11.78 36 4.43 6.50 20 3.54 46 Pathuzn gai 34.04 10 16.88 20 8.24 8.50 10 2.95 48 Lpburi 23.31 19 13.17 31 7.04 6.12 25 8.92 19 Chai Nat 16.02 35 13.02 2 6.83 6.19 22 12.42 8 Singhuri 22.64 23 15.31 26 13.57 1.44 65 8.81 21 Nonthaburi 49.43 4 16.25 24 10.35 5.67 32 3.77 45 Ang 7t~g 22.78 20 17.06 9 8.96 7.84 14 8.16 24 Reion 2

*Chonburi 40.24 8 14.19 9 6.78 6.96 17 10.76 14 Chachoengsao 22.73 22 11.58 40 5.49 5.81 29 na x Rayong 23.56 17 18.76 6 10.56 6.54 19 na x Chantahbi 22.77 21 32.17 5 16.19 8..64 9 23.57 2 Trat 23.97 16 29.39 7 13.60 13.97 2 19.03 4 Prachinburi 16.64 33 10.91 3 5.43 4.74 42 12.76 7 Nakorn Nayak 19.61 27 18.72 7 8.41 7.50 15 23.67 1 Samut Prakan 61.89 2 .1.80 5 5.73 5.80 30 4.1 43 reim 3

Mbon Ratchathani 8.51 56 .1.64 9 4.69 5.12 39 11.95 10 Nakorn Ratchaslma 14.50 39 9.93 6 6.27 3.45 58 5.30 34 Buriram 5.75 62 7.31 8 2.77 4.26 48 5.26 35 Surin 5.96 61 6.62 4 2.55 3.03 61 0.83 54 Sri Saket 4.19 6 6.91 2 2.50 4.22 49 na x Chaiyaphum 6.29 0 6.65 3 3.06 2.91 62 4.54 41 yasothorn6 na x 9.53 8 2.83 6.44 21 5.02 36 -7­

rable I (cntimed)

Pert of Per Capita Per capita MPH Non-budgeted mpoynmt Per Capita mwH Exendi- mqxeditures on per capita outside Ttal MWH tures on Provincial and Expenditures agriculatrel Eqnditure2 "D=nmmvnt District Health (revenues fra (1970) 1973 of Provincial Adm. & MIprove- hospitals & Hospitals 3 nent & Epansion health center: Region and Province of Health Centrs contributions 1973 1973 etc.)5 73

4% Rak ah Rank aht Baht Rank Baht Rank

Udorn 11.13 47 6.43 65 2.72 2.76 63 4.98 37 Ihon Kaen 10.47 50 7.38 57 3.15 3.84 54 8.78 22 Maha Sarakham 4.43 65 7.50 56 2.23 4.32 46 5.72 33 Rai Et 4.98 64 7.15 60 3.26 3.88 53 5.84 31 Kalasin 5.34 63 8.38 52 2.86 5.12 39 0.45 55 Nakorn Phancm 8.28 57 10.88 44 5.71 4.66 45 8.21 23 Sakorn Nakorn 7.42 58 9.89 47 3.60 4.20 50 4.77 39 Nong Fhai 10.50 49 11.66 38 5.09 6.17 23 4.82 38 Loei 6.52 59 19.35 15 10.85 7.98 13 4.60 40

Lmapang 16.60 x na. x na na na x Chiang Mai 23.42 18 13.52 30 5.91 6.73 18 3.36 47 Mae Hong Son 12.22 45 24.33 10 20.60 3.35 59 na x Lamphun 15.24 36 10.23 45 4.92 5.30 37 4.23 42 Prae 14.99 38 16.29 23 9.37 5.60 33 11.24 13 Nan 9.02 55 18.34 18 12.08 5.44 34 12.07 9 chiangRai 9.72 53. 7.53 55 3.97 3.04 60 0.89 53 Uttaradit 13.81 43 7.84 54 6.26 1.27 66 9.81 17

Region 6 1

Phitsanulok 14.27 41 19.62 14 13.12 5.04 41 16.84 5 Sukhotai 10.99 48 11.69 37 6.85 3.41 56 0.12 58 Tak 17.03 31 27.32 j 22.14 4.27 47 13.15 6 Kampaeng Phet 9.50 54 9.10 49 5.61 3.48 57 7.35 27 Uthai 7ani 10.14 51 16.36 22 5.66 8.39 U 11.48 U1 Nakorn Sawan 19.46 28 11.02 42 4.81 5.32 36 10.47 15 Phichit 13.15 44 7.24 159 2.18. 4.67 44 1.89 49 Petchabun 43.76 x na x na na x na x Region_7 Nakorn Path=n 26.88 14 18.48 51 2.18 5.97 28 na x Suphanburi 15.09 37 4.98 66 3.40 1.48 64 na x Kanchanabri 20.76 25 *12.52 33 5.9.0 6.12 25 6.93 28 Ratchahzri 30.54 1 21.98 12 14.61 5.30 37 1.60 50 Table I (continued)

Per Capita Per capita MPH Non-budgeted Percent of Per Capita MOPH Ecpendi- Expenditures on per capita Empoyrnt Total M _PHtures on Provincial and Expenditures Ex iture2 M omv t District Health (revenues fran ztside & agricul- of Provincial Adm. & Improve- hospitals 1 Hospitals 3 ment & Expansion health .nters tre 1973 . (1970) 1973 of Health Centers ontributions 1973 etc.)5 1973 Fegion and Province ,_-- Baht Pan Region 7 (continued) % nk Baht Rank Baht Baht Rank 3.94 52 6.15 29 Petchaburi 27.54 13 7.86 53 3.71 Prachuab Khi.ri 30 25.42 15 12.14 34 6.27 5.69 31 5.97 Khan 0.18 57 Songkhrmn 48.08 5 7.15 60 0.00 6.17 23 Sanut 6.06 27 3.81 44 Samut Sakorn 42.27 7 14.44 27 7.81 Region 8

Nakorn Sri- 1.49 51 Thammarat 14.02 42 8.67 50 2.08 3.80 55 33.37 3 21.60 11.31 5 8.85 20 Krabi 1.90 46 x 57.90 3 24.74 9 15.19 8.73 8 n.a. Phuket x 0.35 56 Phang Nga 34.20 x n.a. x n.a. A.a. 6 45.62 1 27.88 17.73 1 n.a. x Ranong 45.44 16 18.30 30 15.82 25 7.35 8.38 12 9.98 Chumphorn x n.a. x Surat 7hani 16.33 x n.a. x n.a. n.a. Region 9 19.80 26 40.25 2 33.56 5.43 35 9.79 18 Songkhla 1.46 52 Phattalung 9.81 52 14.421 28 5.21 9.09 7 29 11.12 41 5.61 4.68 43 7.57 26 Trang 19.40 32 14.41 40 22.50 11 11.17 10.76 6 5.77 Sathun 16 7.73 25 Pattani 16.72 32 16.56 21 7.48 7.10 21.61 24 30.72 6 18.28 12.28 4 n.a. x Yala 3 11.46 12 Narathiwat 16.38 34 32.30 4 19.86 12.29 1. Derived from 1970 Census of Population and Housing "Table 22: Economically Active Population Eleven Years of Age and Over By Major Industry Group, Work Status and Sex". "Outside of Agriculture" means outside of Agriculture, Forestry, Hunting and Fishing. 2. Derived from Total MOPH Expenditure by Province 1973, excluding health programs not operated by the provincial administrations, divided by provincial population, according to the Census Division, Department of Provincial Administration, December 31, 1972. 3. Derived from MOPH expenditure by Province on Improvement of Provincial Hospitals,1973, divided by Population as per footnote 2 above. 4. Derived from MOPH expenditure by Province on Provincial and District Health Administration plus Improvement and Expansion of Health Centers divided by population as per footnote 2 above. 5. Derived from total health expenditures by province for 1973 not budgeted by the MOPH, from sources such as hospital and health center revenues, local contribu­ tions, and contributions by provincial government and other Ministries divided by population as per footnote 2 above. 6. In 1970 Yasothorn was still part of Ubon Ratchathani, so no separate employment figures are available. - 10 -

For several years one of the MOPH's main concerns in the rural areas has been to complete the infrastructure of the rural health service, to make health care readily accessible to all. At the present time the MOPH feels that a complete infrastructure would consist of a full-fledged hospital in each province (this target has been met), a first class health center in every amphur (district) with a staff of ten to fifteen people including one MD, a second class health center in every tambon staffed by a sanitarian and midwife, and a midwifery center in every tambon with over 10,000 population. Many argue that this infrastructure is not sufficient to provide complete coverage, however. For instance, in imple­ menting a mobile health service in Chonburi Province, the planners assumed that a first class health center can only access about five tambons. Since an amphur has an average of eight tambons, the average first class health center is out of reach of three tambons under this assum.Lption. Project leaders of the Non-Thai Project in Nakorn Ratchasima and the Bang Pa-In Project in Ayuthaya assume that health workers (midwives and sanitarians) of second class health centers can only provide regular and frequent service to populations of 1,500 to 2,500, at least if village visits are to be among their duties. Thus a health center with a staff of two can serve a maximum of 5,000 people. Since tambons average from 6,500 to 7,000 people, at least one more health worker per tambon is necessary to provide full coverage. Table II presents the number of existing health centers as of 1973 (the latest available figures) compared to the target number necessary for complete coverage, assuming that every tambon needs a miawife center as well as a second class health center. The infrastructure is far from complete at this time, and of existing health centers only the second class health centers are fully staffed. The table goes on to consider the cost of completing the health infrastructure and additional operating costs required. It assumes that only eight people are necessary to run a first class health center, although the MOPH target is presently ten to fifteen.

The total cost of construction and personnel training is 01,057.3 million, or more than two-thirds of the MOPH 1975 total budget. This does not include costs of contract adminis­ tration, personnel selection, and other overhead costs. The additional cost of operating the new health centers is 0272.6 million, about 30 percent of the 1975 allocation for provincial health administration. - 11 -

TABLE II Existing and Targeted Health Center Infrastructure as of 1973 Increase Actual Target Needed 1st Class Health Centers 245 555 310 2nd Class Health Centers 2,724 4,375 1,651 Midwife Centers 1,546 4,375 2,829 Staffing: 1st Class Health Center Staff 1,625 5,550 3,925 for Targete Health Centers, Average Staff Per Health Center 6.6 10 825 for Existing ones. MDs at 1st Class Health Centers 214 550 336 for_Trgted Health Centers, 31 for existing ones. 2nd Class Health Center Staff 6,172 8,750 2,578 for Tar­ geted Health Average Staff Per Health Center 2.3 2 Centers. Midwifery Center Staff 1,460 4,375 2,915 for Tar­ geted Midwifery Average Staff Per Midwife Center 0.9 1 Centers, 86 for existing ones. Construction Costs Per Health Center, including buildings, land, electrical & water supplies, fences and roads. 1st Class Health Center 0967,500 2nd Class Health Center 206,000 Midwife Center 90,000 Expansion of Midwife Center to 2nd Class Health Center 161,000 Operating Costs, excluding Salaries 1st Class Health Center )251,300 2nd Class Health Center 33,380 Midwife Center 12,110 Personnel Training MD $250,000 Nurse 25,000 Health Worker (stnitarian), 10,500 Health Midwife 10,500 - 12 -

Personnel Salaries MD (2nd Grade Officer) $2,370/month 5 28,440 Plus Incentive for working Up-Country 2,000 Nurse (3rd Grade Officer) $1,645/month 19,740 Midwife (4th grade Officer-mid-range level) $1,015/month 12,180 Sanitarian (4th grade Officer-mid-range level) 01,015/month 12,180 Total Cost for Construction and Staff Training: 310 1st Class Health Centers 1299,925,000 each with 1 MD (310) x 250,000 77,500,000 1 nurse (310) x 25,000 7,750,000 2 midwives (620) x 10,500 6,510,000 2 sanitarians (620) x 10,500 6,510,000 (Total-for 1st Class Health Center $398,195,000) 1,651 2nd Class Health Centers 340,106,000 each with 1 Sanitarian x $10,500 17,335,500 1 Midwife x $10,500 .17,335,500. 2,829 Midwife Centers $254,610,000 each with 1 Midwife x 010,500 29,704,500 Grand Total $1,057,286,500

Operating Costs for New Health Centers 310 1st Class Health Centers 310 MDs $ 9,436,400 310 Nurses 6,119,400 620 Midwives 7,551,600 620 Sanitarians 7,551,600 .Operating Costs. (Supplies,Maintenancp,etc.) $77,903,000 1,651 2nd Class Health Centers 1,651 Sanitarians 020,109,180 1,651 Midwives 20,109,180 Operating Costs 55,110,380 2,829 Midwife Centers 2,829 Midwives 034,457,220 Operating Costs 34,259,190 Grant Total 172,607,150

(Cost figures from 1975 MOPH budget appropriations, D'enartment of Health Planning, and training costs from Scott Edmonds). - 13 -

Obviously, given the MOPE funding levels, it will take several years to complete this infrastructure. Generally the budget provides for construction of ten first class health centers, 166 second class health centers, 100 midwife centers to be expanded to second class health centers, and 100 to 200 new midwife centers. At these rates it would take 30 years to complete the first class health centers, seven years to complete the second class health centers, and perhaps 30 years to complete the midwife centers. Even with population growth rates reduced to two percent per year, however, Thailand's population will have doubled in 20 years, far exceeding the infrastructure's ability to service it. From this standpoint alone the MOPH would do well to consider increasing its emphasis on the family planning program. Besides the budgetary constraint, a major problem is the difficulty in finding skilled medical people, particularly MDs and nurses, who are willing to work in the more remote areas. MDs are now required to seve two years in government service, but Since there are shortages of doctors all over the country they still have their choice of location. The average increase in medical personnel in the government service per year, based on 1968 through 1971, is as follows: Physicians 190 Nurses 740 Midwives 450 Sanitarians 835 The vast majority of doctors and nurses go to Bangkok and the provincial capitals. As the Phitsanulok Project demonstrated a complete infrastructure does not guarantee that the health service will be used. One survey indicates that, nationwide, under 15 percent of all health care is given by government agen:cies and only 4.4 percent by health centers. In rurq; areas that latter figure increases to close to 7 percent. L Other surveys reach similar conclusions. The average health center in Amphur Non-Thai treated only 480 people per year prior to implementation of the project (1971), or only 1.8 people per day.

"Table 2.11." Base'Year Data and Background Information. National Health Programming-Thailand. January-February 1975. - 14 -

Besides the rural health service, there are several other government health programs at work in rural Thailand, including communicable diseases control, leprosy and T.B. control, malaria eradication, maternal and child health, family planning, and others. These programs, which except for malaria eradica­ tion have budgets of under 40 million baht each, are operated quite separately from the rural health service, with their own local workers and supervisory personnel. Most of them are under the authority of the Provincial Chief Medical Officer (PCMO) but their contact with health center personnel is quite limited. Some efforts are now being made to "integrate" the specialized programs into the general health service in areas with no critical disease problems, to utilize existing health personnel more efficiently. These are discussed in more detail later. Outside of the MOPH, the MOI has "tambon doctors" in all tambons, about 5,000 all together. They have received only two weeks training, ho.ever, and are used more for reporting of vital statistics than for treatment. ARD has trained over 1,000 paramedics to work with the second class health centers in remote areas of ARD provinces. This is the extent of government health services to rural areas. There are several private health services available to villagers. Almost every village has an injectionist, or "quack",who is often a person with some limited medical background, a druggist, an indigenous midwife, and an herbal doctor. To the extent that their activities involve the injection or sale of controlled drugs, they are illegal and, if drugs are carelessly used, may be dangerous as well. Though indigenous midwives do not usually use dangerous drugs, they often lack knowledge of such things as proper delivery techniques and sterilization of equipment. These practitioners work on a profit-making motive and usually do not make exceptions for the poor in charging for services. One study using a sample of population from all regions of Thailand showed that over the sample period, the average cost for treatment of an illness was 077.49. This was divided further into place of service: Self-treatment through purchase of drugs from drugstores 028.69 Health Centers $36.82 Government hospitals $166.91 Private clinics and hospitals $141.71 Herb doctors, quacks, and granny midwives $ 64.89 - 15 -

Thus, health centers are less expensive than indigenous practitioners but more expensive than drug stores. It is not surprising that in the study over half the medical care was given by drug stores. 8/ The MOPH realizes that it cannot afford to prohibit activities of village practitioners until it can offer a rural health delivery system to replace them, but where that system is in place it is looking for ways to convince villagers to use it. Its basic assumption is that the best way to improve village health care, and eventually villagers' health knowledge and attitudes, is through the rural health infrastruc­ ture.

I/ Table 2.13, 1 bid. - 16 -

Major Considerations in Implementing a Program to Expand Rural Health Services

are a number of problems and constraints which There should be affect the existing health services and certainly in implementing any major health program. The considered project which -­"ollows is derived from interviews with list which have directors and various articles and evaluations on the Thai rural health service (including been written Rural Health DTEC's Evaluation Report on the Comprehensive June-July 1973). The Country Health Programming Project, the next Team, when it has completed its analysis within should come out with a fairly broad and couple of weeks, ways listing of constraints, including recommended detailed list which of dealing with them. In the meantime, the follows covers the major points. The most obvious constraint to expanding 1. Cost. in services is the price tag, as discussed rural health have an previous section. Family planning projects the many times able advantage in this respect, since they are sale of contracep­ to defray their own expenses through the Non-revenue ­ producing programs must concentrate tives. or discover on ways of better utilizing existing resources which require little additional MOPH funding. new resources Redefin- There are possibilities in both of these methods. of presently underutilized health center ing the duties able to is one of them. Some projects have been personnel project carry out fairly large scale training and handle 4 on using only existing provincial or district administrat decrease health staf-i and supplies, without any apparent provincial and in other services. This indicates that at as well as at the health centers, there district levels ways. flexibility for utilizing personnel in new is some for a new Village volunteers are a popular possibility Funds from the provincial administration a-e resource. can be another possibility if the provincial governor priority. Probably, convinced that rural health should be a involving large scale construction, though, projects to the and new job categories which are additive equipment, capability present system are beyond the present financial of the MOPH. - 17 ­

2. Underutilization of the rural health system. No project based on the existing rural health system can expect to be well-accepted unless it has incorporated within it some means of increasing villagers' acceptance of the health system itself. The issues to be considered include the following: a. Lack of Curative Capability. Health workers are trained to give preventive service but are allowed to give very little curative treat­ ment. Villagers are mainly interested in the latter, however, so they go first to the local practitioners who can treat them. If health centers are to be utilized, te-y must be able to provide the services that villagers demand. b. Limited hours of service.

Office hours at the health centers are regular business hours, but at these times villagers are out in their fields. Health workers are not available, except in private practice, during the times when they could reach the most villagers. c. Physical and social distance. There is a distance between health workers and villagers, both physically and socially. The physical distance of a kilometer or two may be sufficient to cause a villager to go to a closer local practitioner. More frequent village visits by health workers could alleviate this. Many times health workers do not come from the tambon to which they are assigned. They are not long-standing neigh­ bours with the villagers they serve, and uliat is more, they are better educated than most and they are representatives of the central government. All of these things tend to build up a social distance between health workers and villagers which hinders communications. d. Presence of local practitioners. Local practitioners are more than competitive with health workers. They are close at hand, available day and night, often able to give injections and intravenous medication, and well known to the villagers. Both physical and social distance are minimal. At this point health workers have no special advantages over the other practitioners which would draw people to them. Possibly the offering of inexpensive family planning services could become one. - 18 ­

e. Inadequate supervision. The most important factor in the underutilization of health centers and the consequent indifference of health workers is their inadequate supervision, infrequent refresher training and re-motivation, and in general insufficient contact with both peers and superiors. There are national targets for the number of village and school visits which a midwife or sanitarian is to make each month, bat unless the District Health Officer or the chief of the first class health center or both is interested enough to visit and discuss their activities with health workers regularly and often there is no way to ensure that the targets are met. It is easy for a health worker to falsify a record, so good contact with both health workers and villagers is necessary for good supervision. But supervision needs to stress health education and reinforcement of health workers in the importance of their work as well as record checking, especially where they do not receive much positive reinforcement from villagers. Whether supervision and motivation of health workers is good or bad presently depends very much on the personality of the responsible District Health Officer (DHO). If the DHO is enthusiastic, chances are that the health workers are too. Perhaps it would be useful for the MOPH to do an in-depth management study of its rural health supervisory structure, which would identify the problems in the present supervision and recommend changes that would reduce the dependence of health workers' output on the personality of their immediate supervisor. Training curricula of all rural health personnel should include a major element emphasizing their supervisory responsibilities. 3. Recognition of the private sector. Despite the fact that the great bulk of the medical care is given by local practitioners, until recently there has been little attempt to include them in a rural health program, because doing so might legitimize practices which do not meet government standards and may even be illegal. - 19 -

Yet these practitioners have the potential for being excellent disseminators of health information to villagers, information gatherers for health workers, and family planning educators, because they are the traditional local health resources. Secondly, while the MOPH cannot control their activities, it can improve the quality of medical care they give and decrease misuse of dangerous drugs through training. Some projects are already training certain local practitioners such as indigenous midwives and tambon doctors, but they have only hit the top Of the iceberr. 4. Lack of coordination both between departments of the MOPH and between ministries. In the past, projects requiring cooperation between departments of the MOPH have had difficulties in implementation. The most common example is that of projects which attempted to establish referral systems between provincial hospitals and health centers, formerly under different departments. Specialized disease programs have maintained their own field personnel, but there has been little exchange of information between them and the health workers. Lines of communication continue to run up and down, ,ot across, and any successful health project must keep this in mind. The situation has changed somewhat, however, with recent reorganizations of the MOPH. Now provincial hospitals and health centers are under the same department, and all provincial health personnel (except a few programs working from regional offices such as Malaria Eradication) are directly under the authority of the PCMO. There has been a trend in the past five years to consolidate special programs into the general health service, making health workers multi­ purpose workers, responsible to both the rural health service and the special programs. These changes may ease intro­ departmental communications.

There are some joint health efforts between the MOPH and other ministries, such as the ARD health programs and the school health program,but not without problems. The MOI collects village vital statistics and operates the tambon doctors program completely separately from the MOPH, however. Other joint projects with other ministries are rare, and again, lines of communication run up and down within a ministry rather than across ministries. Yet other ministries have a real stake in rural health and population growth, especially in-terms of agriculture and education.Their stake needs to be stressed if the cooperation of other ministries is to be elicited. - 20 ­

5. Centralization of Authority. As point (4) above implies, in the MOPH as in other minis­ tries control of program operations is centralized in Bangkok. Some divisions are more centralized than others; for instance some disease control programs are regionalized in order to more effectively administer the varying disease problems of different areas of the country. Nevertheless -for most provinces it is Bangkok which determines their budget, not just in total but by category of spending, leaving the provin,?: health administrations without much leeway to deal with their own particular health problems. It is very important in implementing new health programs that provincial representatives have input in developing and operating them, adjusting them to match their own needs and resource capabilities within the programs'major targets. For instance, a mobile health service to remote areas will vary both in cost and type of services offered according to a province's ability to supply MDs or nurses to staff the teams, number of vehicles available, completeness of the health infrastructure, quality of the road network, local geography, and village structure. A village volunteer program must take into consideration provincial differences in ethnic background and level of wealth of villagers, village structure, quality of communications and transportation, coverage of local health workers, villagers' attitude towards the central government, and many other things. In other words,' successful programs must account for all kinds of regional differences in village living patterns and attitudes, localized health problems, completeness of the rural health service, geography, modes of transportation, alternative local resources, and other things, which are likely to receive inadequate considera­ tion without input from provincial health authorities. 6. Lack of epidemiological data. Vital statistics on the village level are very poor. Birth and death registrations are filed by the village headman, if he hears about them. With his limited knowledge about symptoms and causes of death, he often files a vague report. The Country Programming Team was forced to use provincial hospital statistics in its measurements of morbidity and mortality. Since hospitals only serve small percentage of the ill and deliver a small percentage of the births, these statistics cannot give an accurate accounting of the real disease problems in Thailand. Setting of priorities and targets for health care is consequently difficult. Health centers also keep records of services performed, but again they cover only a small portion of the area's population. - 21 ­

7. Lack of baseline and ongoing data collection by which to evaluate projects. In many of the projects covered by this report, little evaluative very data were available. Baseline data were not developed and collected prior to implementation could be maintained which and updated during the project period for ongoing analysis of effectiveness. evaluation, Without ongoing a project may not be receptive to its EVery health project own problems. should incorporate the reporting of certain easily collectable data which can regularly be summarized (perhaps monthly) in some meaningful way with minimum effort. Other forms of evaluation, and such as before after KAP Surveys, while important, do not interim progress point out or development of bottlenecks which might impede project success. 8. Poor health education. Villagers' health knowledge, attitudes, and practice are fairly low, for family planning and nutrition causes and symptoms as well as of diseases. Some health education is given in the schools, but much of that is traditional forgotten, while beliefs are reinforced through village tioners. Villagers practi­ need to be educated in the importance of disease prevention, nutrition, sanitation, health, and family maternal and child planning, if they are to be expected to accept the services health centers can provide. health education Ongoing has not been stressed in most of the projects so far, health outside of family planning, nor has there been a major effort to improve health education Some in the schools. MCH and nutritional education has been offered child clinics at well­ and Child Nutrition Centers, but the former have not been well accepted and the families latter reach only those which can pay for their services. Health should be incorporated education into the services offering curative treatment, which villagers do accept. 9. Legislative restrictions. Where projects call for creation of new job classifi­ cations or revision of present job classifications greater to include curative responsibilities, national legislation at least complete or MOPH concurrence is usually necessary to legalize the change. The problems to implementing be encountered in the change must be considered, and for major changes resistance should be anticipated. - 22 ­

10. Climatic Conditions. Any new project involving frequent supervision and field trips at the village level should choose its implementation dates keeping in mind that during planting and harvest time and in some areas rainy season contact with villagers may be difficult. Training of volunteers, for instance, should not occur just before harvest season if follow-up contact by health personnel must be delayed for the two months immediately following training, when the new volunteers are most enthusiatic. In general, projects have been most successful when training of health workers and villager groups have been followed up within the next few months. The longer the period between training and follow up, the less effective the results. - 23 -

The Kinds of Health Projects Presently Underway in Rural Thailand

I. Village Volunteers

The use of village volunteers is by no means a new idea, but in the past two years it has gained a great deal of momentum. Health volunteers can provide a fairly inexpen­ sive method of extending the health service at the same time as directly involving local communities in health care. The first experiment utilizing village volunteer workers in Thailand was carried out by the Malaria Eradication Program, which trained selected villagers to take malaria smears, give malaria suppression pills, and assist malaria team workers by identifying new houses or sheds in reed of malaria spraying. The program has been expanded over the years to become a major element in the whole Malaria Eradication Program, with .,mewhere between 7,000 and 8,000 volunteers, of whom between 63 and 75 percent are active.

In the mid '60's the rural health service began experimenting with v.Lllage volunteers, first in Amphur Wat Bot of Phitsanulok, then in Amphur Saraphi of Chiang Mai. These projects utilized two different types of volunteers. One was called a "communicator". Communicators were meant to be the basic village contacts between health workers and villagers. They would be informed of the days when the health workers would be at their village, and on those days would stay home from the fields to visit with them. They could answer health workers' questions about any illnesses, pregnancies, deaths, new families in the village, and other village health-related information. Then the health workers would know what homes to visit to give health care. Communi­ cators would also inform the other villagers of upcoming visits by the health workers and set up appointments for treatment, vaccinations, and family planning examinations. There was to be one communicator for about every fifteen households. - 24 -

The other type was a "village health post volunteer". These volunteers were usually selected from the most enthusiastic and active communicators and given two to four weeks of training in first aid and basic health care. They were sometimes given simple government remedies to sell to villagers at low cost. They were to set up their home or store as a "health post", where they could perform the same functions as communicators as well as give first aid and simple treatment, take samples for malaria, TB, or other diseases, coordinate the activities of the village's communicators, and allow people to gather for vaccinations or appointments with health workers. Although the Volunteer program has faded oui at Wat Bot and is relatively inactive in Saraphi,and despite a dearth of any evaluative evidence of their success, the volunteer idea developed in these projects has caught on in other areas. Amphur Non-Thai in Nakorn Ratchasima has used health post volunteers for several years and began using communicators as well about a year ago. Projects of schools of community medicine at Amphur Bang Pa-In, Ayuthaya, and Amphur Soong-Noen, Nakorn Ratchasima, have recently trained communicators, as has the DEIDS project in Lampang. Health post volunteers are to be selected later. Even the Malaria Eradication Program has begun to train malaria communicators as auxiliaries to its volunteers. There are slight variations in all of those projects as to methods of selection, duties, and supervision of volunteers. It is as yet too early to judge the effectiveness of any of them. Other projects include an experiment of the Institute for Population and Social Research of Mahidol University, which tested the relative effectiveness of using full-time, part-time, and volunteer field workers to spread family planning. Although there were some acknowledged problems with design and conduct of the experiment, the final report published in 1973 found that volunteer field workers performed bntter than the other two types. The cost per acceptor was higher, however, when the monthly reimbursement for expenses was taken into account. In 1974, the Community Based Family Planning Services Project began utilizing village volunteers to distribute contraceptives. A similar project is scheduled to begin in 1975 through the Faculty of Public Health of Mahidol University. - 25 -

Most of these projects are barely off the ground. There are some general statements, however, which can be made about the elements that go into a successful volunteer program, based on the experience of these projects thus far. 1. Selection. There have been several methods of selection of volunteers. One has been through the joint choice of health workers and village leaders such as headmen and monks, on the basis of leadership in the village and interest in health problems. (One midwife in the Bang Pa-In project, for instance, selected communicators on the basis . of their family planning accept-nce.) Another common method has been the use of a "sociogram", or questionnaire, given by the health workers to every household in a village, asking for names of the people visited most frequently. The person who seems the most popular among a given cluster of houses is then asked to be the communicator for that cluster. The CBFPS project used village elections in some Northeast villages to select volunteers, because political awareness is high there. The best Anethod of selection varies according to regional differences. In selection of effective volunteers, certain considerations have been noted by various projects: a. Volunteers should be people who spend most of their tim, in the village, or at least who are able to stay home from the fields frequently, to be easily accessible to both health workers and other villagers. b. Active volunteers have usually been middle-aged, well established in their community, literate, perhaps with a higher educational level than the average villagerand active in community affairs. c. Villagers who have migrated in from other areas and therefore have few family connections in the village tend to communicate with people outside their own family more frequently than do others. Their wide range of friends makes them good communicators. - 26 ­

d. Regional differences must be considered. For instance, Central Plains villages and, even more so, Southern villages tend to be spread out. Homes are not clustered as they are in Northeast and Northern villages. Therefore community involvement and communications are not strong, so volunteer programs have not been as effective in these areas, and it takes more volunteers to reach the same number of villagers. Women are given a fairly low place in society in the Northeast and are expected to stay close to home, so they can rarely be volunteers. On the other hand, Northern women are quite active in community affairs, and consuquently make good volunteers. 2. Training. The length of training depends on the duties of the volunteers. Communicators have generally been given no more than two days of formal training, with one day refresher training two or three times a year. Single­ purpose volunteers (malaria eradication or family planning) require only two or three days of training. General-purpose health post volunteers have generally been given at least two weeks of training and perhaps a week of refresher training per year. The kinds of training all of these volunteers need are well within the capabilities of provincial or district health center personnel to give. Training can be given at the District Office or first class health center, or possibly at second class health centers, so trainees can return home at night. Some projects have not offered per diem or compensation for work-days lost to trainees, particularly those receiving only a few days of training. Then if existing staff can select trainees, prepare curricula and teach the courses the only additional training costs incurred are for travel of trainees, possibly noonday meals, and printed materials. 3. Incentives. Most project directors feel that incentives have not been, nor should be, an important factor in recruiting or keeping volunteers. A good volunteer is motivated by concern for the welfare of his or her neighbours, and the prestige involved in being the village's health volunteer, should be incentive enough. The one exception is the certificate, which almost all projects award their volunteers in some kind of special ceremony. Credentials are an important source of pride and prestige to most villagers, and their official government volunteer certificates find prominent places on the walls of their homes or shops. - 27 -

Softie projects do offer additional incentives, however. One project offered free medical care to volunteers. A conflict developed, however, when volunteers began to demand free medical care for their families and friends as well. One project gave bicycles to health post volunteers, but this could certainly not be replicated on a national scale without great expense. The family planning projects allow volunteers to make a small profit on the sale of contracep­ tives. It is too early to determine the effectiveness of this. It may turn out to be a necessary incentive, regard­ less of its small amount. Should the family planning program lose its access to free contraceptives, however, the volunteer distributors' share could represent a real drain on its budget.­ 4. Duties. Duties of volunteers and communicators vary greatly from project to project. Volunteers have been able to take samples such as malaria smears, distribute simple medicines and contraceptives, and keep log books and other reporting forms without difficulty, as long as their supervision was good. Their duties must be limited, however, so that they do not include tedious reporting assignments, take too much time, or cover too large an area in population, so that they become disincentives for the volunteers. Volunteers should have a clear idea, from the very beginning, of their duties and their relationship with the health workers or other supervisors. Too vague a definition of duties may have been one of the factors leading to project failures in the past.

5. Supervision. Supervision is the key to success of a volunteer program, just as it is to the health service in general. The local health workers or other supervisors should meet with each volunteer regularly, to discuss the health situation in the village, resupply medicine or contraceptives, check over reports if there are any, and spend some time in friendly conversation. The malaria program calls for visiting each volunteer at least twice a month. This seems adequate to keep up volunteers' morale and is possible from the stand-point of health workers' time, at least in several villages per tambon. If health personnel cannot give adequate supervision to volunteers in a village, there is little merit in having the volunteer program in that village. District health officers should also meet volunteers occasionally, at least in groups. - 28 -

Besides giving the DHOs a better idea of what the volunteers are doing, it gives the volunteers reinforcement that their activities are important and appreciated. Health authorities should look carefully at the time and distance constraints facing the health workers in each tambon, and select volunteers only in those villages where the health workers can provide adequate supervision. Countrywide, this might amount to less than half the total villages. 6. Costs Because of the wide variety of volunteer programs in terms of training, responribilities, and incentives, costs also vary greatly. They range from virtually no additional costs in the Bang Pa-In project (which involves no formal training, no incentives, and no reporting functions) to fifty or more dollars per volunteer per year in family planning projects (involving training, incentives, and motivational campaigns). Some typical costs are listed below, excluding general overhead costs of project administration and any required medical supplies for distribution (contraceptives, medicine, slides for blood samples, etc.). 1. Selection made by health workers during regular village visits. No necessary additional costs except "sociogram" forms, if they are used.

2. Training - by district health personnel at district office or health center Cost Per Volunteer 3 days 2 weeks Compensation for Worktime lost @ $20/day 60 $ 200 Lunch @ $10/day 30 100 Transportation @ 020/day 60 200 Printed materials @ 020/copy 20 20 Certificate @ 05 ea. " 5. 5

0175 0525 - 29 ­

3. Supervision. No additional Cost Thus the only important cost is training, which may cost near $175 per volunteer for a communicator or single purpose volunteer, or near $525 per volunteer for multi­ purpose health post workers. Some projects find it unnecessary to pay compensation for work time lost and transportation, reducing cost per volunteer to $55 or 0125. Some projects have additional costs for health post signs and posters for volunteers, bicycles for volunteers, and special trainers from Bangkok, but it is not clear that these add to volunteers' effectiveness. If health workers require training about their responsibilities for supervision of volunteers, this training may also require additional costs, although training could be done by provincial staff at the district level. Using the above costs, to train a health worker for each village in Thailand might cost Y17,250,000. Excluding transportation and compensation, the cost would be $6,250,000. 9/ Yearly retraining of one day might cost from $10 to $50, depending on payments for per diem or transportation. This means a total of anywhere from $500,000 to $2,500,000 per year. Eventually new training must be held for replacements for inactive volunteers. If formal training were held for, say, ten communicators per village, for three days, this training might cost as much as $262,500,000. It is possible to recruit communicators without formal training, however, or to hold training down to one day. If only half the villages in Thailand meet the supervisory requirements for implementation of a volunteer program, of course, costs are also halved. The other alternative is to hire new personnel as volunteer supervisors. This can be done in a single purpose volunteer project where the supervisor does not need a great deal of medical knowledge, as is being done in the CBFPS project. This project has one supervisor per amphur at $900 per month. Supervisors must have their own transportation. The cost per year of one supervisor for all 550 rural amphurs in Thailand would be $6,012,600, excluding training, reporting costs, and supervision of supervisors. (Salaries plus additional gasoline allowance only). 9/ Whether it is necessary to pay transportation costs depends on the size of the district (i.e. distance to the District Office or first class health center where training is to occur), condition of roads, and the districts ability to provide its own transporta- tion to trairneeq. It is safest to assume that transportation costs must be incltdA. -30-

Reporting for ongoing evaluation should be possible without significant additional costs. A monthly report of volunteer activities can be prepared by the local health workers and sent up to the DHOs, who can in turn summarize them and send them to the provincial health offices. It appears that a carefully budgeted volunteer progrm can fall withii the MOPH's financial capabilities, at least if it is implemented over a period of several years. Since its only direct cost is training, which can all be done locally, there are no direct foreign exchange costs involved, except for additional imported medicines and contraceptives which expanded service will require.

7. Effectiveness. There is no apparent reason for a volunteer prcgram to fail, given continuous remotivation and supervision of volunteers and some care as to definition of their responsibilities and training. A one hundred percent activity level of volunteers is too much to be expected -­ even the malaria volunteer program., which is generally considered very successful, only has a 60 to 75 percent activity rate. With their limited training, volunteers can do little in the way of treatment, but can serve only as the village eyes and ears of the local health workers. Their big advantage is that, if carefully selected, they have the potential through their enthusiasm and their position in the community for changing villagers' attitudes towards the government health service. By putting their stamp of approval on health programs such as family planning (and increasing accessibility as well) they can increase villagers' acceptance. Once again, the relationship between volunteer and health worker is the most important factor for success. For family planning volunteers, not only volunteers' motivation, but resupply of contraceptives, report checking, revenue collection from sale of contraceptives, and most important, follow-up on new acceptors, those suffering side-effects, and recent drop-outs all depend on regular and frequent contact with health personnel or other supervisors.

With all the volunteer pilot projects underway at the present time, the best strategy for the moment is to wait until some information as to their effectiveness is available. - 31 -

In the space of a year or a year and a half, some interim evaluations or at least some before and after health center service statistics can be expected from the Non-Thai, DEIDS, Bang Pa-In, Soong-Nern, CBFPS, and Mahidol University Village Volunteer Contraceptive Distributors P:rojects. These projects will be able to provide a wealth of information which should certainly be considered before implementing any new health volunteer projects.

Volunteer Projects

Title Annex Number Phitsanulok Project I Saraphi Prcject II Non-Thai Project III Malaria Volunteer Project IV Ramathibodi Community Health Program-Bang Pa-In V DEIDS VI Community Based Family Planning Services VII Pilot Study on Expansion of the Government's Family Planning Services Using Village Volunteers VIII Seong-Nern Project not included - 32 -

II. Cooperation with Village Indigenous Health Services and Village Level Programs Of Other Ministries. 1. Present Activities In line with the volunteer concept of utilizing village resources to extend the rural health system, several projects have begun training of village practitioners and other community leaders. Some are geared only towards improving the health knowledge and practice of the village practitioners, without asking them to provide any direct service to the government. Others are geared towards training village leaders for specific purposes, such as distribution of family planning materials. The former projects do not produce ben"efits which are easily measurable in the short run, but they do zepresent an attempt by the MOPH to direct the activities of the people who provide the bulk of the health care. The letter projects, which are all fairly recent, indicate thas far that villagers are quite willing to accept training and participate in project activities. These projects might have been classed with the Volunteer projects of Section I, but they have been separated out here because they concentrate on villagers who are already serving as health practitioners or who hold positions which give them broad influence in their communities. Several years ago the MOPH began training traditional midwives in proper delivery techniques, prenatal care and afternatal care, with assistance from UNICEF. Now several other projects such as the Chonburi Project, Accelerated Maternal and Child Health Development, and DEIDS include training elements for indigenous midwives. The Chonburi Project in particular encourages the active participation of village leaders, indigenous midwives and tambon doctors. In remote areas of the province, to which mobile health units are sent to provide medical and health care, indigenous midwives are asked to assist the government midwives at the mobile clinics in ANC, family planning, well-baby clinics, and immunizations. Tambon doctors or local teachers assist in registration of patients for the clinic iervices. The government midwife asks tambon doctors, indigenous midwives, and local leaders to spread the word to the villagers of the mobile unit's arrival. - 33 -

In all villages of Chonburi headmen and tambon doctors have been given training in identifying symptoms of diseases and causes of death, in an effort to improve the epidemiolo­ gical information recorded on birth and death certificates. Chonburi has instituted a Provincial Health Advisory Council made up of provincial and district government health staff and urban and rural private practitioners which meets twice a year to discuss health problems and advise in the planning of the yearly operational plan for health. Finally, village druggists in Chonburi (and perhaps other provinces as well) have received one day training by the Food and Drug Control Division, MOPH, on the effects of overuse of certain types of drugs. This is, to my knowledge, the first official attempt to train and direct druggists in prescription of drugs on the dangerous list, although such druggists provide over half of the health care in Thailand. Up to now, the MOPH has been unwilling to give village injectionists, or "quacks", official recognition by either training them or requesting their assistance. An exception is the malaria volunteer program, which willingly recruits quacks, because they have been found to be among the most effective volunteers in terms of activity and coverage. Family planning projects have not emphasized the use of village practitioners, although indigenous midwives could potentially be an effective resource, given their close contact with pregnant women and new mothers. They have instead concentrated on utilizing other government workers who are in close contact with villagers, such as the ARD Tambon Paramedics, the tambon Community Development Workers, and local teachers. There are over 1,000 paramedics scattered throughout the Northeast, North, and South. They are lifelong residents of the villages they serve, so they are well known and trusted by their neighbours. There are over 4,000 Community Development Workers all over rural Thailand. Thus in quantity and area covered, these 5,000 to 6,000 people can greatly increase the accessibility of contraceptives to villagers, as well as give them their endorsement. Supervision and resupply in both cases come through their regular supervisory channels. - 34 ­

2. Costs In general, costs are similar to those of volunteer projects because their major element is the same: training. Any formal follow-up or supervision required is given by the local health workei-s as part of their regular duties or, in the case of the community development workers and paramedics, through their own supervisory channels. Training in most cases occurs at the district level, using district and/or provincial health staff. Costs of training as estimated in various projects look like this: Indigenous Midwives, One Week 50,000 midwives @ $100 05,000,000 Tambon Doctors, One Week 5,000 @ 0100 500,000 Druggists, two per tambon, One Day 10,000 @ 025 250,000 Family Planning Distributors: Paramedics, 1,000 @ 0702.5 702,500 Community Development Workers (Training was given to 90 CDW supervisors, who in turn trained CDWs) 294,800 Retraining or remotivation courses might be advisable yearly, for at least some percentage of these people. These costs are probably within the financial capabili­ ties of the MOPH, particularly if implemented over several years. Like the volunteer projects, all costs are local and requie no outlays of foreign exchange, except the possible future cost of increased contraceptive supplies. 3. Effectiveness Training of village practitioners for such short periods cannot be expected to have a profound effect on village health care. Indigenous midwives may improve their delivery techniques and may be more apt to go to the govern­ ment midwife for assistance with difficult cases; druggists may use more care in prescribing drugs; but these will not produce measurable effects except over a long period. This type of project does open up channels of communication between the government and the private practitioners, - 35 ­

however, which may in the future lead to an increased ability by the government to direct their activities and gain their cooperation. Movement in this direction will continue to be slow because the government does not wish'to run the risk of legitimizing health practices which are improper or illegal by giving them official recognition. It is too early to judge the impact of the participation of village leaders and other local government leaders in health care and family planning, but initial results are positive. Those indigenous midwives, tambon doctors, and other village leaders trained to assist mobile units and improve reporting of birth and death statistics have been receptive to training and participating, and have in that way given these activities their approval. The community development workers and two hundred paramedics trained thus far were responsible for over 10,000 new family planning acceptors in the last five months of 1974. Evaluations have not yet been done on all of these projects; in fact, some projects have not- completed training as yet. Concrete information as to their impact will for the most part have to wait a year or more. The concept is a good one, however, and there is room for experimentation with more projects of this kind, particularly in combination with other types of projects such as village volunteers. Projects Involving Village Practitioners and Village Leaders Title Annex Number DEIDS VI Chonburi Project IX Accelerated Maternal and Child Health X Community Development Workers as Family Planning Educators and Distributors XI Tambon Paramedics as Family Planning Educators and Distributors XII - 36 -

III. Retraining and Redefinition of Duties of Existing Health Personnel. 1. Present Activities Several projects involve retraining health personnel and increasing their responsibilities, with various aims. A. Increased fieldwork and supervision. Several projects aim to increase fieldwork requirements of midwives and sanitarians, or at least to clarify and quantify their responsibilities in this regard, in order to increase their contact with villagers and consequently gain greater villager acceptance of their services. In the Non-Thai, Bang Pa-In, and Accelerated Maternal and Child Health Projects, for example, health workers have been instructed to construct village maps, family folders, and household registers for their villages, giving basic demographic and health informa­ tion about each family. These are to be kept up-to-date through'regularly scheduled visits to the villages. Targets are set for numbers of visits made to each family during the year, vaccinations given, deliveries offended, family planning acceptors, and other things. In the Accelerated M.C.H. Project, targets are set to visit every pregnant woman at least twice for prenatal care and again soon after delivery, and to discuss family planning at these times. While these projects involve no actual change in health workers' responsibilities, they place increased emphasis on field work and set specific service goals. In line with the targets set for health workers, these projects also clarify the responsibilities of the district and provincial levels for better supervision, setting targets for the number of supervisory visits to be made by each staff level of the health service per month and the activities to be discussed during these visits. Some projects provide for supervisory training for certain positions. The Accelerated MCH Project trained district level nurses as nurse-supervisors, for whom supervision of midwives was to be among their most important and time consuming duties. - 37 -

B. Retraining of health personnel for "integrated health services". In the areas of consolidation of special programs into the general health service, all categories of health personnel are retrained as multi-purpose health workers. Midwives and sanitarians become responsible for the functions previously performed by special program field workers, such as follow-up of active cases of certain diseases and communi­ cable disease surveillance. Supervisory personnel from the special programs as well as the rural health program are retrained as multi-purpose health supervisors. Integration of health services only occurs in areas where communicable diseases are well under control. The additional responsibilities of the health workers can be taken care of on their regular village visits without much additional time or trouble, and sometimes result in increased contact with villagers. Supervision is also increased, since the special program supervisors as well as the first class health center personnel visit the health workers. C. Expansion of health workers' curative functions. Family planning projects are actively seeking ways of increasing the availability and range of family planning alternatives open to villagers, by training health workers to provide various kinds of family planning methods. One such project allows midwives to inject depo-provera, a popular three month contraceptive injection which presently can only be given by physicians. There are also small-scale experiments in use of health personnel to insert IUDs and even perform vasectomies.

Within the general health service, the Bang Pa-In Project has attempted to improve the Curative capabilities of health workers by providing them with flow charts by which they can identify a fairly large range of-diseases and prescribe non-injectable medicine. Apparently some increased health center use has resulted. 2. Cost The costs are once again those of training, and depend on the difficulty of the skill to be learned. Clarification of duties and setting of targets for field work and supervi­ sion can be done by the provincial and district health staff, including an orientation for the health staff. Training for integrated health service can also be given by district and provincial health staff. Training at the district level requires no perdiem or transportation payments to the health center personnel in attendance. Training at the province level may require transportation and perdiem for some of the - 38 ­ health workers of outlying tambons. The midwives trained to inject depo-provera had three days of training, at a cost of about $275 per midwife. The health workers of B.-ig Pa-In needed no formal training to use the flow-charts for non-injectable medicine. Generalizations about the costs of training are difficult to make, since they vary from project to project according to the task to be learned. Orientation training of health personnel in health targets and supervisory responsibilities and training in additional responsibilities of health workers for "services integration" can both be given without undue strain on a provincial health administration's budget. Special curative training may well require additional financial input. As in other training programs, all direct costs are local. 3. Effectiveness. This report has already emphasized the need for better supervision at all levels of the health service and increased fieldwork by health workers to gain villagers' acceptance. The types of projects described here which set supervisory and service targets to accomplish this are a step in the right direction and deserve to be analyzed carefully, revised and improved on until workable systems are-erived which are adaptable to all parts of the country. Increasing their curative capabilities is an important method of enabling health workers to compete with local practitioners, since it is curative services which villagers demand. A series of training courses, over time, which improve the health workers' ability to treat the more common diseases from which villagers suffer, might prove valuable in increasing both villagers' acceptance of health center services and health workers' motivation, even if they are still prohibited from giving injections. Projects Involving Retraining and Redefining Duties of Health Personnel Title Annex Number Non-Thai Project III Ramathibodi Community Health Program-Bang Pa-In V Accelerated Maternal and Child Health X Use of.Midwives to Inject Depo-Provera XVII - 39 -

IV. New Categories of Health Personnel 1. Present Activities There are three projects involving the creation of new categories of health personnel at the present time. A. Paramedics. The ARD paramedics, while not financed by the MOPH, work at health centers under the supervision of sanitarians. After their six month training they are allowed to perform many of the same functions as health workers. They can give vaccinations, prescribe simple medicines, and give first aid. Though based at the health centers, they are field workers, expected to spend most of their time in the villages. B. Family planning field workers and clinic workers. These are village women hired to assist midwives in visiting pregnant and recently delivered women in the villages and in reporting on field work activities. They are women of limited education and have no curative responsibilities. They receive only a five day orientation course.

C. MEDEX. The DEIDS project plans to train nurses, midwivessenior sanitarians, or others with similar health backgrounds to be MEDEXes, physicians' assistants with the ability to perform many of the curative functions of MDs. They are meant to be placed at second class health centers, where they will serve as supervisors of the health workers as well as provide treatment to villagers.

In theory, these new personnel are all additive to the existing health center personnel. The family planning field and clinic workers are certainly additive, since they require the presence of a midwife to provide direct, daily supervision and cannot replace the midwife in the services she performs. MEDEX, however, may in reality replace health workers. They are chosen from nurses, midwives and sanita­ rians, and on completion of training may go back to their old health centers with better qualifications and higher salaries but without their previous job slot having been filled. If this turns out to be the case, MEDEX may fit better into the "Retraining and Job Reclassification" category of projects than in this one. The ARD paramedics are also meant to be additive, but they have been placed - 40 ­ in areas with shortages of health workers and it may be that their presence has enabled the rural health service to keep their personnel additions to these areas low. The paramedics were never meant to be expanded into a country-wide program, but only to provide health care to certain politically sensitive areas. 2. Costs To he extent that they are additive to the present system these projects are expensive. They all involve not only training but salaries of at least one position for every health center, of which there are now 3,000 and will be more every year. Given the MOPH's inability to support full staff levels at its health centers now, replicability of projects like these is doubtful, unless the new positions replace rather than add to existing ones. The total budget for 1975 for the paramedics program, including salaries of 1,136 paramedics and 110 supervisors and training for 200 new paramedics, comes to around $21,000,000. The yearly cost for salaries of 3,000 family planning field and clinic workers, eere this program expanded countrywide, would be about 027,000,000. The yearly cost for salaries of 3,000 MEDEX (to have one in every second class health center), given 1975 salary scales, would be near $68,k.00,000 (at a salary of $l,900/month). If they were to replace existing health center personnel, however, the additional salary cost would be about 010,000,000 per year. These figures exclude training and retraining costs. 3. Effectiveness New categories of health personnel at the tambon level may be quite effective in extending the reach of the rural health service, either by providing more curative services or by increasing villager acceptance by close con­ tact. The paramedics seem to have been effective in the latter. Since health workers are presently underutilized, however, it would seem less costly to upgrade their training in curative functions and to increase their contact with villages than to hire new personnel to do that, leaving the health workers underutilized. - 41 -

If new categories of personnel are felt necessary, regular and frequent supervision is just as important for their continued motivation as it is for the health workers. The paramedics program, for instance, considers an important factor in its success the presence of special paramedics supervisors, hired specifically to oversee the paramedics in their field work, with one supervisor for every ten paramedics. Supervision by the local sanitarian alone, it is felt, would be insufficient, because he does not accompany the paramedic out in the field. Often, even first class health centers with MDs are underutilized in Thailand. The presence of a new type of skilled health worker does not ensure that a health center will increase substantially its services to villagers. That also depends on the effort of all the health workers to decrease the "distance" between themselves and the villagers. In a decision to use new categories of personnel, lines and methods of supervision, targets for field work, and ways of minimizing the "distance" from villagers should be carefully thought out. Projects with New Categories of Health Personnel Title Annex Number DEIDS VI Accelerated Maternal and Child Health X ARD Tambon Paramedics XIV - 42 -

V. Mobile Health Units. 1. Present Activities Mobile health units are used to bring health services to remote areas which are not regularly visited by the rural health workers. They are usually thought of as a stop-gap measure to provide health care until the regular health infra-structure has been completed, rather than as an integral part of a health service. For several years ARD and MOPH have jointly sponsored mobile medical units to travel to remote areas of the ARD prorinces. More recently, many provincial governors have authorized funds for their own provincial health units, utilizing provincial health staff. A major element of the Chonburi Project consisted of organizing nine mobile health units to serve all amphurs of the province. Family planning projects are also using mobile teams. The Family Planning Communications and Integrated Campaign Project uses mobile family planning education units to teach about family planning using various motivational techniques. PPAT's Mobile Vasectomy Teams are groups of MDs who travel to different areas of the country performing vasectomies for large numbers of villagers.

One of the biggest problems in implementing a mobile health service is finding the staff willing to serve on it. Serving on a mobile team means spending long hours away from home, sometimes overnight, treating mostly routine cases and rarely a really "interesting" one, and having to give up evenings in one's private practice which is usually quite lucrative. Even if physicians and nurses are willing to go, the health centers or hospitals where they usually work must be left short-staffed. Mobile teams usually rotate staff members on and off the teams so that no one will have to go out into the field too often, and usually pay per diem for trips lasting twelve hours or more. None­ theless, staff considerations must be carefully thought out in implementing a mobile service. - 43 -

The mobile vasectomy teams use slightly different methods. "Motivation teams" precede the vasectomy teams, provide family information and set up appointments for the vasectomies in several villages within a target area. The local health workers are not involved in the fieldwork until the days of the vasectomy operations, when they may assist. The teams service several villages in one stop and stay at a stop for three or four days until the operations have been completed so that they serve several hundred villagers at a time and have no need to return to the area regularly. As they perform the operations, they train the physician from the first class health center to give them also. The mobile vasectomy teams have the same problem as the mobile health units: finding MDs with knowledge in giving vasectomies who are willing and able to leave their positions and private practices for several days to go out with the teams. Mobile units are beginning to be used for health education. The Family Planning Communications Development and Integrated Campaigns Project has put nine mobile family planning education units into operation, one for each region in Thailand. These units first train health personnel in motivating villagers, then go out to the villages for a day according to a set schedule, to have discussion7 with fertile women and village leaders and to provide movies and other entertainment with a family planning message. Team members are permanently. assigned to the teams, so staffing problems are avoided. Health workers participate in the mobile units' activities by informing the villagers of their arrival and asking them to attend the discussions. They are present at the day's activities and provide follow up to supply new acceptors who have been motivated by the team. 2. Cost

The costs of mobile units can be rather high. To implement a nation wide mobile service similar to that in Chonburi, which has one mobile unit serving each district plus two more per province, (760 vehicles all together,) and assuming that vehicles presently owned by the provincial and district government can be used and that no additional personnel are required, the total annual additional cost of operating the teams would be only $ll,000,000,roughly 014,400 per vehicle, excluding additional drugs. Including drugs, the cost increases to $133,379,000, or 0175,500 per vehicle. In reality, however, new vehicles would undoubtedly be required and the life of existing vehicles would be significantly shortened, particularly in areas with very poor roads. Chonburi has a very good transportation and communications network but many provinces are not so fortunate. - 44 -

For these provinces, vehicle maintenance, gasoline and additional perdiem costs would all bring the costs up, not to mention the effect of additional gasoline price rises. The Mobile Medical Teams Project estimates that the cost to operate each of its teams averaged $355,900 in 1974, excluding salaries. The nine family planning education teams are estimated to cost $220,000 each to operate. A large chunk of the cost of operating a mobile health service is for vehicles and vehicle maintenance, gasoline, and medicines not produced in Thailand. For this type of project, then, foreign exchange implications must be taken into consideration. 3. Effectiveness Mobile teams for medical and health care have been accepted well by the villagers whenever the local health workers have laid the groundwork well informing the villagers of the date and place of their arrival. As in other projects, enthusiastic health workers are the key to success. Mobile units which go out according to a well-organized schedule and notify health workers well in advance can treat from fifty people (Chonburi Project) to one hundred or more (Mobile Medical Teams) per day. In Chonburi, where doctors are in short supply at the health centers, nurses usually head the mobile teams. It is felt that villagers do not accept treatment from nurses as readily as they do from MDs. It is also quite clear that villagers are not interested in the health care services which the mobile units offer, but only the curative treatment. On the mobile vasectomy teams and the health education teams as well the health workers are key people. They inform the villagers of the team's arrival, ask them to attend discussions and participate in the team's activities. No matter how great an impact the health education team may have in motivating villagers to accept family planning, the follow-up to prescribe pills, supply contraceptives, set up appointments for IUD insertion and sterilizations and treat complaints of side effects depends on the health workers. Involvement of the haalth workers works two ways. Where the mobile units are well received and appreciated, the health workers' acceptance by the villagers may be improved as a result of their participation. - 45 -

Information on the impact of mobile units is scarce, but the general feeling seems to be that the best way to affect villagers' health attitudes and to give health care is through daily contact. People do not delay their illnesses until the day the mobile unit is expected to arrive, and the health advice given by a team which visits once every three months cannot compete with the traditional health advice villagers receive every day at home. As long as there are areas which do not normally receive government health services, however, mobile teams are the only modern health services available to them and are therefore considered an important interim part of the general health delivery system. Projects with Mobile Units Title Annex Number Chonburi Project IX ARD, Mobile Medical Teams XIV Family Planning Communications Development and Integrated Campaigns XV Mobile Vasectomy Units XVI - 46 -

VI. Mass Media Although television, newspapers, and cinema are not commonly used forms of entertainment for rural villagers, radio is very popular and there is no part of Thailand which does not receive a station. Those who have no radios listen to their neighbours'. By law, radio stations in the provinces must broadcast messages of the provincial government free of charge. In those provinces which operate their own radio stations, the provincial health administrations broadcast weekly half-hour programs of health information. The Family Planning Communications and Integrated Compaigns Project has prepared radio broadcasts for family planning information and motivation which are regionally attuned and are now being aired weekly in 35 radic stations throughout Thailand, to give nationwide coverage. The project has also prepared slides for cinema and television spots, although these have more urban than rural appeal. Several projects, including this one and the Mobile Vasectomy Units have engaged local entertainment groups to perform songs and dances with family planning messages, but this project is the only one actively utilizing radio as a motivational resource, to my knowledge. The cost of producing the various mass media materials was about 01,860,000, and operating costs probably run near 0480,000 per year, nationwide. At this cost, a good deal of expansion of this type of program is possible. This project only began in 1974 and though impact studies are to be included in its evaluation they have not yet been done. Like the family planning communications mobile units, however, radio broadcasts can only provide motivation. It remains for the local health workers to provide the follow-up. Projects Using Mass Media Title Annex Number Family Planning Communication Development and Integrated Compaigns XV ANNEXES

These annexes consist of brief descriptions of the projects covered by tha preceding report, including comments on their possible effectiveness and any particular problems. Cost information was very scarce in most cases; costF have been estimated for a majority of the projects based on thc experience of other projects and on golernment budgetary data. Wherever possible, costs have been expressed in terms of cost per iervice unit, cost per population serviced, or cost per family planning acceptor. rince the costs are only rough estimates, however, and since little information is available as to the population aLty one service unit can reach, it did not seem lgiti:-ate 9o compare projects in terms of these per unit or per capita costs. They are included only to give a little more meaning to the total cost figures.

Much of this information was collected during interviews, so there may be errors on specific details. The reader's corrections are welcomed.

Two memos are also included, one describing the tambon doctors program and one on the role of the private sector. TABLE

OF

CONTENTS OF ANNEXES Annex Number Title Pame Number

I PHITSANULOK PROJECT 2

II SARAPHI PROJECT 6

III NON-THAI PROJECT 12

IV MALARIA VOLUNTEER PROGRAM 23

V RAMATHIBODI COMMUNITY HEALTH PROGRAM 29

VI DEIDS 34

VII COMMUNITY BASED FAMILY PLANNING SERVICES 39

VIII PILOT STUDY ON EXPANSION OF GOVERNMENT'S FAMILY 51 PLANNING SERVICES USING VILLGE VOLUNTEERS

IX CHONBURI PROJECT 56

X ACCELERATED MATERNAL AND CHILD HEALTH AND 69 FAMILY PLANNING SERVICES

XI COMMUNITY DEVELOPMENT WORKERS AS FAMILY PLANNING 76 EDUCATORS AND DISTRIBUTORS

XII TAMBON PARAEDICS AS FAMILY PLANNING EDUCATORS 79 AND DISTRIBUTORS

XIIi UNIVERSITY STUDENTS PROJEC9 81

XIV ARD MOBILE MEDICAL TEAMS AND TAMBON PARAMEDICS 83

XV FAMILY PL4,NNING CO2MUNICATION DEVELOPMENT AND 87 INTEGRATED CAMPAIGNS

XVI MOBILE VASECTOMY UNITS 94

XVII USE OF MIDWIVES TO INJECT DEPO-PROVERA 97

XVIII TAMBON DOCTORS 100 XIX ROLE OF THE PRIVATE SECTOR IN HEALTH DELIVERY 102 -2-

ANNEX I

PHITSANULOK PROJECT

"Yilot Project in Strengthening the Rural Health Service" MPH/WHO

Period: 1963 - 1970

TARGET POPULATION: PhLtsanulok Province, with special emphasis on Amphur Wat Bot

I. PURPOSE A pilot project to determine the feasibility of expanding the formal health service to a comprehensive curative and preventive health service, utilizing communicable disease control personnel where possible.

II. NETHODS

The Yaws control program, among others, had diminished the frequency of the diseases until the intensive activities of the disease control units were no longer necessary and overly expensive. At the reco mnendation of WHO, the MOPH decided to integrate these disease control programs into the general health service in Phitsanulok, on a pilot project basis. The MOPH felt that in order for the rural health service to support its added reuponsibilities, its infrastructure must be strengthened and personnel retrained.

1. Improving the Infrastructure

The MOPH set the following targets as the infrastructure necessary in every province to support a comprehensive health delivery system:

a) One first class health center per amphur. b) One second class health center per tambon. c) Midwifery centers for tambons e.xceeding 10,000 population. d) One ND per first class health center, three nurses, 15 personnel in all. e) One midwife and sanitarian per second class health center. -3-

The government constructed all health and midwife centers to meet its target in Phitsanulok; however, it was unable to recruit sufficient personnel to staf2 posts up to target level. There were MDs in all first class health centers. In total, there were seven first class health centers, 24 second class health centers, and 70 midwife centers. 2. Personnel Training and Integration.

As disease control responsibilities were transferred to the healtb centers, most disease control personnel were moved to other areas of the country. Some were retained in supervisory categories, as well as such positions as malaria spraymen who were still necessary for disease control. Thus, integration was not total.

Amphur Wat Bot was the first area to have integrated health services in 1965. In 1967 it was expanded to three other amphurs, two more in 1968, and the remainder by 1970. All categories of personnel were given training in their new diseaf.e control functions, as well as follow-up refresher courses, with emphasis on collectior of information on vital statistics, giving vaccinations, taking blood and sputum smears, and basic medical care. Training differed in time and content depending on the previous training of the health personnel. Trainers were from MOPH Bangkok, the provincial hospital, and disease control teams. Midwives and sanitarians also spent three days per month at their first class health center for additional training during the project period.

Midwives and salLitarians were to visit each village monthly, spending one to three days per village, seeing patients at a "health room" and making home visits. Reporting forms were developed for the health workers which are now used country wide.

Health workers also had referral forms, and were expected to refer patients to first class health centers and the hospital if they could not service them. The hospital was also to refer downward so that health workers could provide follow-up.

UNICEF provided vehicles to the first class health centers for supervision o'f midwives and sanitarians. The MD of the first class health center spent mornings in the second class health centers on a regular basis, fcr supervision and patient care. In Wat Bot, second class health ceiter personnel selected village health comnimcators to serve as informants on health problems -4­ in t6eir community, to set up appointments for villagers to meet with health workers, nd to provide a "health room" where health workers could meet patients on their regular stops.

III. COSTS

We construction and staffing of first class health centers for all amphurs, second class health centers for all tambons and midwife centers for all large.tambons are already long-range targets of the MOPH, and are slowly being implemented. (For instance, the 1975 budget allocates funds for 10 new first class health centers, 166 second class health centers, 110 e;pansions of midwife centers into second class health centers, and 100 new midwife centers). Therefore these costs are not included here as new costs.

As for costs involved in training health personnel and volunteers and in reporting and referrals, these ar,, similar to costs listed under the Saraphi project, so they are not repeated here.

IV. EFFECTIVENESS This project was the first in Thailand to build a complete health infrastrttcture and utilize v-.llage resources to improve and extend the rural health delivery systeA, and was the basis for the Saraphi and Non-Thai projectwhich followed it.

It was not particularly successful in improving health services, however. Despite easy access to health centers and midwife centers, and despite the presence of HDs at first class health centers, they remained highly underutilized. The village volunteer program faded out after a few years because of lack of motivation on the part of the volunteers. WHO evaluated the project in 1970 in a "Report on Assessment of Health Services Developed in Phitsanulok Province, Thailand" by Dr. Leslie Banks. His conclusions and those of Dr. Chachawan who headed the project and Dr. Pricha of the Saraphi Project included these reasons for the prolect's failures.

1. Supervision of health workers aud volunteers was inadequate, partly due to poor communications and transportation, long distances, and staff shortages. It was felt that regular visits to the second class health centers would have made an improvement.

2. The village volunteers did not feel themselves an integral part of the program because of little contact with government workers, therefore their output was low. -5­

3. As an experiment in "integrated health services", this province' was a poor choice, since there had been very little communicable disease control activity before the project period.

4. Health workers of all categories lacked sufficient flexibility and mobility. At the level of MDs and nurses, their orientation was curative, not geared towards community health or the work at the rural health centers. Midwives and sanitarians' role should have been reconsidered. Though they should have been in daily contact with villagers and indigenous practitioners, communications with them were poor and they did not visit villages frequently enough. The health workers' supervisors, with their curative orientation, were unable to give the health workers proper direction. Retraining of all categories of personnel would have been useful.

5. Shortages of medicine and supplies and delays in deliveries dijcouraged the medical staff and made services look inefficient.

6. The referral system was only a one-way proposition. Because of the administrative organization of the MOPH at this time, hospitals and health centers were under separate departments. Cooperation between the provincial hospital and health centers in coordinating referrels was minimal. In its favor, the project developed report and referral forms for health wurkers which simplified their reporting and made it more accurate. It served as a model wiich future projects could learn from and improve upon.

Since the project period, Phitsanuloke has lost some of t.be MDs from its first class health centers and has been unable to z;,iLace them.

Information from Dr. Chachawan Virabhand, former project director; Dr. Pricha Desawasdi, former director of Saraphi project; and "Report on Assessment of Health Services Developed in Phitsanulok Province, Thailand", 1970, by Dr. Leslie Banks for WHO. -6-

ANNEX 11

SARAPHI PROJECT

M nistry of Public Health

Period: 1968 and ongoing

TARGET POPULATION: Saraphi Amphur, Chiang Mai Province - 60,000 people in 12 tambons and 96 villages.

1. PURPOSE

1. To study ways of integrating malaria eradication other program and special disease projects into the general health services. 2. To improve public health administration and find new and better ways of providing rural health services.

3. To increase understandir.g and interest about health of rural people problems among medical and nursing students, through a comunity medicine program of the Chiang Mai Medical School.

II. 1ETHODS 1. Integration of malaria eradication program and other special disease control programs into the general health service.

Integration in Saraphi was similar to that Health workers in Phitsanulok. at the second class health centers and midwife centers wete made responsible for surveillance and treatment diseases, of communicable following a period of training. Field workers from disease control the programs were transferred to other districts, leaving supervisory personnel of these programs as supervisors and of the midwives sanitarians in their new responsibilities. As in Phitsanulok, disease control certain -;orkers were retained where there weze special problem areas, such as malaria spraymen.

2. Improvement of administration and experimental providing methods of ritral health services. Since Phitsanulok had even with shown that easily accessible and well-staffed health centers utilization -7­

of government health services was still poor, Saraphi put an emphasis on community participation. Saraphi had 11 second class health centers and midwife centers in 12 tambons. The district was divided into 4 areas of 2 or 3 tambons each for experimental purposes:

a) Control area, using traditional methods of government health service, including home visiting at the village level by midwives and senitarians.

b) Area of Child Nutrition Centers (CNCs), for children aged 2-6, staffed by attendants and supervised by midwives.

c) Area utilizing health volunteers and "communicators".

d) Area for intensive well-child care clinic, for infants up to 2 years old.

In the Child NuLrition Center r.rea, the first CNC was constructed by the villagers themselves without support from the government, but motivated by health center personnel. This was the first CNC in the country. Attendants were paid by the government and user contribution, receiving 300/month. Health center personnel supervised the attendants. Childret were fed protein supplements developed by Kasetsart University, although some experimentation was required to find a taste that appealed to them. Mothers received education on nutrition from the midwife.

After the first CNC proved successful, four others were built in Saraphi, financed in part by MOPH and in part by local contribution. At the height of project, 300 children attended the five CNCs.

In the area of volunteer usage, a 2-tambon area, "communicators" were chosen by health workers by the "sociogram" technique - all villagers filled short forms giving basic facts about themselves (age, sex, occupation, number of children, etc.) and rating their neighbors as to popular''ty. The most "popular" villagers were chosen. These communicators (about 20 per tambon) were given one or two days training in their villages about government health services and basic knowledge of diseases. Thev were asked to keep an eye out for certain disease symptoms among the circle of families whom they saw frequently, and to inform the health workers when they noticed any health problems. They were also to inform their neighbors of government health center services and of up-coming visits by their local health worker.

The midwives and sanitarians also selected "health post volunteers", one per village, whom they felt were respected members of the community, to serve as a basic health resource. There -were 15 health post volunteers, 4 of them Buddhist monks. They were given 4 weeks of training at health -8­ centers or village meeting rooms. They were to maintain contact with communicators, identify certain diseases and refer ill people to the health centers. They were given simple home remedies for common ailments, contraceptives for distribution, and bicycles to make coordination with communicators and health workers easier. (The monks were not allowed to accept bicycles). Both communicators and health post volLnteers (HPVs) received pamphlets containing health information to distribute to villagers.

The government health workers met with HPVs on a regular basis for an entire morning. HlVs would set up appointments for villagers to receive vaccinations and treatment at their homes or stores from the health workers at these times. Communicators assisted in informing the villagers and setting up appointments.

During their four week training period, HPVs were picked up by car in the morning from designated spots and returned there in the evenings. Trainers were district her,lth staff.

Per diem of $25 was paid, mainly as compensation for the day's work lost.

Refresher training was given for one week each year. HPVs were asked to keep records of medicines and contraceptives sold and other services performed at their health posts.

As incentives, HPVs were allowed to retain 20 to 30 per cent of the revenues from sale of drugs. They were supplied with signboards for their home or store identifying it as a health post. Both HPVs and communicators were promised free health care at the health centers and provincial hospital.

The area oZ well-child clinics was set up because the CNCs were not rea-hing infants of under 2 years. One morning each week the midwives would meet with the new mothers of a village, teach them about nutrition and child care, examine the babies, and give them immunizations. 3. School of Community Medicine A good decription of the use of Saraphi for teaching medical and nursing students about community health was done by the University of Illinois team for USO}, therefore this information is not repeated here. The Saraphi Project was guided by a Planning Committee of representatives from the Department of Health, MOPH, and the Faculty of Medicine of Chiang Mai University. There was no local representation on the Planning Connitte. outside of the government structure. -9­

111. COSTS

No cost information was provided, but costs of replicating certain aspects of the program can be estimated.

Integration of communicable disease programs into the general health service requires training of the local health workers which usually lasts two weeks. Training takes place at the first class health center or district health office, by supervisory personnel of the coumunicable disease programs. No per diem is necessary. The only costs are for transportation for those health workers who are located far from the trainLag center and printed materials about the communicable disease programs. The total cost per health worker would be %20/day x 10 days + 95 for printed materials s $205. This type of integration cannot be carried out in all areas of the country since some areas still have major co nunicable disease problems which demand a full time specialized staff to fight. In those areas where "integration" is possible, it is being done, in order to free up communicable disease program workers for the more critical areas. By now the entire Central Plains area as well as selected other areas have been "integrated" for many of the communicable diseases. The costs of the HPVs and communicators are similar to those of the Non Thai project, and include the following: COST PER VILLAGE, ASSUMING ONE HPV AND 15

COMKUNICATORS ARZ, REQUIRED SELECTION:

Sociograms (taken and analyzed by midwives and sanitarians on their regular village visits) Oe per family 40

Communicators: (training at village by health workers) Printed materials @ $ 5 x 15 75 Certificates @ Z 5 x 15 75

Health Post Volunteer: (training at district level by district staff, transportation by DHO's car) Per diem @ $ 25/day for 20 days 500 Printed materials @ $ 50 50 Certificate @ $ 5 5 Signboard for home @ $ 40 40 Bicycla @ 9 1,500 1,500 Ini iai Supply of Medicine 200 TOTAL per village 2,485 TOTAL for 50,000 villages 124,250,000 TOTAL for 50,000 villages excluding bicycles 49,250,000 This amount excludes the cost of free medical care for communicators and HPVs. - 10 -

For the first few years, drop-out HPVs may not be replaced. One week training for HPVs each successive year would include:

Per diem @ $ 25/day x 5 days 125 Printed materials @ $ 5 5

TOTAL-per village S 130

TOTAL for 50,000 villages 6,500,000 Well-child clinics involve no added costs, since they are carried out by tha local midwife at the health or midwife center. CNCs can only be effective in villages in which there are enough villagers who can afford to send their children at the $ 30 per month rate. Such villages can usually muster the support in terms of local labor and supplies to build a CNC with minimal, if any, government assistance. Therefore these costs are not considered here.

IV. EFFECTIVENESS Amphur Saraphi's utilization rates of health centers have continued to be low, in all four of the experimental areas. The project has not been able to replicate itself in other sections of the province. formerly Dr. Pricha, project director, feels that this is in part due to the of Chiang proximity Mai city and its wealth of medical services with which the local health workers can hardly compete.

Dr. Pricha feels that in some ways the volunteers and comunicators have been quite successful. The original group is still active Saraphi, no new volunt.ers in have needed to be recruited. He claims to have 100 per cent coverage for imnunizations and family planning. The important factor has been good and regular supervision of these people. Some criticisms have been raised of the volunteers and communicators, however. Because they were allowed free medical care, many and communicators volunteers began demanding it for their families, too, and after their families their friends. It has been said that the health centers in the area were soon running almost entirely for the benefit of the coumnunicetors and their relatives. This may not be entirely bad, in that it instills in a significant number of people the habit of going to the health centers, but the constant demand for free service caused hard feelings both by those villagers not eligible for it and by health workers who felt pressured to gLe it. - 11 -

The five CNCs, while successful at first, have now dropped enrollment to a total of 100 children. They reach only a small percentage of the total number of eligible children, and not those who need them most.

The well-child clinics were not effective. Attendance was quite poor, because mothers grew tired of bringing their children to the health centers each week.

One important feature of this project is that, except for the School of Community Medicine activities, it required little additional government funds. The bicycles and some funds fov training of health volunteers were provided by UNICEF, but the great part of training, supervision, and administration was prov1ded by existing personnel of the district health service, with assistance from the local community.

NOV : Information is based on interviews with Dr. Pricha and Dr. Chachawan now connected with the DEIDS project.

Information from Dr. Pricha Desawasdi, former project director, now with DEIDS. - 12 -

ANNEX III

MEMORANDUM

To: Dr. Edward S. Vanderhoof, PHO/HPP Thru: Dr. Edgar C. Harrell, AD/P

From: Vivikka Molldrem, Health Economist, O/HPP

Subject: Korat Multi-Purpose Health Project, Non Thai District, Nakhon Ratchasima.

I. Background:

Korat (Nakhon Ratchasima) is the second largest province in

Thailand in terms of population (1.558,859 in 1973) and one of the largest in terms of area. It has 19 amphurs, approximately 170 tambons and 2240 villages. There are only 7 1st class health centers in the 19 amphurs. There are 153 second class health centers but only 89 sanitatians, so many health centers are staffed only by midwives.

There are also 153 midwifery centers. Prior to implementation of this troject, there were also 14 special health programs operating in

Korat besides the general health service, each ith its own administrative structure and field personnel, including Malaria Eradication, Leprosy

Control, T.B. Control, Trachoma Control, Maternal and Child Health, etc.

Non Thai, the pilot project location, is a particularly poor area.

This amphur, with a population of about 90,000, has no 1st class health centerand 11 2nd class health centers (with 12 sanitarians and - 13 ­

10 midwives) of which several have been built since the project began.

Average family cash income is estimated at under $2,000 per year,

and total family wealth about % 44,300 (1973). The area receives very

little rain (two years with no rain is not unheard of). The biggest health problem in the area is protein calorie malnutrition.

II. The Problem:

There was a severe shortage of rural health service personnel, particularly for supervision of second class health center and midwifery center personnel. Consequently field work by these personnel was low and utilization oI health centers quite poor. (Division of Health

Plannin-, MOPH estimates that in the Northeast only 7.8 per cent of total health services are provided at health centers. A survey of rural areas in Korat by Mahidol University in 1972 found that for the major disease problems of infants, children, and adults other than pregnancy-related diseases, health centers provided 9.8 per cent of total services and the provincial hospital only 2.3 p~r cent. The baseline survey of this project averages a workload of 480 cases per health center per year for

Non Thai District).

At the same time, there was great duplication in areas covered by field workers from the various special health projects. Several disease control proSram bad their projects well under control, thus the cost of maintaining field workers was considered too high for their caseloads. - 14 -

III. Non-Thai Project

At the end of 1968 a pilot project was implemented in Non Thai

Amphur to deal with both of these problems. Personnel of second class

health centers and midwifery centers were to assume responsibility for

functions previously performed by field workers of the special programs,

e.g. passive case detection, active case treatnent and follow-up,

school health, etc. The field workers were then freed up to be moved

to areas of greater need. This demanded a great increase in village

visitation by the health workers.

Vaany of the supervisory personnel of the special health programe were

retained to become multi-purpose supervisors, and to provide expertise in their own area. These supervisors have divided the amphur into

areas of responsibility and make frequent visits to the health centers

and villages in that area. For example, malaria sector and zone chiefs

were both retained to supervise health workers and visit with the malaria volunteers in the villages. Their salaries are still paid out of their special program budget allocations.

The sanitarians, midwives, and all supervisory personnel in the amphur were trained in their new responsibilities for multi-purpose

health services. The Provincial Governor provided funds for training

ind for printing of forms from revenues of the Provincial Administrative

Organizaticn (provincially-produced revenues). The Non Thai Nai Amphur (District Officer) allocated some funds from his own budget for imple­ mentation costs (not specified), and assigned members of his staff to assist in coordination of this activity.

The ten day training for midwives, sanitarians, and special program personnel was given at the Amphur Office. Trainers were provincial health personnel: MDs and senior murses and special program leaders.

No per diem was given, but manuals were provided to all the trainees.

IV. Project Operation:

Each midwife and sanitatian is expected to visit each village in her or his responsibility at least one time per month, seeing at least 1/5 of the population each time (based on malaria program house visitors), and to examine the school children in all schools in the area at least once per month.

Project leaders feel that to meet these targets midwives and sanitarians must limit their activities to populations of 1,500 to 2,500. Therefore they choose 2 or 3 villages each within their tambon which they will concen'Crate on. The other outlying villages and schools will only be visited once a year, or when special problems arise. The"inner area" of regular and frequent health service covers about 60 per cent of the population.

The first project year, multi-purpose health service was provided in only one village per midwife of Non Thai. The midwives prepared

"family folders" for every household in these villages, including demographic information, health status, and "sociograms" for future

"village comunicator" use. These folders are updated regularly. - 16 -

The second year, midwives expanded operations to one more village

and the following year a third until the' met their population coverage

limit. Sanitarians did likewise. Therefore it was not until 1971

that the entire amphur (at least the "inner areas"') received multi­

purpose health servicesi

By this time, however, it was apparent that the program worked quite well in Non Thai. As part of the first provincial 5 year plan (1972-1976),

the target was set to expand the program into 4 or 5 amphurs yearly i until the entire province was covered. Training funds were provided by

the .rovincial Administrative Organization. By January 1975, 11 amphurs

have begun implementation and the Governor has approved the training

budget for the remaining 8 this year.

Each amphur is to set its own plan and yearly targets for MCH,

family planning, disease control, school health, and environmental

health, in line with provincial targets and its own staff capabilities.

V. Village Participation:

1. Construction of health centers. About 70 per cent of the

health centers in Non Thai, and about 607. of all the second class health

centers in the province were built entirely through village resources

in lumber and labor. (The U.S. air base assists also by providing

sufficient cement blocks for 3 to 4 centers yearly). MOPH is willing

to provide supplies to these centers, but unwilling to entirely support - 17 ­ the increased staff needs, so staff must often be diverted from other health centers.

2. Village Health Posts - In Non Thai, a -villagehealth post was identified in each village at the home or store of a willing person.

This person would be able to distribute certain medicines (e.g. malaria suppression tablets, trachoma eye drops, government household remedies) at a slight profit, take blood and sputum samples for case detection, and inform villagers about the next scheduled visit of the health worker so that appointments colild be set up if need be. The volunteers were trained locally by the health workers. An arrangement was made with the local baht-bus company to deliver samples to the health

centers free of charge. No inceutive other than a profit on medicine has been offered.

Of 90 village health posts started in Non Thai, only 50 are

actively reporting and providing services. Since the health posts are

in a eecific location, volunteers tend to wait for people to come to them

rather than to actively promote health services. Therefore this program

is not considered entirely successful.

3. Village Communicators - While health workers' target is to

visit 1/5 population of a village with each village, they are rarely able to during the daytime when most villagers are working in the fields.

This has been a cause of frustration for many health workers. On

a pilot project basis, villagers have been selected by the health

workers 3n the vasis of contact with their neighbors (the "sociograms" - 18 ­

collected along with the "family folders") to be "communicators". They are to know in advance when their health workers are coming, and on those days stay home from the fields. They have no formal training or formal responsibilities, except to answer.a few simple questions.

("Has anyone been coughing heavily for the past 3 weeks?" "Is anyone running a high fever?" "Has anyone had a baby?" etc.) The health worker can then follow up where necessary. Communicators receive no incentives, not even a certificate. The health worker is to spend time with them, giving some health education and motivating them to watch out for certain symptoms.

There are presently 1,000 communicators in Non Thai, half of whom have been active for about a year, and half of whom have just been selected. (Thereis to be one communicator per 10 - 15 households). An evaluation of the first group is presently underway, to be completed in 2 to 3 months. There are no plans to increase their responsibilities or expand the program to other amphurs until it has proven itself. The project leaders hope to be able to choose future health post volunteers from very motivated comnunicators.

VI. Effectiveness

The project is in various degrees of implementation for various amphurs in the province, and Non Thai was the first fully-integrated wmphur and the only one for which comparative measures are now available. All measures refer only to the "inner" service areas. - 19 -

IMMUNIZATION COVERAGE:

Smallpox BCG DPT

(Children under 5)

Prior to 1971 30% 257. 207.

Target 80% 807. 807.

Actual 1973 857. 657. 707.

FAMILY PLANNING:

Practicing Eligible Women

1971 8-107.

Target 10% increase each year

1973 227, -.20 -

SANITATION

Target: Construction of 40 Privies/sanitarian/year.

1973: 40 new privies/sanitarian (Previous years this target had sometimes been met; sometimes not)

Communicable Disease Control:

Active known cases: Leprosy 100 cases

Malaria 50 "

Trachoma 1,200 "

TB. 90 i Health personnel can provide regular treatment for 75% of these cases.

SCHOOL HEALTH

75 schools in Amphur ­ 13,000 students

48 schools in inner areas - over 7,000 students Target: Provide physical examinations for 807. school children in

inner areas per month. This target can be met. Generally disease is discovered in 107.

school children examined each month. Examinations are given to school children in outer areas only once per year. Since no targets for school health had been set prior to project imiplementation, school examinations were previously infrequent. - 21 -

MATERNAL AND CHILD HEALTH

Deliveries by Government Midwives

Prior to 1971 12-207. all deliveries " Target 307. i " " Actual 1973 30%

AVERAGE UTILIZATION OF HEALTH CENTFRS

Prior to 1971 480 cases/health center/year

(approximately 0.9 cases/health worker/day)

1973 600 cases/health center/year

(approximately 1.2 cases/health worker/day)

While these figures are not earth shattering, there does appear to be a noticeable increase in family planning, MCH, school health, and immunizations, and adequate care of communicable disease cases.

Despite the increased field work more cases at the health centers than they did prior to project implementation.

VII. MAJOR POINTS:

1. Some improvement of rural health rervices has been given without additional staff or major retraining, but through improved management of existing pnrsonnel.

2. The program has used no additional MOPH funds. Training, printing, and administration costs have been paid through provincial revenues. Existing staff members have provided training, supervision, and planning. This has undoubtedly required a good many hours of - 22 ­

several staff members, and what sacrifices had to be made is unclear, but each year 5 to 8 more districts have been included in the project without apparent undue strain on the PCMO's staff. 3. Local participation has been successfully recruited, in construc. Ion of health centers, in the baht-bus sample delivery system, and in the volunteer experiments now being attempted.

Information from interviews with -

Dr. Prachuab Somphong, Div. of Health Education, MOKH Dr. Siripanth Chaturongkul, Non Thai Project Director and

"Implementation of Multipurpose Health Project, Non Thai District,

Nakhon Ratchasima Province", MOPH 1972.

Information from Dr. Prachuab Somphong, Division of Health Education; Dr. Siriphanth Chaturongkul, Project Director; and porject documents. - 23 - ANNEX IV

Malaria Volunteer Program Division of Malaria Eradication, MOPH

I. Purpose Initially, volunteers were meant to serve in sections of "consolidation areas"* not covered by the rural health service to identify new houses, spot cases of the disease, take blood smears and give malaria pills. Since health center personnel could not adequately cover their areas of responsibility volunteers were trained in these areas also. Now volunteers are being trained in "attack phase areas" where it is felt they can also be effective. II. Methods A. Selection Volunteers are selected by the local malaria workers such as the sector chief who know the village people pretty well and have some ideas as to who wc-ild be interested and effective. Where the malaria workers are not well enough acquainted with the villagers, they receive suggestions from the phuyaiban. B. Training Volunteers receive 3 days of training in taking malaria smears, correct distribution of malaria pills, and filling out the reporting forms. They are trained at a convenient place in the village by the malaria eradication team. They receive no per diem or compensation. They receive a medical kit including equipment for taking smears, slides, medicine, a manual with pictures, and reporting forms. (cost of kit is approximately $70). C. Incentives They receive free medical care at the government health centers and hospital, but this does not apply to their families. If they remain volunteers for 2 years they receive a certificate, signed by the provincial governor, director of malaria eradica­ tion division, and sector chief, and presented by the nai amphur in'a formal ceremony.

* "Consolidation areas" areas where malaria has been brought under control to such an extent that chances of re-introduc­ tion of the disease are slight, large scale spraying is no longer necessaxy, and the general health service can take over the surveillance and treatment. "Attack phase areas" still have high incidence of mala::ia, require intensive program. - 24 -

D. Duties Malaria volunteers are to notify malaria eradication team members of new houses and farm sheds for spraying, spot cases of malaria, take malaria smears and give malaria pills. Each volunteer has a signboard in front of his home or place of business informing villagers of his services. There is also a poster in a prominent place in the village advertising his services. The sector chief, surveillance squad chief, and house visitor all make regular, scheduled visits to the village, so each volunteer is contacted by one of them at least twice a month. At that time they collect information, reports, and smears, resupply the volunteer, and spend some time in just visiting, to keep the volunteer's morale high. Between visits, the volunteer sends smears to the malaria office via post or public transportation, which are free for this purpose. In "integrated health service" areas, the malaria staff is small. (See integration section below). Here contact with volunteers is made by personnel from second class health centers and midwife centers. The sector chief and zone chief also make regular contact with the volunteers. In 1973 there were 5,159 malaria volunteers, by now there are estimated to be 7,000 to 8,000. In hilltribes areas, volunteers are either hilltribesmen or BPP who are well known to them. In communist insurgent areas malaria volunteers have been accepted by the villagers and are used, though contact with the government staff is not easy to coordinate. E. Communicators Thc use of"malaria communicators" is new, based on the Saraphi and Pitsanuloke communicators. They are meant to provide information to the volunteers and the team about new houses and farm sheds and suspected malaria cases, to provide malazia health education to the villagers, and to act as guides for the house visitors. They have no formal reporting responsibilities at this time, but may be asked to set up appointments for nouse spraying. Contact is to be made at least once a month by team members. If a communicator is motivated and enjoys the work, he/she may be retained as a malaria volunteer. It is hoped that the quality of volunteers can be improved in this way. - 25 -

Training by malaria team members lasts five days and includes basic information as to causes, symptoms, treatment, and prevention. Communicators are not allowed to take smears or give pills. They receive no per diem or compensation, no certificate at the end of training, only a manual of basic information. Their motivation is completely a function of their contact with the malaria team and volunteers. In December, 1974, the first 10-15 communicators were trained at Surat Thani and plans are underway to train another group at Lampang.

III. General Comments on Malaria Volunteers Dr. Suwan, Director of the Malaria Eradication Program, and Dr. Chaiyat, Chief of Region 6 (Songkhla to Trat), made the following general comments on the use of volunteers for the malaria program. A. Almost all the volunteers and communicators are male, not because of any particular requirpments of the job but because they have been the interested parties identified. B. There are regional differences to be considered in implementing a volunteer program. 1 - In the Moslim areas of the South, houses in the villages are scattered, not clustered. There are no easily identified central meeting places for groups of families and contact with neighbours is less frequent than in other areas of Thailand. Volunteers have not been effective because they lack both community spirit and contact with large numbers of neighbours. 2- In the Northeast where the cluster-home structure is prevalent and community spirit great, volunteers have been successful. Women have low social status and therefore are ineffective volunteers.

3 - In the North the cluster-home structure is also prevalent. Women play a much more dominant role here, so effective volunteers can be of either sex.

4 - In the Central Plans, communications and transporta­ tion are good almost everywhere, the health service infra-structure is fairly complete, and the villagers are relatively well-to-do. When ill they tend to go right to the clinics and hospitals. Volunteers are not often utilized, and therefore soon lose their motivation. - 26 -

C. Very wealthy people and local government officials are too busy to make good volunteers. On the other hand, very poor people lack the community status tq'be listened to and the time to do the job. D. Dr. Chaiyat feels that quacks make good malaria volunteers because they are usually personable fellows, have some medical background, and are willing workers because the prestige adds to their business. The same is true of pharmacists. They require good supervision, however, to ensure that they do not start charging for their volunteer services. E. In "integrated service" areas where the major responsibility for the malaria program has been transferred to the general health services, volunteers do not seem to work well. There seems to be the feeling that health workers spend inadequate time in the field for good supervision. F. 60 to 75% of the malaria volunteers are active. Good, regular supervision is essential for active volunteers. IV. Costs

The costs of maintaining a malaria volunteer program are relatively slight. Training is carried out locally by the local malaria workers. Supervision does not require special trips by the workers, but is done during their regularly scheduled village vis.its. Delivery of malaria smears to the laboratLZy for testing is done free as a public service by local baht buses and the post. Laboratory testing and supply needs have undoubtedly incrcazud, but it is not possible to obtain figures on the amounts. The volunteers report forms require additional clerical work but this can be handled by present malaria team staff. Costs include the following: Training: Volunteer kit (@ 470) Certificate ceremony after two years Certificate (@ 05) Transportation (@ 020) Depot post for volunteer's home (@ 020) Poster for prominent place in village (@ 010) Communicator Training Manual (@ 910) - 27 -

VI. Effectiveness The Malaria Volunteer program is generally considered quite successful, although only 60-75% of the volunteers have remained active since their selection and training. Of active volunteers, turn over is very low. Their work is not particularly difficult to learn or time consuming, and does not interfere with their regular jobs. Volunteers gain an element of prestige, probably more prestige than a general health service volunteer has, because their job involves spoting and treating a disease which is frightening to most vilidgers. This prestige is undoubtedly an important part of their motivation. No quantitative data are readily available proving the effectiveness of the volunteers. Recorded malaria deaths have declined by over 90% from 1950-1970, but since then there have been slight increases. Annual parasite incidence has also increased from 2.24 percent in 1969 to 4.41 percent in 1973. (Report of NMEP Assessment Team, 1974. p.17 and Annex 22). On the other hand, in the past 5 years areas representing 47.1% of the country's population have been transferred to integrated health service areas, although no areas are completely integrated. This may be responsible for the recent increases in malaria incidence. The best indicator is the fact that the volunteer program has been steadily expanded to provide nationwide coverage, which indicates the Malaria Eradication Programb faith in it and its ability to finance it. The program has been able to double its total number of volunteers from 1971 to 1974 despite a budget decrease of over 50 percent. The Independent Assessment Team of WHO/USOM apparently approved of the use of volunteers, because among its recommen­ dations were increased allocation of Zunds for their training and increased supply of malaria suppression drugs for their use at the local level (p. 92, 93). According to Ms. Orathip at NESDB, one of the major arguments for implementation of the Village Health Volunteers Program is the success of the malaria volunteers. - 28 -

A drop-out rate for volunteers of up to 40 percent is rather high, however* Malaria Program people attribute thIs to regional differences, poor methods of selection of volunteers and inadequate supervision and remotivation in some areas, particularly the integrated areas. Choosing volunteers from among active "malaria communicators" is meant to solve the problem of poor selection. If supervi­ sion by health workers is indeed a problem, then as more of the country enters the "integrated stage" motivation of volunteers will become more and more difficult. VII. Integration of Malaria Program into General Health Services. The malaria eradication program has been or is being integrated into the general health services in sections of 23 provinces, a process which began in the Central Plains area five years ago, where the inciuence of malaria was too low to warrant a full field staff, and in an effort to economize with withdrawal of U.S. support. The criteria for integration are:' 1. The area must be in the consolidation phase, with very little likelihood of recurrence of malaria. 2. It must have a strong health infrastructure with fairly complete coverage. In these areas, the malaria education section trains health personnel, from senior nurses on down, in malaria surveillance and treatment. The health center and midwife center personnel perform the surveillance aspects and provide contact with volunteers. Most malaria workers are then transferred to other areas of need. The zone chief and sector chief remain to supervise health center personnel and contact volunteers. Some sector chiefs may be transferred to the authority of the PCMO and retained as health workers, filling vacancies at health centers, since they have been trained as health workers and receive the same salary.

Information from Dr. Suwan Wongsarojana, Director, Marlaria Eradication Division, MOPH. - 29 -

ANNEX V

RAMATHIBODI COMMUNITY HEALTH PROGRAM

Project Period: 1970 and ongoing

TARGET POPULATION: Medical and nursing students, rural population of Amphur Bang Pa-In, Ayuthaya (50,000 people)

I. PURPOSE

To develop education&t programs in community medicine for medical and nursing students which would prepare them to serve in the rural health service, and to utilize the medical school's resources to find innovative approaches to rural health care delivery.

II. METHODS

1. Development of a Community Medicine Program

Bang Pa-In was chosen as a "rural district prototype" because it was close to Bangkok - one hour by car. A new first class health center, six second class health centers, and a dormitory-teaching center were constructed. A sequence of five courses is offered. "Health and Demographic Survey", an elective course, involves planning and carrying out a demographic survey in selected study villages. It is meant both to teach tiLe students to obtain valid amd useful data through the survey technique and to introduce them to village life. "Analysis of Health Problems" is a classroom course in the management of and epidemiological problems in delivering rural health services, and includes role playing. There are also brief field studies of particular problems. "Community Health Planning" is a required course, which reviews, examines, and analyzes Thailand's major health problems and programs. During the required "Community Health Clerkship" groups of 10 to 12 students spend six weeks at Bang Pa-In, carrying out field projects, seeing patients two or three mornings per week at the first or second class health centers, going on home visits and school health visits with student nurses, and attending seminars on health planning. The "Internship Rotation" is a required ona-month rotation at a first class health center, either at Bang Pa-Tn or elsewhere, for direct patiant care and other nonclinical act:.vities. 30 ­

2. Approaches to Rural Health Care Delivery The Bang Pa-In Project uses techniques rural health similar to several other projects to improve health delivery, but has added advantages in terms of both funding and motivation. First, because of the large number of students, other medical people and visitors who come to observe or participate in the project, there is a constant source of contact and supervision of the health workers, who- themselves feel rather proud of their contact with these visitors. class Secondly, the first health center has two people assigned full-time to supervision health workers of arLd volunteers, which is aluxury many d.itricts cannot afford. (One of the supervisors is a Peace Corps Volunteer).

a) Village Maps and Registers

Midwives and sanitarians from the second class health centers and midwife canters put together village maps, family folders, and household registers in 1972, which are kept fairly well Only the "inner up to date. areas", the areas which the health personnel are able to visit regularly, have been completely mapped and coded. The maps assign a number to each house, which corresponds with family the number on the folder and household register for that family. Information kept iticludes basic demographic, economic, nealth and family data for all planning family members. Data which change frequently, such as pregnancies, family planning, illnesses, vaccinations, quarterly etc, are revised and maintained on marginal punch cards, designed for easy hand sorting, one card per family. Each midwife and sanitarian to keep is able up-to-date summaries of quarterly changes in these variables through the use of these cards.

The second class heplth centers and midwife centers keep simple graphs and charts on the wails of their offices, their progress which plot in vaccinations, deliveries, school examinations, etc, on a monthly or quarterly basis, understandable to the observer at a glance.

b) Village Health Communicators (HC)

In 1973, the Bang Pa-In project directors decided to attempt to extend the rural health service by identifying for "outer "communicators" areas" of service or marginal "inner areas". These volunteers would be informed of upccming visits by the health workers, and would be able to notify villagers of their expected visits, gather villagers at their own homes for immunization clinics, tell the health workers about any chronic disease problems, pregnancies, or new infants in the village, and relay information to the villagers from the health personnel. - 31 -

In mid-1973 groups of medical students surveyed the target villages with "sociograms", to determine good communicators. They used both the Non Thai project's sociogram and the form developed by USOM's Robert Texter ("Manual for Rural Community Health Worker in Thailand", 1958). Neither "sociogram" form seemed to work, partl "because the houses in villages in that area are not clustered but strung ouc along the canals, so that villagers could identify no local leaders other than their headmen. So in 1974 the midwives and sanitarians met with village headmen in 15 "outer area" villages and selected about 30 communicators. Communicators are very often headmen, wives of headmen, or other wealthy villagers such as shop owners. Their age averages 30 years old. Thus far, no formal training or orientation has been given to either health workers or communicators, nor have there been any incentives offered, although certificates are being prepared now. Second class health center personnel visit the communicators in their areas at least once every tiiree weeks. Since these communicators only became active in November, 1974, there was a period of a month and a half with little health worker contact, since they were busy with harvesting. In February, visits resumed again.

It is too early to reach any conclusions about these communi­ cators, but there have been some positive signs. For instance, the health workers of one tambon scheduled a mobile immunization clinic at one of the villages with commur.icators in early February Due to the communicators' efforts, the village of 367 people received the following immunizations:

Cholera 150 DPT 40 BCG 33 New vaccinations, smallpox;= 39

This extremely large turn out was probably due to a cholera scare in the area about that time, but whatever the reason, the word of the immunization clinic was well spread. These vaccinations were all given to people not reached by the school health service, so there was no duplication.

c) District Health Development Committee

This committee, made up of district health personnel and local leaders, meets several times a year to discuss health problems and plan for district health improvement. For instance, one of the committee's recent plans is to provide loans for villagers to build their own privies. Atr an added inducement for both privies and family planning, - 32 ­

free sterilizations and IUD insertions are offered to all owners of privies. (Since 30 percent of families in the district have privies, these people are already eligible for the free family planning. A new privy costs about $600).

The health workers spread the word of the District Health Committee's policies to the villagers in their areas, with the help of the communicators in the "outer areas". Communicators may later be selected as Health Volunteers, with duties similar to those in the Non Thai project.

d) Improved Curative Capabilities for Health Workers Despite the project's efforts, utilization of second class health centers has remained rather low, because midwives and sanitarians can deliver only minimal curative treatment and are legally prohibited from giving injections.

To improve their curative capabilities, the MDs at the first class health center have developed a manual made up of flow-charts, by which health woxrkers can quickly look up a symptom, find a detailed description of symptoms from which a particlar patient suffers under that general heading, and find the disease and non-injectable medicine which should be prescribed. The flow is something like this:

Major Symptom.. detailed symptoms- -- ailment---->medicine

The health workers have been using these flow charts for about a year, and have been quite responsive to them. No "mistakes" have been reported, and there are indications that out-patient use of health centers is increasing.

III. COSTS

Thus far there have been no significant costs of the volunteer program, other than increased immunization supplies, since there has been no training. The District Health Development Committee requires minimal expense to hold its meetings, since transportation costs are slight within a district and per diem is not necessary. The policies it develops may involve costs, however. Village maps, household registers, and family folders also involve costs in office supplies, but probably not more than 4,250 for a district with about 8,500 families, like Bang Pa-In. The marginal punch cards used in Bang Pa-In, however, must be replaced annually for an annual cost of $8,500 (one baht per family). As for the flow charts for non-injectable prescriptive use by the health workers, they are about 60-page mimeographed booklets, well within the financial capability of r:he district to reproduce for its fifteen second class health centers. .IV. EFFECTIVENESS

It is difficult to assess how a project like this would fare without the presence of the School of Community Medicine's enthusiasm, frequent visits to the health centers by MDs, students, and others, and financial support by the medical school and other agencies. Certainly these have all had their effect on the motivation of the health team.

7te use of village maps, household registers, family folders, and village health communicators is similar to several other projects. If their use is found to be more successful in Bang Pa-In than in other areas, it may very well be due to the large number of vivitots and regular supervision of health workers and volunteers. On the other hand the proximity to Bangkok and all of its medical facilities may prevent Bang Pa-IT's health centers from ever being very popular, despite their service.

District Health Development Committees can be replicated in other areas, but if they are I.o be policy-making oodies, as in Bang Pa-In, they must have full goverrment support and access to funding. For instance, a committee coul,'. not offer loans for construction of privies without financial sup-iort of a government agency, such as a grant from the DOLA or Chanf~wat Administrative Organization, or funding from the MOPH. It could not offer free sterilizations and IUD insertions ithout support from the district health center and possibly the PCMO. Still, the potential is therefor an effective locally-based body.

The flow charts for non-injectable medicine are also replicable. In the case of Bang Pa-In, they required no additional training for second class health center personnel. Good supervision is important for implementation of flow chart use, however, to answer the health workers' questions, make sure that they under. tand the charts and prescriptions, and encourage referrals to the first class health centers or hospitals for cases beyond their capability. Through better knowledge of identi­ fication of diseases, epidemiological itformation can also be improved, even though the health workers may not be able to treat the diseases identified. This is at least a first step in increasing the health workers' curative capabilities, which are much more important to villagers thai prevention. - 34 -

ANNEX VI

DEIDS - Notes on Discussions with Dr. Pricha, Dr. Chachawan, Dr. Pian, and Dr. Wilson of DEIDS on January 16 and 17, 1975 04OPH/APHA/USAID/W)

TARGET: Lampang Province - Hang Chat District first, especially 2/3 women of child bearing age dnd children under 4 Lampan$: Population - 660,000 (estimated - 1974) Women of child-bearing age: 133,700 (estimated) or 20.2 per cent Children 0-4: 94,600 (estimated) or 14.3 per cent

Hanx Chat District: Population - 40,854 (7 tambons, 61 villages)

Women of child-bearing age: 8,2S3 (estimated - based on 20.2 per cent) Children 0-4: 8,642 estimated - based on 14.3 per cent

PROJECT PERIOD: 1974 to 1980

I. COAL: Development and Evaluation of Integrated Delivery System for rural health in Lampang Province, beginning in Hang Chat district for the first two years. Emphasis is to be placed on the target population of women of child-bearing age and children under four, so the major concentration will be on maternal and child health and family planning, but environmental health, communicable diseases, and nutrition are also included.

II. M.MTOD:

1. Attempt to improve administration and organization of existing rural health system.

2. Create para-physician above the position of nurse but below that of MD who can perform many of the curative functions if the MD. HEDEXes will be licensed -mdcertified, given civil service status, and placed at second class health centers with health workers and midwives.

3. Retrain present health center personnel at all levels to better function in an integrated services system, and to better supervise those below them.

4. Recruit, train, and utilize two types of volunteer workers ­ based on experience of Saraphi project - health communicators and village health pos. workers. - 35 ­

5. Implement on-going reporting and project evaluation in several aspects: vital statistics reporting, community surveys, nutrition surveys, clinical records, service records, task analysis, cost analysis, and administrative analysis.

More Detail:

1. Improve Administration and Organization-of Health Service.

This will be on an on-going basis, and will depend in part on the retrain­ ing of personnel, added supervisory fmctions for some, and additional categories of health workers. Before the project will be expanded to all of Lampang province, first class health centers must be constructed and staffed in seven more districts. Optimally, secbnd class health centers would also be constructed for each tambon, but this is not considered necessary for project expansion. Job descriptions for all categories of health workers are being written which may be adjusted as the project goes on for appropriateness of activities of workers. Some thought is being given to revision of reporting forms for simpli­ city and to extract new kinds of information.

2. MEDEX. Anticipated training of MEDEXes will begin by June 1975, and continue for a year to a year and a half in five groups of 15-20, 85 altogether. Curriculum is now being developed. MEDEXes are chosen from existing health personnel: nurses, senior health workers, and midwives. At conclusion of training they are to be placed at second class health centers, over the miawives and health workers, however in cases where MEDEX were recruited from second class health center personnel, the latter will probably not be replaced so total number of staff will remain pretty much the same. Legislation must be passed before MEDEX can be certified - DEIDS staff is not very concerned about this. Civil service status has not yet been given MEDEX either, but MEDEX trainees will be assured a station by the government and will know where before commencement of training.

While MEDEXes are meant to be supervised by MDs in first class health centers, in actuality there are no MDs in some districts, so MEDEX may head first class health centers.

3. Retrain Present Personnel. "Cross training" of present personnel is meant to enable them to function in both health care and medical care. Training of health personnel is to begin in February and be on-going. Trainers will be taken from DEIDS staff and provincial officers.

Training of indigenous midwiveR iE also anticipated to begin later this year, probably a two week course taught by province health personnel. Development of training curricula is not yet finalized. - 36 ­

4. Village Health Post Volunteers and Communicators. Communicators are meant to provide surveillance on the health needs of a group of" ten or so households in a village, to refer these villagers to the government health services, and to provide the health workers information about the villagers. Their two-day training explains the government health service and the new DEIDS program, describes health problems of villagers and shows them how to spot certain diseases, give nutritional, environmental, and family planning information. At the completion of training, they receive jackets with DEIDS insignia, certificates, and some health educational materials to pass out. (Per diem = $25/day, estimated cost per person: $100/day).

After the communicators have been operating for some weeks, each group of village communicators will elect a village health post volunteer (VHV) who will receive two weeks of training at the district health center in basic curative treatment and methods of reporting. The VHV's job will be to supervise the communicators, provide simple treatment to the villagers, refer thea to the health centers, and do reporting on vital statistics for the health centers. VHVs will be supervised by the second class health center personnel, the greatest responsibility lying with the IMDEX. Family planning activities of volunteers have not yet been determined.

A total of around 6,000 communicators will be trained during the first two years in Lampang (about one communicator per 100 people). Sketch of communicators trained thus far:

Total number 113

Male: 45 Female: "68 Below level 4 education: 9 Farmers: 80 Merchants: 15 Dress-makers and hair-dressers: 4 Handicraft workers: 3 Other 11 Granny midwives: 3 (All granny midwives were listed under other occupations as well) Although the "Yellow Book" recommends use of monks, questions on the sociograms were written in such a way as to exclude monks. These questions may be changed for future sociograms, but the Thais are not over-anxious to recruit monks, since they cannot be used for family planning. Later in the project they may be reconsidered. -. °

As of now there is no supervisory structure for these communi­ cators, since MEDEX have not been trained and health personnel have not been retrained. New groups of communicators will be trained throughout the year, all of them without supervision and little communication with the health service.

VBVs will probably not be chosen for a few months.

A few communicators complained of having to leave children unattended or losing a day's work during training, but none complained about the training itself.

Hill tribes will be included in the project, but probably will not have communicators and VHVs, since this has been set up with the culture of the lowland Thais in mind. 5. Evaluation. Thus far, no baseline data have been collected, and health center data provided by taiabon doctors are not considered accurate enough to be usable.

A community survey began January 20, 1975 using Hang Chat and two control districts. This will be compared with a re-survey at the end of the two year pilot study. A smaller nutrition survey is scheduled for late March or April. Vital statistics reporting may be made an assignment of the village volunteers, but this means that the whole district cannot be covered until all volunteers have been trained, so before and after comparisons ccnnot be made. Other types of reporting and evaluation procedures have not yet been worked out. An accounting system for cost analysis is in the process of being developed.

Dr. Pian of the Information Research Evaluation Division of DEIDS pointed out that only the Community Survey evaluates the project's impact -n the community. All other evaluations are internal to the project.

I1. GENERAL IMPRESSIONS

This project is for the most part still in the planning stage and a great many questions remain unanswered as to hoi the responsibilities of all classifications of health workers are to be changed and how changes can be implemented. The first communicators have been trained without a clear idea of what they are to be used for and who is to maintain contact with them. I was left confused as to the'direction of the program. This project has many good ideas. It is attempting to involve the private sector through its training of volunteers and indigenous midwives. It plans to change job descriptions and retrain health personnel to make their jobs more relevant to villagers' needs and demands. It plans to incorporate increased supervision. So far, however, these ideas have not been considered as an integrated system. Volunteers have been trained before an organization has been developed for them to fit into. MEDEX training will begin before civil service and certi­ fication questions have been answered, which are necessary to give training its proper direction. The baseline survey in Hang Chat began after the DEIDS staff had moved in and comnunicators had been trained, which may affect the results of the survey.

In short, the project is moving ahead too fast on certain aspects. As a result, inappropriate training, loss of motivation of volunteers and health workers, and bottlenecks in general can be expected. The present operation may reduce DEIDS chances of success.

Information from DEIDS project documents; Dr. Ronald Wilson, Dr. Chachawan Virabhand, Dr. Pricha Desawasdi, and Dr. Pein Chiewvanich, of DEIDS - 39 -

ANNEX VII

COMMUNITY BASED FAMILY PLANNING SERVICES (CBFPS) IPPF/PPAT

TARGET POPULATION: 28 districts of 23 provinces during 1974 3,039 villages 2,115,804 total population 284,799 eligible women To be expanded to 60 districts (tota) during 1975

I. PURPOSE

To expand access to contraceptive methods and spread the family planning message in rural Thailand by utilizing indigenous people and channels of com.unication. On a pilot project basis, village volunteers are recruited and trained to distribute contraceptives under the supervision of government health workers in some areas, and specially trained workers paid by the CEFPS program in other areas.

II. METHODS 1. Development (Praparation) of District for Program Implementation

Districts are selected to provide a representative sample of population distribution throughout the country, with various densities and inconne levels, and are in general restricted to those where no other special family planning activities -re occurring which would bias the results. An independent evaluator has been contracted, which collects baseline data on F.P. KAP in each district. in 5 districts, 2nd class health center staff provide supervision. In the other districts, supervisors are selected by CBFPS staff. Supervisors are local people with at least 10th grade educations. They are often specialized disease control workers who have been dropped from the MOPH payroll, and therefore have experience in health and in field work. After selection of supervisors, distributors are selected, the method of selection varying by area of the country. In the Northeast where local political involvement is high, the distributor is elected by popular vote at a village meeting. In some areas, the First Class Health Center MD, district officer, and local officials may make the selection. In other areas, the CBFPS staff, with the help of the supervisors'and village leaders,choose. One distributor is chosen for each village or cluster of villages. - 40 ­

2. Training of Volunteers

Training of the distributors, or volunteers, is a one-day course given at the district by CBFPS field staff. It emphasizes the distributor's role, motivation of new acceptors, countering rumors, medical referral, and a simple method of record-keeping and follow-up of drop outs. Volunteers receive $20 for transportation and $10 per diem. They receive a meal at the training session, pamphlets, certificates, identification cards, and a large aluminum sign for their store or home.

3. Operation

a. Duties of distributors. Distributors are to visit the eligible women in their village and motivate them to use family planning. They are allowed to sell pills and condoms at $5/cycle of pills, %3/5 condoms, of which they keep $1 and return the rest to their supervisor. In the case of new pill acceptors, distributors must arrange for a physical examination with the government midwife within a month of sale of the first cycle. The midwif3 is paid 2/examination by the CBFPS headquarters. The distributor also arranges appointments with the nurse or doctor of the First Class Health Center for sterilization and IUD acceptors. The distributor keeps a record of all clients and knows the dates they should come for new cycles. If they drop out, it is his/her responsibility to find out why and if possible remotivate them.

b. Motivation. In half the districts, an intensive system of motivation is used, including distribution of family planning materials to villagers, stands at temple festivals, posters, movies, and other activities. The distributors and supervisors participate in these activities. Family Planning T-shirts, underwear, and other items are made available for sale at village stores. Family Planning songs based on popular tunes have been written and are taught to the children, through cooperation with the village schools. In the other villages, motivation is left up to the distributors.

c. Characteristics of distributors. There are about 50% men and 50% women, of various age groups but most commonly in the 30-50 bracket. They come from all occupational backgrounds: farmers, shopkeepers, teachers, indigenous practitioners, and head men. They are all literate at this time, although that is not a necessary criterion for this program. Their only monetary incentive is the profit from sale of pills and condoms. They receive motivation through the supervisors, retraining after one year, and monthly newsletters.

d. Supervision. In 5 districts, supervision including resupplying and collection of money is done by the second class health center and midwifery center staff. They are to visit with distributors once a month and can receive feed-back on their performance through the villagers they consult. - 41 -

In the remaining districts, one supervisor is hired per district, as described in section (1) above. Supervisors receive $800/month salary, plus $lO0/month for gas if they travel by motorcycle and $300/month if they travel by boat. They are expected to visit each distributor once a month, but in districts with 100 or more distributors this is quite a formidable task. For physical examinations, sterilizations and IUD insertions, referral is made to thc health centers, not to these supervisors.

The supervisors received no formal training until a 5 day course was given in February 1975. Their only duties are to make sure the distributors have adequate supplies, to check that report forms have been completed properly and collect them, to collect revenues from sale of pills and condoms, to motivate distributors, and to assist in motivational activities.

Supervisors are in turn supervised by the MD of the First Class Health Center. Therefore this project has been limited to those districts which have first class health centers with MDs. The MD meets monthly with the supervisor, resupplies him/her and collects report summaries and revenues from sale of pills and condoms. He/she also provides free IUD insertion and sterilization for people referred through the distributors, and gives field supervision quarterly. For these services CBFPS pays the MD $l,500/month. Other supervision is provided by the staff of CBFPS field offices, one in each region of Thailand, who visit and accompany each supervisor in their region 4 days per month. e. Evaluation. Data collection is ongoing through the distributors' reporting. Reporting gives demographic information about the acceptors and distinguishes between completely new acceptors, those who have used FP in the past, and those who switch-over from buying pills or condoms at the local health center or drug store. Evaluations will be done in both 1975 and 1976.

f. Other aspects. Distributor3 are experimenting with selling two types of pills, one at $5 and one at $9, to give the buyer a choice.

Poor women can buy pills on credit for a period of 12 months. If they stay on the pill the entire period, they need not pay back the debt. CBFPS will pay the distributor his/her share.

In an effort to provide extra incentives for acceptors, CBFPS is now considering marketing the agricultural products of village acceptors for them in larger towns, where they can receive up to 30% higher prices. CBFPS would arrange for the transportation and marketing. This might lead to CBFPS participation in community development projects later, if successful. - 42 ­

ii:. COSTS

New costs per district, in Baht. Assuming 100 volunteers, 10,000 eligible couples, excluding contraceptive costs.

lt year: Development (actual) 4,300 Supervisor, MD training 2,000 Volunteer training (actual) 9,600 Motivation 41,000 Distribution and Supervision 45,200 Central Administration 15,700

TOTAL $117,800

2nd year: Volunteer Retraining $ 9,600 Distribution and Supervision 33,000 Central Administration 15,700

TOTAL $ 58,300

Other years: Retraining of Volunteers, Supervision and MD, assuming 10% turnover of Supervisors, 307. turnover of Volunteers 3,080 Distribution and Supervision, Inc. supplies for 30% new distributors 37,200

Central Administration 15.700 TOTAL 55,980

Year Year 2 Other Years

Cost per volunteer $1,178 $583 $559.8 Cost per acceptor $58.9 $23.4 $22.2 (issuming 20% year 1, 25% year 2) Cost per NEW acceptor, year 1 988.4 (Assuming 15%)

Revenues from Sale of Pills and Condoms Per District: (Assuffe average of 20% acceptance rate achieved) Average eligible couples per district: 10,000 20% average couples: 22000 $4/cycle x 12 months x 2,000 - $96,000/district - 43 -

Therefore once 207. acceptance rate has been reached the program can pay for itself. A 157 acceptance rate provides a revenue of $72,000/district

Distributor's profit from Sale of Pills and Condoms:

If each district has 100 distributors and 2,000 acceptors, each distributor averages 20 sales/month, $1 for pills and $2 for condoms. Monthly income therefore runs $20 - 30. - 44 -

IV, EFFECTIVENESS

The project has not yet proved its effectiveness. district It began in one in February 1974 and expanded to other districts and winter of 1974, during fall so insufficient time has passed to compare acceptance and continuation rates. Project Director Meechai-could only say that on the average, by the end of two months, distributors reached a 5% acceptance rate by eligible users in each district. Impressive, This is not since many of the districts involved already had'acceptance rates of higher than 5% before the start of the program. It has become apparent that the first buyers already from distributors are those using family planning, who switch over from health drug store purchasing. center or Next are former users who for one reason another have or dropped-out and now begin again. Only then do distributors seem the to reach the new acceptors, and the extent to which they can do this is not yet clear. In comparison of the different methods used in the program, government supervision vs. CBFPS supervision and intense motivation vs no motivation, Meechai has no clearcut facts as yet opinions. but has definite He feels that districts of private supervision than districts work better of government health worker supervision, mainly the latter are unmotivated because and uninterested in assisting. He does not feel that an intensive motivational campaign makes number a big difference in of acceptors - the key as he sees it is the motivation personality and of the distributor. This motivation is since not financially-based, the income from contraceptive sales is quite small, based on genuine but must be concern. The success of the program depends on identifying such concerned people and keeping them motivated through frequent and supportive contact. A number of criticisms have been made of this program's the use methods. First, of specially hired supervisors working under CBFPS teams sets up regional a parallel structure to the RTG rural health service, which may be no more effective than the latter, services. besides duplicating One supervisor has responsibility for all district, which volunteers in a range in number from 27 to 137. He/she is to meet each volunteer at with least once a month, but in larger districts this requires 6 to 8 visits a day on a 6 day work week, not to mention higher transportation costs than in smaller districts. Only two people supervise the supervisor: the district MD, who probably has very little free time to leave the First Class Health Center, and a CBFPS regional staff member. The regional staffs are supposed to spend 4 days per month each supervisor, with so that during a month of 20 work days member one staff can meet with 5 distributors. The regional enough staff may be large to spend this much time with distributors in the active, but for the 28 districts now program to expand to all 620 districts, 124 people -45­ would be neccessary. In actuality, volunteers in larger districts may only be visited once every 2 or 3 months. Resupply may become very difficult, and with inadequate supervision conditions may lend themselves to black market activities. Supervisors with limited health background and infrequent contact with distributors cannot be expected to keep them motivated.

At the same time, there are about 5,000 midwives working in all districts in rural Thailand, whose main duties are MCH and FP and who regularly visit the villages in their areas of responsibility. While their superision is probably little better than that of the CBFPS supervisors, they have much smaller areas of responsibility, know the villagers, have medical background and the authority to prescribe pills, and hava time on their hands.

Second, there is understandably hostility between the government health center personnel and CBFPS workers. The government workers feel they are being by-passed completely and are losing some revenues from family planning acceptors to the distributors. Meechai himself admits that some 30% of the health center staff in CBFPS dis-ricts have expressed doubts about the program.

Third, pills are on the dangerous drug list. While distributors are expected to arrange examinations with new acceptors by government midwives for prescriptions, there is no strong control on this.

Fouzth, there is the question of where the revenues go. The revenues from contraceptives collected by the midwiVes and health workers go to maintenance and supplies of the health centers. The revenues collected by the CBFPS project go towards paying its own expenses.

Finally, distributors working under supervision of the general health service can provide them with other kinds of health infomration through their contacts with villagers - pregnancies, births, deaths, illness, etc. Distributors working under special supervisors do not get the information to the people who can do sbmething about it.

In its favor, the CBFPS project has shown that it is not difficult to recruit villagers who are willing and able to spread the family planning message, at least for a short period of time. It has tapped an inexpensive and potentially effective family planning resource. It is the first family planning program in Thailand to make contraceptives available to the poor, by providing them free if the acceptor uses them for at least one year.

As the follcwing cost-revenue breakdown shows, once a 207. (or even a 15%) acceptance rate has been reached in districts of 10,000 eligible couples, the program can pay for itself after the first year.

Informatian from Mechai Viravidya, Project Director; and Project Documents. - 46 -

BREAKDOWN OF ESTIMATED COSTS PER DISTRICT (BAHT)

1. Development of District for CBFPS Project: Includes field trips to meet with district health personnel, village leaders, identify supervisors and distributors, collect baseline data and set targets:

Estimated cost/district $8,400

Actual cost/district for first 28 districts $4,220

2. Supervisor Training and MD Training.Because districts are scattered throughout the country, training took place in Bangkok. For anationwide program, training could occur at povincial or regional level.

MD Transportation (by plane round trip BKK) $1,000 $lO0O/MD

MD Perdiem ($lO0/day for 5 days) $500/MD

Supervisor Transportation (by bus round trip BKK) 100/supervisor Supervisor Per Diem ($120/day for 5 days) $750/supervisor

Written materials ($20/person) $20

T-shirt, other motivational materials ($30/person for 2 people) $60 TOTAL $2,000

Assume trainers are fron CBFPS staff, training occurs at CBFPS headquarters, audiovisual equipment, etc., already owned by CBFPS.

3. Volunteer Training Cost breakdown ­ see Attachment A

Estimated Cost Per District $17,500

Actual Cost Per District (for first 28 Districts) 9,580 Estimated Cost Per Volunteer 175

Actual Cost Per Volunteer (first 28 districts) 126 - 47 ­

4. Motivational Activities (one-time only)

T-shirts $15,000

Stickers 2,000 Posters 1,000

FP. Booklets 2,000

8 movies/district, via mobile van 8,000 Stalls at temple festivals 3,000

Prizes (e.g. for best distributor) 10,000 $41,000

5. Distribution & Supervision Salaries of MDs: $1,500/mo. for 12 mo. $18,000/yr. Salaries of Supervisors $800/mo. for 9,600/yr. Transportation of Supervisors Assume average %200/mo x 12 months 2,400/yr. Depot signs, log books, ID cards, etc. $100/distributor, estimated 100 distributors/ district, first year only 10,000 Res,pply of report forms for log books @ $10 each after first year 1,000/yr. Delivery Charges, $100/mo. 1,200/yr.

Distributor Newsletter 1,000/yr.

Medical examinations by midwives @2/new acceptor (10,000 eligible couples per district) 1st year: Assume 1,500 new acceptors, to bring acceptance rate from 5% to 207. 02 x 1,500 3,000 2nd year: 5% increase (500 more acceptors) 1,000 Other years: 500 examinations for new acceptors, former drop outs, etc. 1,000 -48 ­

6. Central CBFPS Administration

1974 budget $834,000 1974 Cost per district (28 districts) $ 29,800

-, If the program were taken over by the MOPH Family Planning Division, certain additional personnel would be needed to oversee it. Assuming that present office space, facilities, transportation, and A-V equipment are sufficient for project implementation, the following additions might be needed:

Project Coordinator-salary, (2nd Grade Official) $ 28,800 Regional teams:

Given requirement that regional staff must spend 4 days/month with each supervisor, with 20 working days/month each staff member can see 6 volunteers/ .uonth. Given 620 districts in Thailand, there must be 124 regional or provincial staff members, pe :haps working from the P01M office, 2 people for large provinces*.

1. Salary-4th grade official @ $l,100/mo. $1,100/mo. x 12 mo. x 124 $1,636,800 2. Transportation $60/trip x 6 trips/mo. x 12 mo x 124 535,680 3. Per diem $60/day x 3 days/trip x 6 trips x 12 mo. x 124 $1,607,040 Clerical Staff for compiling and summarizing data from 620 volunteers.4 clerks @ $750/mo x 12 mo. $36,000

Administrative assistant @ 0l,100/mo. x 12 mo. $13,200 Office supplies and expenses $200,000**

Central Office travel (20 flights @ 9l,000/flight) $20,000

* It may be possible to reauce supervision to I or 2 days/month so that 30-60 staff members are require&.

** Pure guess. - 49 -

-Central Office Per Diem (40 days at $lO0/day) ]4,000

Total Central Budget $4,081,520

Central Budget Per District (620 Districts) $1,570 AP 14 - 50 -

ATTACHMENT A

TRAINING COST (Duration: 1 day) TYPE A DISTRICT

COST PER DISTRICT

I DISTRIBUTOR TRAINEES (100) 300

Transportation (100 x 1) 100" Per Diem (100 x 1 x 0.50) 50 Meals (io X x ' io. Pamphlets (100 x 0.25) 25 Certificates and Identification Cards (100 x 0.25) 25

2 INSTRUCTORS 410

Transportation 150 Staffs :100: Doctors (2 x 25) 50

Per Diem (all inclusive) 260 Staff (12 man days x 10) 120 Doctors (4 man days x 35 Honorarium inclusive) 140

3 OTHER COSTS .165

Signs, Banners, Charts, Photographs 50 Local Help (6 x 2 x 2.50) 30 Press (Transport and Per Diem) '10 Representation .75. TOTAL COST PER DISTRICT IN DOLLARS: $ 875

TOTAL COST PER DISTRICT IN BAHT ($20 ­ $1.00) A 17,500 - 51 -

ANNEX VIII

A PILOT STUDY ON EXPANSION OF GOVERNMENT'S FAMILY PLANNING SERVICES USING VILLAGE VOLUNTEERS

Public Health Administration Department, Faculty .of Public Health, Mahidol University/National Family Planning Program, MOPH, Institute for Population and Social Research, Mahidol MDI University/

PROJECT PERIOD: 1975 - 1977

TARGET POPULATION: Fertile couples of Angthong Province, Po-Thong District, Total population - 45,000

I. PURPOSE

To increase acceptance and continuation of family planning through widespread availability of contraceptives and information. To determine (1)most effective type of village volunteers; (2) total number of family planning acceptors by using this approach; (3) continuation rates; (4) annual cost per acceptor.

II. METHOD

Village volunteers will be selected to supply pills and condoms, make referrals, and dispel rumors about contraceptives. The volunteers will be chosen by the village headmen and local health personnel on the basis of age (25-50 years old), popularity among villagers, and attitude towards family planning.

Midwives and sanitarians, who will be the volunteers' major government contacts and supervisors, are to receive one day of training in their suparvisory responsibilities. They will also attend the volunteer training classes, which will occur in three one-day sessions over a Wo year period. Training will emphasize motivation techniques and counteracting rumors. Each volunteer will receive two types of posters, one for the front of his/her house or business, and one in a prominent place in town, advertising his/her services. Local radio stations will make F.P. broadcasts twice a day, announcing the volunteer's name, location of his or her house, and price of the contraceptive provided. - 52 -

MDPH will supply pills and condoms to volunteers. During the first three months of project implementation, new pill acceptors must be examined by midwives. After volunteer retraining, if they prove able to check acceptors themselves, volunteers may be allowed to prescribe pills. Pills will be sold at 95/cycle. Condoms will be sold at %5/dozen. The volunteer may keep %2 for each cycle of pills or dozen condoms sold.

Field supervision will follow these lihes: M.D. at first class health center will provide occasional supervision and assist in training, and will recetve per diem of 9300/supervisory trip.

The District Health Officer will be responsible for resupply of contra­ ceptives, collection of monthly reports, and supervision of volunteers and health workers, making at least two visits per month to each one. For each visit he will receive %80 for expenses.

Midwives and sanitarians will collect volunteers' reports and summarize them as monthly reports, collect revenues, check reporting, and visit each volunteer once a week receiving per diem of %20/visit.

Village volunteers will keep a daily record of pill and condom distri­ bution, note the dates acceptors are expected to return, and follow­ up if they do not. Since health centers will only receive 93 from cycles of pills and condoms sold by the volunteers instead of the %5 they would have received had the health center personnel made the sale, the project will pay the supervising health center %2 for every sale of the volunteers.

Prior to project implementatinn, a IXAP survey will be taken for baseline data. After the project has been in operation one year there will be a follow-up KAP survey and after two years, a final follow-up on coutinuation rates and project success. The following evaluation criteria have been established:

1. Increase in F.P. acceptors. 2. Increase in contraceptives distributed monthly. 3. KAP survey I and II comparison. 4. Comparison of district's present and past performance in F.P. acceptance. 5. Pill and condom distribution rates greater than hational average. 6. Cost per acceptor below national average. - 53 -

Evaluation criteria for the most effective type of volunteer will be:

1. Those who recruit the most F.P. acceptors. 2. Those whose acceptors have highest continuation rates. 3. Those who remain active the longest. 4. Those who get along well with the local health workers. 5. Those who keep good records.

III. COSTS

Expansion of Program Countrywide 50,000 volunteers 1. Administration Office Supplies (record book, village posters, depot signs, etc.) $100 per volunteer 95,0009,00

2. Training & retraining of personnel Health workers - 6O/da.x 4 (training every 3 months) 9,000 health workers 92,160,000 Village volunteers - 60/da.x 3 5,350,000

Per-diem and travel for lectures (if done nationally, trainers could be district & provincial health personnel. No per-diem or travel required.)

Training materials @ 92.0 ea 1,000,000

Per-diem for trainers: 10 trainers x560 districts x 4 trips x 9160 3,584,000

3. Field Supervision Local health personnel a. ND or other representative of first class health center 0300/visit x 2 visits/ mo. x 12 mo. x 560 districts 4,032,000

•b. District Health Officer 980/visit x 2 visits/mo. x 12 mo. x 560 districts 1,075,200 c. Local health workers 920/visit x 4 visits/mo x 12 mo. 8,640,000 - 54 -

Exnansion of Program Countrwide

4. Payment to health centers for sale of contraceptives. Estimate (for 1st year) 20 F.P. acceptors/ volunteer/month x %2 x 12 mos. _24,000,000

TOTAL: $54,841,200

Cost per volunteer during year 1 1,097 Cost per acceptor during year 1 %54.8 (Not all will be new acceptors many will switch over from other sources of purchasing) Since revenues from sales go to volunteers and health centers and do not go back to the project, they do not offset any of the project costs.

ON-GOING COSTS 1. Office Supplies (%40/volunteer) 2,000,000 2. Retraining (retraining for all personnel 1 time/yr. training for new volunteers ­ assume 30% turnover yearly.) 2,478,000 Retraining: 960/day x 59,000 x .07 2,478,000 New training: Volunteers: 5,350,000 x .30 1,605,000 Health Workers: %2,160,000 x .30 Training 648,000 Material @ %20 ea. x 50,000 x .30 300,000 Par-diem: %3,584,000 x .30 1,105,200 Per diem: 10 trainers x 560 districts x $160 896,000 Supervision (same as first year) 13,747,200 Reimbursement to health centers for volunteer sales of contraceptives @ 92/sale (ifacceptor rate stabilizes at 25 F,P. acceptors/volunteer/month) 30,000,000

TOTAL: 952,779,400 Cost per volunteer 91,056 Cost p-r FP acceptor $42 IV. EFFECTIVENESS

This project attempts to correct for some of the criticisms of the CBFPS project. First, it utilizes the existing health structure instead of setting up a duplicate parallel structure. Midwives and sanitarians are given the major responsibility for contact with and supervision of the volunteers. Provision is made for better super­ vision and motivation of health workers by their superiors, with the added incentive for good supervision of per diem for supervisory expenses. Health workers have only 5 to 10 volunteers to visit and supply, in villages which they are supposed to visit regularly anyway, so their new responsibilities are not overburdening. The volunteers can provide them wic:h other information about health problems in their villages, and may become general health "communicators" to sonis extent.

While the health centers do not lose any of their own revenues to the volunteers, the fact remains that the supervision, retraining, and health center reimbursement costs have to come from somewhere. As the project is presently set up,none of the revenues from contra­ ceptive sales are used Lo defray project costs. If the revenues of %3/sale went back into the project's fund, and the health centers were not reimbursed, the annual revenue of %45,000,000 per year would more than cover the costs. Cost per acceptor is slightly lower than the CBFPS project even including the reimbursement to health centers and without it becomes significantly lower. The MPH may not be willing, however, to set a precedent nationally of making a per diem payment ot health center personnel for supervisory and village visits, which are part of their regular duties.

Information from Dr. Debhanom Muangman of Department of Public Health Administration, Faculty of Public Health, Mahidol University; and from project proposal. - 56 -

ANNEX ,LX

CHONBURI PROVINCE: PROGRAM SYSTEMS ANALYSIS (P.S.A.) PROVINC IAL ADMINISTRATION/MpH/HO

Period: 1972 on-going

Target Population: Chonburi Province, particularly people in rural areas not presently adequately covered by health service.

I. PURPOSE

To improve and expand the rural health services in Chonburi without exceeding Province the province's financial capabilitities, by a systematic analysis of the present health status and facilities, determination major problens, of targets, goals, and constraints, and implementation of methods of achieving goals including revision of administrative structure.

II. METHODS

Background information on Chonbur: Province:

Government Health Care Amphurs: 7 Hospitals: 3 - Provincial, Red Cross, Military Tambons: 71 lst Class Health Centers: 5, eq.w. M.D. Villages: 542 2nd Class Health Centers: 64 Population: 602,800 (1973) Midwifery Centers: 14 CNCs: 12

Private Health Care Modern clinics: 40 Native Midwives: 161 Midwifery clinics: 15 Tambon Doctors: 71 lit Class Drug Stores: 12 - 57 -

With the help of a WHO team, the provincial staff carried out a health planning exercise in 1972 very similar in many respects to the WHO­ assisted Country Health Program Planning of early 1975. It involved the following steps:

1. Summarize existing national and rovincial development policies, priorities, and targets.

2. Develop projections for 1971-81 of provincial population and socio-economic trends.

3. Identify the problems of health conditions/diseases based on available information, identify their impact on provincial development policies (economic growth, education, environmental quality, etc.) and categorize them by underlying causes or factors. Determine the trend in the 10 leading disease conditions, to establish disease-socio­ economic change relationships.

4. Project health problems based on (3)above, and determine necessary targets for future. 5. Determine public and private health resources, and project their number and utilization over this period.

6. Analyze the constraints to the health sector in implementing targets - i.e., a list of current features of the system that inhibit the achievement of objectives.

7. Determine criteria for services design to deal with above constraints. rhe major problem disease groups identified were:

Stress diseases Environmental diseases Communicable diseases Nutrition MH and family health

The major constraints inhibiting implementation of targets for these groups included:

1. Insufficient coverage of population due to maldistribution of facilities, lack of private facilities, sub-optimal staff motivation.

2. Inadequate epidemiological bases of health programs due to insufficiene data.

3. Misallocation of staff time due to unclear objectives, inadequate training aid supervision. 4. Imbalance of budget allocation between medical and health care.

5. Inadequate coordination within MOPH and between ministries.

6. Laws not supportive of standard health objectives. Based on the disease problems, targets, and constraints, the WHO group and PCMO staff came up with the following suggestions for improving health services within the financial capability of the province.

1. Establishment of a Provincial Health Advisory Council

This committee is made up of the Governor as chairman, directors, hospital mayors,nai amphurs, the PCMO and assistant PCMO, ind a few representatives of urban and rural practices. They meet discuss twice a year, to proposed service changes, to provide input into the annual and five year health plans, to coordinate activities of various agencies, to promote and newr sources of resource allocations. The council has no authority to make policy but can only suggest. Thus far the PCMO's staff can point to no specific program modifications for which responsible; this council is however it is a first step in coordination between the various bodies which provide health care, and it has promoted usage of limited local resources, especially for purchase of medical supplies and construction of health centers.

2. Implementation of a Provincial Mobile Health Service Strategy The mobile health service is to provide health per year care four times, to :emote villages which are out of reach of first clas,. health centers. (If: is assumed that each first class health center tambons, accesses five therefore 46 tambons and 327 villages are to be visited by the nine mobile units, or 35-40 villages each). Te teams are to stress nutrition, environmental health, family planning, and diseases. communicabli Implementation has been very slow, but by the end of 1974 there were nine mobile units in operation, one from each district health and two office from the PCMO office. Only existing personnel and existing vehicles are used. Each mobile unit consists of a senior nurse or occasionally an MD as team leader, one sanitarian and two midwives from the DHO or first class health center. District health personnel rotate for service on the mobile units, which go out twice a week. The teams operate like this: the midwife and/or from sanitarian the health center or midwife center nearest the village to be visited is informed in advance, and in turn informs certain village volunteers such as the local tambondoctor, Other granny midwives, headman or community leader. These volunteers spread the work to the villagers. - 59 -

The day before the mobile unit arrives, the sanitarian from the first class health center arrives in the village, and with assistance from the local tambon doctor, provides health education and shows a movie (movies, projectors, screens, generators provided-by health education division).

The midwife or sanitarian from the local health.center, the tambon doctor, granny midwives, and perhaps some other volunteers join the mobile team in providing services on the scheduled day. The team sets up a center at a local meeting place with the following set-up:

Villagers Enter

Registration for Service, by Tambon Doctor or local teacher

General health Mothers Children Patients I4

Sick Clinic ANC and Well Baby Clinic (Nurse or MD) Family Planning immunizations, weight $5 charge (Government midwife and height measurements and granny midwives) for determining nutritional standards (Government midwife, perhaps granny midwives)

Dispensary (Medicines, lab examination, zeferrals) (Sanitarian)

One government midwife goes to the local school and gives vaccinations and physical exawinations. During the afternoon, house calls are made.

For people requiring hospital or health cente-r care, the headman is responsible for ensuring that they have transportation.

Hospitals give first priority to patients who have referral slips from the mobile units. - 60 -

The activities of one of the first mobile units to begin operating (in Banglamoong District) are shown below for a three month period during 1973. 41 villages visited 78,000 total population

Target Actual

Total population serviced 2,770 3,400 Sick clinic 1,905 1,938 ANC (at mobile center, not house visits) 322 148 PNC 559 0 Family Planning: New acceptors 753 67 Vaccinations: Small pox: Age group: 1-4 593 5-7 268 8-14 25 BCG: Age group: 0-1 63 1-4 439 5-7 249 8-14 25

Cholera 295 Total vaccinations 1,963 Average population serviced per trip 83 Average vaccinations per trip 48

For all mobile units for 1974, Dr. 3anthao Eukul, Deputy PCMO of Cholburi, estimates an average of 40 to 50 people serviced per team per trip, and 30 vaccinations per team per trip.

This decrease in activity may be due to the distance in time between the initial motivation and training of village volunteers (described in section 3) and actual implementation of the mobile teams. There is apparently also a reluctance by villagers to accept treatment by a nurse, preferting a doctor who can give stronger medicines. It is obvious from the figures that village:s are much more interested in curative treatment than in disease prevention or health education. - 61 ­

3. Provincial Health Education Program In an attempt to increase the awareness at the village level of health problems, orientation or training of selected groups of "health educators" was given during 1973, including government health parsonnel (as supervisor), local teachers, headmen, kamnans, traditional midwives, tambon doctors, and other village leaders. These training courses, which were given at the PCMO office, generally lasted 5 days and were geared towards describing the PSA program and the mobile units, providing basic health education, and instructing them in surveillance and reporting of diseases, in order to improve epidemiological reporting as described in section 4 below. Those from remote areas were asked *to assist the mobile units. The followi.ng numbers were trained:

Indigenous midwives 98 Tambon doctors 68 Teachers 57 Kamnan . 55 Puyaiban (headmen) 406 Others 136 Total 1,081

(Total cost, 100/person, 008,100)

Government personnel:

Health workers 144 Supervisors (district staff) 33 Lecturers 32 Grand total 2,032 (Total cost, @ 9100/person, $203,200)

In addition, during 1975 further health education is being providedto private health practitioners. In January, one day training was provided to 200 druggists, to point out harmful effects of certain drugs, give pointcrs as to safe precription of drug3, and dispel false information. This trainingvas provided by the Food and Drug Control Division, MOPH. All known indigenous midwives will be trained for one week in seven groups of about 20 beginning February 17. They have previously been identified and registered by government midwives as part of the PSA program, to provide for better coordination between government and private midwives. Training will be geared towards proper delivery techniques, PNC, ANC, family planning, and basic curative treatment. - 62 -

All tambon doctors in the province will receive one week's training in three groups, beginning May 12, 1975. Their training will include first-aid, disease prevention, health education, simple government remedies, family planning, and referral to the government health service.

Midwife and tambon doctor retraining is funded by WHO.

To provide continued motivation of the village leaders, and to include them in the health planning process, each DHO holds a tuonthly meeting with them at the District Office at the time they come to collect their salaries. Health problems of their areas are discussed and some health education is given. The DHO tries to visit all village volunteers three times per year, for follow-up and supervision. 4. Epidemiological Surveillance

Vital statistics on births, deaths, and causes of death are recorded by the headmen and kamnans on the birth and death certificates. They have no training in identifying causes of death, and are not always aware of all births and deaths that occur ia their community, so statistics are vague and inaccurate. In order to correctly identify health problems and goals, Cholburi has initiated this epidemiological surveillance system. During the training of kamnans and headmen the need for better statistics 4W stressed, and some common symptcms of major diseases were given. Each trainee received a manual listing the symptoms of various diseases for their use in completing death certificates. Indigenous midwives and tambon doctors, during their training, received more detailed instructions for identifying diseases and were asked to assist the headmen in determining cause of death. They are encouraged toreport all births and deaths to the headman of which he might be unaware. If they cannot identify the cause of death, they are asked to send for someone at their healt]' center for assistance. Again, motivation of village leaders to improve their health statistics is given at their monthly meetings with the DHO.

As a second part of the epidemiological surveillance system, government midwives and sanitarians are to follow-up on all cases of communicable diseases which they discover. Lab tests must be done on each case to verify disease prognosis. Then the health workers must determine all the major contacts of the diseased person, collect lab samples on each if them and if lab tests arepositive provide curative treatment.

Health information is compiled and summarized from the basic birth and death certificates, hospital, health center, and mobile unit report forms in a number of new ways. New information outputs include comparison of maternal death and infant mortality by parity and age of mother, reports on contact examinations, province and district activity - 63 ­ reports of various units, activities of mobile units, etc. These new tables are to be used to provide a better basis for health planning. Six.clerks have been hired to compile the information and prepare, the summary tables.

No information is available yet on the effectiveness of this surveillance system.

5. Other Aspects of the Program not given such high priority, to be implemented after the above, include development of improved procedures, in-service staff training, creation of emergency/disaster plan, accident prevention, local emergency transport and communication, drug control program, and health center delivery program. Thirteen CNCs have been established near health canters and midwife centers. They have been built mainly by local contribution, servicing an average of 30 children each. One aide is hired per 30 children at $300/ month, financed by parent's contribution of $30/month. The children, aged three to five, receive high protein lunches. Volunteers assist the aides, all are supervised by the midwife. The Nutrition Division, MOPH, provides $10,000 per unit per year.

Like all CNCs, these take only those children whose parents can pay the price, but will make a deal for more than one child (e.g., first child pays, second child free). They do not reach the poor who are most in need of added protein, child health, and health education.

III. COSTS OF PROJECT EXPANSION

1. Health Planning Exercise

Every province must now develop operational yearly plans and five year plans for health; this exercise simply provides a framework for developing statistics and examining problems. No new statistics need be collected. Staff time and funds presently allocated to provincial planning should be sufficient, perhaps with assistance from Bangkok staff with experience in this kind of planninag for the first few years.

2. Provincial Health Advisory Council

Selection of participants is made by the Governor with help of the PCHO staff. Schedule and agenda of meetings are arranged by them. Contact with participants and provision of information about purpose of this Council require minor staff time and administrative costs. - 64 -

Meeting might require small financial inputs: (Assume 25 participants per meeting)

1. Transportation for nai amphurs and other 750 representatives (15) @ $50 ea.

2. Luncheon (25) @ $25 ea. 725

3. Printed materials @ $5 ea. 125

4. Mailing of minutes $ conclusions @ $2 ea. 50 Cost of one meeting 0l,650

Two meetings per year per province $39300

140 total meetings $231,000

3. Mobile Health Service

Ascume: No additional staff requirement or vehicles, no additional audio-visual equipment. Continuing on the Chonburi model, there is one team operating from every district health office, and two from the provincial health office, for a total of 760 mobile teams.

1. Training of local leaders to assist mobile units from "remote villages" was given at the same time as training in epidemiological surveillance (section 5) and is not separated out here. The training could be given by local health staff, once it has itself been oriented, at minimal cost.

Training for: Government midwives $5,000

Government sanitarians $3,000

TOTAL $8,000

@ $100 ea: remote areas only $800,000 2. Transportation

Fuel: 104 days x 760 vehicles x 40 km x 3.8 9 92,402,816 5km

Lubricant: 104 days-x 760 x 40 kmx 57 % 90,106 2000

Routine Service: 104 x 760 x 40 x 48 75,878 2000

Spare Parts: $5,000/car x 760 3,800,000

Service: $2,500/car x 760 380,000 5 years

TOTAL TRANSPORTATION $6,748,800

Decreased life of vehicles is not considered here.

3. Per diem allowance for personnel, for approximately 1/3 of total trips 104 x 760 x 3 personnel x $30 $2,371,200 3

4. Equipment replacement & repair ($1,250/team x 760) 950,000

5. Increased drug and supply needs, approximately $l,750,000/province x 70 (based on Cholburi project estimates) $122,500,000

TOTAL $133,370,000

Total excluding drugs $10,870,000

Total People Served @ 50 treated and 30 immunized per trip, 79,040 trips/yr. 6,323,200 Cost per person served excluding drug $2

Cost per person served including drugs $21 Revenues from $5 service charge from sick clinic, @ 50 people per trip $19,760,000 - 66 ­

4. Provincial Health Education

Training of village leaders in the Chonburi project was for three purposes: assi',ting mobile health teams, assisting in epidemiological surveillance, and "eneral health education. Training costs of village headmen, tambon doctors and granny midwives have been listed under epidemiological surveillance (section 5 below), even though health education was intermixed. This section concerns only training specifically for improved health education.

Training of granny midwives for better delivery techniques, ANC, PNC, F.P., and general care. 50,000 midwives @ $100 ea. $5,000,000 Training of tambon doctors in first aid and general health care. 5,000 T.D.s @ $100 ea. 500,000 Training for village druggists 10,000 druggists (2 per tambon) @ $20/day for one day 2009000

Manuals for druggists @ $5 50.000

TOTAL $5,750,000

5. Epidemiological Surveillance

Training of village leader @ $100 ea.

Kamnans and headmen 50,000 Tambon Doctors 5,00( Granny midwives 50,000 105,000 $10,500,000 6 clerks/province to organize and summarize data @ 9750/month 31780,000 Supplies and other support @ $10,000/province x 70 provinces 700,000 Total first year training $10,500,000 Ongoing costs assuming Retraining of 20 per cent per year $5,530,000 - 67 -

V. EFFECTIVENESS The total program has just got off the ground during 1973-74, and it is difficult to draw cunclusions, or even obtain opinions from PCMO staff at this time. These points can be made, however:.. 1. This is one of the first attempts to recognize, cooperate with, and direct private practitioners and local government officials in health planning and service. The Advisory Council only includes two or three rather famous rural practitioners, but does include the voluntary agencies. While it meets infrequently and has no power, it at least provides some interchange of information.

2. Tambon doctors and indigenous midwives as well as other volunteers have been quite receptive to training. Their continued motivation is dependent on the health workers, however. The personalities and motivation of the midwives, sanitarians, and the District Health Officers are the key to success of both mobile units and epidemiological surveillance, because they are the people with direct contact with iolunteers and villagers.

This project, however, includes no increase in supervision or motivation of these lower level health officials other than five days of training and in some cases visits by the mobile health units. More emphasis needs to be placed on them far greater success in the villages.

3. On the provincial level, the success of the Advisory Council and health planning depends to a great extent on the interest and attitudes of the Go",ernor and P(24O. They alloca e staff time, vehicles, and funding to the various aspects of the program and can slow it down or speed it up as they desire.

4. The PCHO considers the mobile units very expensive, especially considering the decrease in attendance of late and rising gasoline prices. There are no plans to abandon the program,however, since there is no alternative for providing services to remote areas at this point. According to cost estimates listed here, mobile units can pay their own way except for the cost of drugs and medicines, with revenues from their service charpof 95 per patient. Other provihces may not be so fortunate in having the vehicles or the staff to implement a mobile health service that can go out :egularly without sacrificing other services. For provinces which must buy additional vehicles or hire additional staff for a mobile service, costs will be much higher. In provinces which do nothave the good roads which Chonburi has, vehicle maintenance, gasoline, and per diem costs may also be much higher. Cost for a mobile service must be determined on a provincial basis. - 68 -

Preventive services of the mobile units have not been well accepted, despite the participation of the local granny midwives in administering them.

5. It is too early to tell if bette: information on morbidity and mortality in rural areas will result from the training given village leaders, but at least they have begun to learn about the importance of their health reporting.

Information from Chonburi ptoject documents;Dr. Yutthana Sukamiti, Division of Health Planning; and Dr. Banthao Eukul, Deputy PCMO of Chonburi Province. - 69 - ANNEX X

ACCELERATED DEVELOPMENT OF MCH AND FAMILY PLANNING SERVICES

U FPA/WHO/UNICEF/NFPP, MOPH

(FPA/551/THA/9) (WHO Thailand 0130) Project Period: July, 1972 to September, 1976

TARGET POPULATION: Women of child bearing age and children of 4 and under

in four NE provinces:

Total Population (1970)

Kalasin 5739000

Khon Kaen 1,025,000

Roi Et 780,000

Udorn Thani 1.118,000

TOTAL 3.496.000

I. PURPOSE

To demonstrate by means of a pilot project that strengthening certain aspects of the MCH service results in improved maternal and child health and family planning. To demonstrate the feasibility of delivering family planning services effectively by a concerted effort during and soon after pregnancy, when desires to space and limit births are high, to determine if this project's approach is feasible for extension to other areas of the country. Finally, to coordinate existing MCH resources so chat optimum use is made of them.

II. METHODS 1. Strengthening the MCH System

The project originally hoped to build four MCH subcenters, one per province, each with 22 beds, two MDs and supporting staff. These subcenters would essentially be MCH hospitals offering 24-hour service, unlike the provincial hospitals. The project also planned to expand the MCH facilities at provincial hospitals. Unfortunately, delays in implementation and soaring contruction costs have eaten away the budget. - 70 -

Construction must be limited to three MCF1 subcenters, two presently being built in Amphor Pol, Khon Kaen, and Suwauapoom, Roi-et, scheduled for completion in late 1975, and one other not yet started. Funds for a fourth subcenter are being requested.

2. Motivation of Pregnant and Recently Delivered Mothers Since this project is designed to work within the existing rural health service structure, the key personnel for contacting and motivating village mothers are the government midwives of the second class health centers and midwifery centers. Thus a great deal of emphasis is placed on training, supervision, and support of these midwives. a. Training

Orientation seminars for key provincial and central office personnel were given in March, 1973. Training and orientation were provided for the supervisory personnel (nurses) and service level workers (midwives) in May and June 1973. Training was meant to acquaint them with the methods this projec:t would utilize, inform them of their new responsibilities and explain the referral system which was to be established. To assist the midwives in information gathering and reporting, 97 family planning clinic workers and field workers were trained and hired, and 50 more will be trained in 1975. Their duties are.described below.

b. Information Collection

Village maps, household registers, baseline study.

The first duty of the midwives, following trainLg, was to prepare village maps, based on malaria house visitors' maps, and household registe,s. These would identify pregnant and recently delivered mothers, children in need of immunization, family size, and deaths. They are to be updated very two months.

A baseline KAP study was also prepared. The resulting data show that the average number of live births among sampled fertile women is 4.2 and that 62 per cent want no more. 75 per cent were not practicing family planning. About 50 per cent had attended antenatal clinics at one time or another, but 90 pir cent of the deliveries oczurred at home. Only about six per cet.t used well-child clinic services, but 50 per cent used government health services to treat their children's illnesses. This information will be used to provide some comparisons for evaluation. c. MCH Duties of Midwives and Family Planning Workers With the help of the information from village maps and household registers which midwives have collected, they are expected to - 71 ­

visit all pregnant women they have identified at least twice, referring those in need of special care to the health centers, supplying all with iron and vitamin supplements and tetanus toxoid, and providing information on nutrition, child care and family planning. Midwives are to return within two weeks after birth to examine the baby, immunize, refer if necessary and advise on family planning.

Family planning clinic workers are local women, usually with little formal education, who are positioned in the larger midwife or health centers to keep the family planning records up to date, keep a "tickler file" for follow-ups on PNC and ANC, and submit monthly activity reports to the first class health centers. Family planning field workers are also local women with limited education, who make and up-date the maps and registers in villages not serviced by midwives, provide services such as family planning, nutritional, and child care information and referrals, and assist the midwives in scheduled visitsto women. Both field and clinic workers have full-time paid positions.

Midwives under the project have been provided motorcycles to make their field visits; family planning field and clinic workers have received bicycles.

d. Supervision

Nurse-midwives at the provincial an4 first class health center level are responsible for supervision of midwives and family planning workers. They are expected to visit each midwife and health center under their supervision at least once a month, to make sure that field work is adequate and check on reporting and referrals. Although nurse midwives are paid per diem and transportation costs for their field trips, they do not have their own vehicles and are dependent on the local bus service. There are fifteen nurses to supervise some 75 to 85 midwifery and health centers. While each nurse has only five or six stations to visit monthly, inadequate transportation often makes this difficult. The Provincial Health Officers and the project's central staff in Bangkok do overall supervision.

e. Referrals

A referral system has been established to provide both upward referrals (from health centers to hospitals) and downward referrals (for follow-up treatment by local health personnel). The nurse midwife in each hospital, MCH subcenter, and health center is responsible for the referrnl mechanism.

The local midwife, in referring a woman or infant to a higher institution, uses a form which makes copies in triplicate. One she keeps for her record, one goes to the patient, and one goes to the - 72 ­

hospital or health center. When she shows her copy, the patient receives priority in obtaining treatment. Once treatment is completed, the midwife for the patient's village is advised of treatment given and additional follow-up needed, as is the patient. The PHO is to see that referral forms are delivered.

At each of the four hospitals in the project area a clerk has been hired, who spends 80 per cent of working time at the hospital and 20 per cent at the PCMO office, to handle the increased paperwork which the referral system creates, and compile information on referrals and follow-up.

3. Utilizing Existing Village Resources

During 197-5 and 1976, approximately 1,020 indigenous midwives will be trained in family planning and MCH. The ten day training will be given by nurse-midwives from central and provincial offices. Some of these midwives have already been trained in 1965 under an MOPH/UNICEF program, however, it is felt that retraining for these midwives is worthwhile. Midwifery kits will be provided at the end of the course.

4. Evaluation

The monthly reports of the midwifery centers' and health centers' activities prepared by the family planning clinic workers and information acquired through the referral system will be submitted to the Research and Evaluation Unit of the MCH Divi.ion for the remainder of the project period. These data will be tabulated and analyzed, so that regular reports can be made to provincial authorities.

A second sample of fertility, family planning continuation rates and KAP will be carried out in 1975-76. Results will be compared to 1973 data tc determine the project overall impact.

At this time, however, information leading to conclusions as to either the project's actual workings or its general impact is unavailable.

I1. COSTS

Costs are broken out in the Project Revision Form prepared in 1974 (in HPP files). Since this is a pilot project, it includes a substantial evaluation component which may not be completely necessary in a nationwide expansion. Cost figures also include constiuction and staffing of one MCH center rer province. The project has had difficulty in implementing this aspect even on pilot project scale. Since completion of the basic health center infrastructure is not yet completed, it is not clear that construction of MCH subcenters would or should have priority over that - 73 ­

of health centers and midwifery centers. Staffing of MCH subcenters with two MDs each would also be difficult, given the present shortage of MDs at provincial hospitals and first class health centers.

Therefore, only the cost of motivation of pregnant and recently delivered women by midwives' house visits and referral are considered here.

Assume nationwide (outside of Bangkok) there are the following numbers of health personnel:

900 MDs 3,000 nurses, of whom 1,000 are to be supervisors 3,500 hcalth workers 5,000 midwives 5,000 family planning clinic and field workers, to assist midwives, one per midwife.

Staff Training and Orientation Nationwide: (number) 1) Central Officer Per diem $80/da-4da (70) 022,400 Travel $500 (70) 35,000

2) MDs (900) Per diem 0100/da-4da 360,000 Travel $60 54,000

3) Nurses (22000) Per diem $70/da-4da , 560,000 Travel $50 100,000

4) Supplies & Support 70,000

Orientation of Health Personnel (14,500) Midwives, nurses, healthworkers, family planning workers Per diem 970/da-2da 2,030,000 Travel $50 725,000 Training of Nurse-Midwives as Supervisors Perdiem $70/da-Sda (1,000) 350,000 Travel $50 50,000 Supplies & Support 35,000

Training of Indigenous Midwives (50,000) 170.000 Total Training: $4,561,400 Yearly Review Workshop (Same as Staff Orientation) 01,201,400 - 74 -

Training for new personnel will be included in their regular training programs.

Additional Salaries & Referral Expenses:

Family Planning Field Workers & clinic workers @ $750/mo. (5,000) %45,000,O00 Referral Clerks, 1/province @ $750/mo. (70) 630,000

Motorcycles for Midwives @ 4,000 (about 1,000 midwives already have them) (4,000) 16,000,000

Bicycles for family planning workers @ $1,200 (5,000) 6,000,000 Gasoline for Motorcycles (28 km/liter, 03.8/liter, av. 100 liters/year) (5,000) 1,900,000

Replacement of Motorcycles and Bicycles 10 per 1,600,000 (Assuming replacement every 10 yrs) cent of 600,000 total

Referral forms, other Reporting Forms (assuming 050/midwife & FP worker/yr) 500,000

Processing of health center data and analysis at central level (pure guess) 1,000,000 (Administrative assistants, clerks, coders, computer time)

ILitial equipment costs: $22,000,000 On-going costs: $51,230,000 Supervisory Expenses:

Provincial: Nurses (one/province) Per diem and travel $3,250/mo. (70) $2,730,000

District: Nurses (930) Per diem and travel, $1,750/mo. 19,530,000

Central Office Project Personnel: 8 visits/province/yr. by 2 people Per diem I00/da ­ 5 da 560,000 Travel $500 560,000

TOTAL $23,380,000 - 75 -

Total one time expenses %26,56.,400 Total annual operating expenses E75,811,400

Target Population (approximate)

Rural women 15-44 $5,868,000 Rural children 0-4 6,233,000

TOTAL $12,101.000

On-going cost per member of target group: 06.3/person Target coverage of eligible population: 25 per cent eligible women, 30 per cent children, Total 3,337,000

On-going cost per covered member of target group: 022.7

Information for Dr. Tirador of UNFPA and project documents. -76 - ANNEX XI

CaeWITY DEVELOPMENT WORKERS AS FAMILY PLANNING EDUCATORS AND DISTRIBUTORS

PPAT

PRlOJECT PERIOD: 1974 and On'oing TARGET POPULATION: Fertile couples withLn areas of coverage of Community Development Workers (CDWs) all over rural Thailand.

I. PURPOSE

To expand availability of contraceptives in rural areas by utilizing over 4,000 CDWs of the MOI as family planning (F.P.) educators and distributors, since they are already serving all over rural Thailand and are well­ known to many villagers.

II. METHODS In mid-1974, 90 key personnel in the Community Development Program from the 9 regions of Thailand were brought to Bang Saen for five days of training in family planning. On returning to their regions, these people in turn provided basic training for the looal CDWs. Since then all CDWs have been allowed to distributc pills and condoms.

As in other family planning distributor programs, they set up examination appointments for new pill acceptors with midwives and for sterilization acceptors with MDs at first class health centers. Supervision is provided by the senior nurse at the nearest first class health center, as well as through the regular CDW supervision channels.

CDWs can charge the government rate for pills and condoms, $5/cycle and $5/dozen, of which they keep $2 as an incentive and return the remainder to PPAT through their supervisor. They mqy provide contraceptives free to people who cannot afford to pay for them.

III. COST The major cost, other than that of supplying contraceptives, is the training at Bang Saen. Supervision is supplied by existing supervisory personnel on their regular rounds. No cost breakdowns were provided, but I have guessed at some below: - 77 ­

90 Trainees' Transportation @ $500 ea. $45,000

90 Trainees' Per diem @ 960/day for 6 days 32,400 (1 day transit, 5 days training)

Teaching materials: pamphlets, T-shirts, etc. 4,500 @ $50/person 5 Trainers' Transportation, by car from Bangkok, 300 gasoline, etc.

5 Trainers' Per diem @ $100/day, 6 days 3,000

Other (donation to Temple, trainers' honoraria, 10,000 misc. supplie3)

Pamphlets, T-shirts, and teaching materials for 200,000 4,000 CDWs trained at their own provinces, @ $50/person $294,800

IV. EFFECTIVENESS In the last three months of 1974, the 4,000 CDWs have distributed contraceptives to 7,135 acceptors, ur just under 2 acceptors per CDW. How many of these are new acceptors and how many are switchovers from other sources is not clear, nor is the number of CDWs who are actively promoting family planning in their areas. Acceptor data for the first three months of 1975, when the program has been well underway, may be more revealing as to the success of using CDWs.

The idea of utilizing government personnel already in place at the village level is logical. They already know the villagers and their place in the community, they work under a system of supervision, and they can be easily contacted and resupplied :hrough the regular government channels of communication. There are a few points to keep in mind, however. First, there has traditionally been very little communication between ministries at the village level. The lines run from the central administration downward, but not across among civil servants of the same level. Even within MOPH, communications between departments or between health centers is limited. Therefore referrals by CDWs to health centers and supervision of CDWs by senior nurses cannot be expected to operate smoothly unless CDWs and health personnel have been well informed by their own hierarchy that this is official policy. Some resentment may develop from midwives who lose family planning acceptors to CDWs. - 78 -

Secondly, CDWs may feel that family planning is out of their range of resposibility, and is really a problem for the MOPH, so that it is not a high priority for them. Frequent motivation may be necessary to maintain their interest in family planning at the supervisory as well as the village level. This project does not at the present time provide for such frequent motivation and re-education.

Information from Dr. Pisut Utamote, Executive Director, PPAT. - 79 -

ANNEX XII

TAMBON PARAMEDICS AS FAMILY PLANNING EDUCATORS AND DISTRIBUTORS

PPAT

PROJECT PERIOD: 1974 and Ongoing

TARGET POPULATION: Fertile couples within areas of coverage of BPP paramedics in rural Thailand.

I. PURPOSE

To expand family planning availability in rural areas by utilizing over 1,000 BPP paramedics stationed in remote areas of the country as family planning educators and distributors.

II, METHOD

During June and July, 1974, two groups of paramedics (about 200 altogether) were given 5 days of traLning at the provincial commnunity development centers of Ubon and Prachuab Khiri Khan. The training, by a Bangkok team from PPAT, MOPH and ARD, included lectures and a day of role-playing at nearby villages. In Ubon, Kamnans also participated in the training. At completion of the course, all trainees received family planning pamphlets and T-shirts, and the BPP paramedics were permitted to begin distributing pills and condoms. They charge the government rates and may keep one baht from a cycle of pills or dozen condoms for their own use, returning the rest to PPAT. Supervision comes through their own supervisory channels.

III. COSTS Like the Community Development Worker project, the main cost of this project aside trom that of supplying contraceptives is training. Costs are estimated here similar to those of the CDW project, but since training takes place regionally instead of centrally, transportation costs are lower. - 80 -

For 2 Provinces Nationwide

Trainees transportation @ 060 200 12,000 1,000 60,000

Trainees per diem @ $60, 6 days 200 72,000 1,000 360,000

Teaching materials @ 050 200 10,000 1,000 50,000

Trainers' transportation, 5 trainers @ 01,000 each 2 trips 10,000 15 trips 75,000

Trainers' per diem @ 100 2 trips 1,000 15 trips 7,500

Other, @ $10,000/trip 20,000 150,000

TOTAL $125,000 , 702,500

Cost Per Paramedic: $625 $702.5

IV. EFFECTIVENESS

The 200 paramedics distributed contraceptives to 3,490 acceptors in the latter half of 1974, or over 17 acceptors per paramedic. As with the CDW project, we do not know how many are new acceptors and how many are swltchovers, but PPAT Director, Dr. Pisut, feels that these acceptance rates are quite impressive for a program which has only been active some 5 months. Paramedics are meant to serve in areas not adequately reached by the governmcnt health service, and the villages assigned to them are not also visited by health workers, so there should not be much duplication of family planning effort between paramedics and healih personnel in an area. There is already some resentment of paramedics by the health workers in the areas, however, who feel that their om z.cceptance by the villagers has been limited by the presence of these other health personnel. While use of paramedics to spread family planning may be quite successful in terms of acceptance rates, it may add to the unfriendly attitude between health center personnel and paramedics. If the paramedics are now serving family planning acceptors who formerly bought their contraceptives from the health centers, then the health centers are losing revenues to the paramedics. The amounts lost must be small, but they can still add fuel to the fire. Projects like this should be carefully coordinated between the Ministries involved.

Information from Dr. Pisut Utamote, Executive Director, PPAT. - 81 -

ANNEX XII

UNIVERSITY STUDENTS PROJECT

PPAT

PROJECT PERIOD: 1974 to 1975

TARGET POPULATION: 120 university students and villagers from 12 districts throughout Thailand, mainly in the North and Northeast.

I. PURPOSE To stimulate the interest of University students in promoting family planning in Thailand, and to utilize small groups of them as village volunteers to disseminate family planning information, education, and communication during their school holidays.

II. METHODS

In .the latter part of 1974, 130 students from universities throughout Thailand were selected by PPAT to participate in 4 days of family planning training at Bang Poong ARD training center, near Don Muang. Training was geared mainly to the importance of family planning and alternative family planning methods. Students received written material and family planning T-shirts before returning to school.

A few months later, these studentswere sent questionnaires to determine their continued interest in family planning. The students who receive the top 60 scores are to be sent to Bang Kae for 4 to 5 days of further training a month before their holidays. Training by PPAT staff will emphasize motivational techniques.

From this group, 36 students will be selected to work in 12 groups of 3, each group to go to a different area during the school holidays, to act as village family planning educators. They will not be allowed to distribute pills or condoms, but only to inform and motivate villagers. The length of time they will remain in their area will vary from group to group depending on school schedules and family needs. They will receive no salary, although their expenses will be paid.

There are no plans for further follow-up work by the students after they have completed their family planning field work in the villages. - 82 -

I1. COST

No cost information was provided.

Information from Dr. Pisut Utamote, Executive Director, PPAT. - 83 -

ANNEX XIV

MOBILE MEDICAL TEAMS. TAMBON PARAMEDICS ARD/MOPH

Since USOM has a great deal of information about these programs its files, in only brief summaries of the programs and where they stand now are included here.

1. Mobile Medical Teams (MMTs)

A coordinating committee of representatives from ARD and areas MOPH determine to be served by both MMTs and paramedics, based on existing health services in these areas, and in the case of the MMTs, on ability of the provincial the hospitals and medical'institutes to supply staff for the teams.

There are presently 59 Mobile Medical Units in 28 ARD provinces. MOPH and The medical institutes in these areas assign personnel to the teams on a rotating basis. MOPH determines the policy, supplies the personnel for the teams, and instructs health center personnel cooperate. to ARD supplies vehicles, gasoline and maintenance, per diem, and medical equipment and supplies. Teams consist of one or two MDs, two to four nurses and/or sanitarians, and a driver.

Each team makes a temporary base in a first class health from the.e cnter, and travels to remote villages three days per week and provides service from the health center the remaining days. The teams visit villages according to a set schedule. up operations They usually set at the local school or health center. Local midwives, sanitarians, or paramedics have informed iil'agers in advance team's arrival. of the ARD staff estimates that teams serve 200 to 300 people per day, but 1973 service tables indicate an average of 105-110 per day. Many of these people are not really sick, but just want to an opportunity see a "real" doctor and receive some medicine. These people given aspirins are oz vitamins. Cases actually requiring treatment are estimated at about 50 per day. - 84 -

Each team works in a fairly small area, so that it can visit each village five or six times a month. After about three months of intensive service to an area, it moves on to a new area for similar service.

2. Tambon Paramedics

Paramedics are men or women, from 18 to 40 years of age, who have completed secondary school. They are recruited from their village to return to that village after training. They receive three months of training at the ARD Paramedic Training Center at Chiang Mai, then return to their province and spend three months in on-the-job training at the provincial hospital or a first class health center under close supervision of an MD.

Once they have completed training they are transferred to the authority of the province from ARD, although their salaries are still paid by ARD. They work at the second class health center of their tambon under the supervision of the sanitarian. If there is no second class health center in their tambon, they use the local school or kamnan's house as headquarters, but are under supervision of the sanitarian in the nearest health center. They have two or three villages assigned to them, one of them their native village. They work according to a schedule, going to each of their villages every day for house visits but also spending some time at their health center, so that they can receive further education from the sanitarian. ARD provides them with bicycles and some medical equipment.

Paramedics are allowed to cure minor ailments, administer simple drugs and antibiotics, give vaccinations, perform first aid, and in some cases distribute contraceptives. For cases they cannot handle, they are to refer patients to the first class health center or hospital. About 30 percent of the paramedici are female. About five percent are former army medics. Some of them are "quacks" as well as paramedics, although ARD discourages this and d-ops them from the payroll if illegal activities are discovered.

Although the paramedics are under the aithority and supervision of the MOPH health service, ARD has also trained paramedic supervisors in 45 day training sessions, one supervisor per 10 paramedics. They are to make frequent and regular visits to the paramedics and report their activities, including any irregularities, to the District Health Officer.

ARD encourages paramedics to become sanitarians, and presently has 30 enrolled in the course (at ARD expense). ARD also pays the salaries - 85 ­ of about 100 sanitarians within the MOPH, for the administrative and technical assistance they give on the MT and Paramedic programs.

3. Effectiveness of the Two Programs

ARD feels that both programs are important and has no plans to abandon either of them. Mr. Somkasem Viseskul, Chief of ARD Technical Services Division, stated in an interview on February 28, 1975, that in his opinion the tambon paramedics have by far the greatest impact of the two. Serious diseases that require treatment by an MD are infrequent in the villages, so that the paramedics can treat most of the villagers' ailments, while MDs do not fully use their skills on the MMTs. Paramedics know the villagers well and are nearby wheaever they need help. M=Ts on the other hand can only remain in an area a few months, then have to move on. They do not have the opportunity to build up the villagers' trust as the paramedics can.

In terms of services provided, the 59 MMTs in 1973 gave medical care to 968,856 people according to the most recent available figures. Assuming that they went out three times per week, this averages out tc 105 people served per visit. The annualnumber of people served has declined steadily since 1970, when the teamz served 1,172,162 people, despite an increase in the number of teams operating.

The ARD budget for FY 1974 for the 59 MMTs; excluding salaries of MDs, nurses, and sanitarians, is about $21,000,000 or about $355,930 per vehicle. (Gasoline costs about B7,500 per vehicle per year. The most important cost is medicine and drugs, which are very high because of the large number of people who are not really ill, but want treatment by an MD. They usually receive aspirins or vitamins). Assuming that they treat approximately the same numbez of people in 1974 as they did in 1973, cost per person served is close to B 22.

The 1,136 paramedics served 4,483,056 people in all during 1974, accordihg to ARD's most recent figures. This is about a million more people than they served in 1973. Assuming that they work a five day week, this averages out to 15 people per paramedic per day. The budget for paramedics in FY 1974 is almost en:actly the same as that for MHTs, about 21,000,000. This works out to a cost of about $18,485 per paramedic or about $ 5 per villager served.

Unfortunately, the figures for people served do not specify type of treatment required or extent of follow-up visits included.

Because there are few difficult or unusual cases for the MDs in the villages and a good many people with nothing at all wrong, MMT work is not particularly interesting for the MDs, besides keeping them away from their regular jobsand private practice. For the paramedics, - 86 ­ however, there is an element of prestige involved in their job, as veil as an opportunity for advancement. With good recommendationo from their supervising sanitarians, paramedics can receive salary increases from their initial %800/month rate, and if they show the interest and qualifications they may be sent on to school to be sanitarians or midwives at ARD's expense.

Mr. Somkasem feels that the paramedic supervisors are necessary for success of the program. The sanitarians at the second class health center do not have time to give adequate supervision, and may in fact take the paramedics away from their own work by assigning them to privy construction or midwifery work. The paramedic supervisors keep these types of assignments at a minimum and cut down on paramedic "quackery" by providing close supervision of both health center and field activities.

hore is some ill-feeling in the MOPH towards both of these programs, because it is felt that rural health should be outside the scope of ARD. In the case of paramedics, there has been some resentment by second class health center personnel who feel that the paramedics are moving in on their territory. If the actual administration of the program operated as it is formally shown, with a coordinating commit'tee between ARD and MOPH making policy decisions, and with the paramedics working under direct supervision of the 3anitarians, these conflicts should not be as great as they apparently are.

Information from Somkasem Veseskul, Chief, ARD Technical Services Division; Pater Barrett, USOH; and Project documents - 87 -

ANNEX XV

FAMILY PLANNING COMMUNICATION DEVELOPMENT AND INTEGRATED CAMPAIGNS

NFPP - MOPH/UNFPA

PROJECT PERIOD: 1972 to 1976

TARGET POPULATION: Entire country, with emphasis on fertile women and village leaders in rural areas.

I. PURPOSE

To spread wider knowledge and acceptance of family planning (FP) throughout Thailand through the use of all possible channels of mass communications and through mobile family planning education units.

II. METHODS 1. Mobile Units

Nine mobile units have been put into operation over the past two years. Each mobile team consists of a health educator, a driver­ projectionist, and a worker. Before beginning operations in a region, the mobile training units are sent to the Provincial Health Office to provide training for health personnel, especially midwives and sanitarians of the second class health centers and midwife centers. The five day training is to motivate the health workers in family planning and to teach them family planning communications and motivational techniques. Health personnel are then asked to assist the mobile teams in their field trips to the villages.

In both health personnel training and village motivation, mobile units stress the use of A-V aids, pictures and charts.

A schedule for visiting the villages is arranged. The day before a mobile team's visit, the local midwife or sanitarian goes to the village and contacts the women aged 15 to 45, asking them to attend a horning family planning discussion. He/She contacts the village leaders, asking them to mect for a noon discussion, and tells as many villagers as possible thot movies will be shown in the evening. The following day the team arrives for the daytime discussions, where villagers learn the importance of family planning, details about the various methods and where to get them, and have their questions answered. The local health center pecsonnel part-cipate in the activities. - 88 -

In the evening, movies stressing family planning are shown, some of them especially prepared with regional dialects and customs in mind. Two types of film are shown, one strictly for motivation, the other for entertainment - perhaps ordinary commercial Thai productions, but narrated with a little family planning slipped in at appropriate moments.

The government midwife who assists the mobile unit has on hand a supply of contraceptives and is willing to give examinations for pills and to set up appointments with the nearest MD for IUD insertions and sterilizations.

The teams each visit one village per day, twenty days per month. They remain in a province only one month, then move on to the next province where they spend five days in training health personnel and 20 days in the field. Thus if all nine units are operating, they can visit 180 villages before moving to the next province.

The mobile teams are now working in the Northeast. They will move to the North after March for several months, then to the South, and finally to the Central Plains.

Two teams will remain in the Northeast when the others leave, to work there on a permanent basis. Similarly, two will remain in the North, two in the South, and three in the Central Plains. Since the teams cannot visit every village, they try to choose central areas in clusters of villages. At each stop 500 to 1,000 villagers attend, depending on the groundwork laid by the midwife and sanitarian. An average of 50 fertile women attend the morning discussions. Reception at village leader discussions is usually good since local government officials feel obliged to attend and bring other local leaders with them.

2. Mass Communications

a. Radio - The NFPP has arranged 30-minute radio broadcasts once a week on 35 radio stations throughout the country, distributed so that at least one broadcast can be heard everywhere in the country. Twenty of the broadcasts are produced by the Provincial Health Offices with NFPP funds as part of general health education programs, but in these cases at least 25% of broadcast time is devoted to family planning. The other fifteea broadcasts are produced by the NFPP itself, completely devoted to family planning. Radio time is free in the provinces because of a legal requirement that government messzges be aired free, but there is a charge for use of Bangkok stations. b. Cinema - All provincial theaters (of which there were an estimated 380 outside Bangkok in 1969) have been sent family planning slides to be shown before the main feature begins. Theaters show these - 89 ­

alides free of charge before each show, by requirement of the provincial government.

c. Television - Seven family planning spots are being prepared for television but have not been shown yet. Television is out of financial range of most rural Thai.

d. Newspaper - No newspaper advertisements are included in this program. Rural Thai do not generally subscribe to or regularly read newspapers.

Production and distribution of radio broadcasts, cinema advertisements, TV spots and other mass media family planning materials as well as coordination of the mobile units and production of their A-V materials are all the duties of the Public Information Unit of the NFPP. The program estimates thac these require 18 new positions; Chief of the Unit, 12 officers whose duties include research and evaluation of the-project, and 5 clerk/typists.

3. Motivation feed-back

Health personnel and local leaders, such as teachers, are being selected and trained in providing feedback on family planning motivation: what are the factors constraining or facilitating motivation work, what types of communication media work best at the village level, what is the relative receptivity to family planning concepts. Two health personnel plus some nurse-midwives and certain village leaders are to receive training from each of 70 provinces. These people will then test, record and report to the NFPP on the impact of various motivational techniques on the villagers, with the assistance of the mobile unit staff.

III. CSTS

Cost estimates are based on estimates of original project budget, revised somewhat to account for price and salary changes since 1972, and making other additions or deletions where actual project implementation has not followed proposal. The result is not an exact breakdown of costs, but should represent a fairly reasonable estimate. Capital or One-Time costs

9 Mobile Unit vehicles %821,OO

A-V Equipment for 9 units 642,900

Recording and teaching Equipment 387,800

Training Supplies 535,340 - 90 -

Freight (shipping of above equipment) $182,000 Common production expenditures for Mobile Units, Training, Mass Media 3.717,000

TOTAL $6,286,040

Operating Costs

Salaries for Mobile Teams, inc. per diemi' $897,600

Supplies for 9 Mobile Units 434,600

GasolineV / 80,000

Maintenance of Mobile Units2 / 5,700

Depreciation4 / 54,800 Depreciation of A-V equipment / 32,200

Operating Costs for NFPP Information Unit; 641,000

Training in communication and feed back 190,000

Insurance 10,000 Drama, TV, Radio Programming 90,000

Further Productions for Mobile Units, training and media (pure guess - 8-107. of intense production included under one-time costs) 300,000

TOTAL $2,736,000

1/ Salaries: 9 health educators for mobile units (3rd grade-mid level, $19,800/yr.) $178,200

9 Driver projectionists ($9,000/yr.) 81,000

9 Workers ($g9000/yr.) 81,000

2 health educators based out of NFPP as backstops and as headquarters logistics unit (019,800/yr.) 39,600 - 91 -

I Base assistant, logistics unit (2nd grade officer, 013,000) 13,000 Per Diem for Mobile teams: (240 days per annum)

9 x 240 days x $60 Health Educators $129,600

9 x 240 days x $60 Driver 129,600 9 x 240 days x $60 Workers 129,600 Per diem for

supervisory and logistic personnel 200 days x $100 20,000

other personnel - 8 in field for 120 days/yr. (These personnel are not specified) 8 x 120 x $100 96,000 (U!4FPA budget assumes 4160/day per diem, but this is above government rates - government rates are used here)

TOTAL $897,600

3/ Maintenance of Mobile units Lubricant:

25 days x 12 months x 40 km x $57 2000 - $342 x 9 - $3,100 approx. Routine Service:

25 days x 12 months x40 km x $48 2000 - $288 x 9 - $2,600 approx. $57 - Lubricant and $48 service based on 25% and 20% increase respectively over figures used for Chonburi Project mobile team expenditures in 1972.

Spare parts included under "Supplies for 9 Mobile Units"

4/ Depreciation - New Car Replacement. Assuming vehicles are usable for 15 years, $41,050 ; 15- $2,740 = $54,800. - 92 ­

5_/ Supplies and parts replacements are included in "Supplies for 9 Mobile Units". This category covers replacement of major items and new items as improvements in communications are made. Assume, roughly, 5 per cent per year.

$642,900 x 5 per cent $32,200

6_/ Operating Costs for Public Information Unit of NFPP includes -

Salaries

1 Unit Chief @ $28,400 (2nd grade officer) $28,400 12 Officers 0 $19,800/yr. $237,600

5 Clerk/Typists @ $12,000/yr. (estimated) $60,000 Communications research $300,000

Support Costs $15,000

TOTAL $641,000

IV. EFFECTIVENESS

Mobile units: The mobile units are still working in the their first area of concentration, the Northeast, and have as yet no evaluative data on the effectiveness of their visits. A small pilot project was carried out prior to this project's implementation, using similar methods. With the activity of the mobile units, family planning acceptance increased by 10 to 20 per cent, but the pilot project employed one unit per district as opposed to nine countrywide.

During this project period, all nine units working 20 days per month can reach 2,160 villages or village clusters in a year. At this rate it would take 25 years to visit all Lhe villages that exist today. If each visit reaches an average of 50 fertile women for morning discussions and 750 villagers for the evening show, the total populations reached in a year are 158,000 fertile women and 1,670,000 villagers. The operating costs of funning the mobile units total about $1,980,000 per year*. Thus, if the units can motivate 10 per cent of the eligible couples which they reach to accept family planning, the cost per acceptor is just under $121 ($1,980,000/16,000).

* Including one half operating cost of Information Unit, excluding other administrative overhead. -93-

Even if the mobile units are extremely effective in motivating and educating villagers, they reach far too few to make an important impact on Thailand's population growth rate. They certainly cannot return to remotivate villagers later, so the task of maintaining the villagers' interest in family planning is left with the midwives and sanitarians.

To visit each village at least one time per year for motivation and remotivation, a fleet of 170 mobile uniLs working 25 days during most months would be required, at a capital cost of somewhere around $35,000,006 and operating costs of %31,200,000 (excluding the cost of running the NFPP Information Unit).

One of the difficulties of ARD's mobile medical teams and other mobile unit projects is finding people willing to staff the teams. This project, surprisingly, reports having hal no difficulties in staffing, but does anticipate that some may arise. The teams leave early in the morning and work late into the evening. Team members can expect to have very little time in their home areas or with their families. The per diem is attractive, since it amounts to nearly as much as, or more than, their base salaries, but it may not be attractive enough over a long period. In terms of cost, assuming that about half of the total production costs were for mass media, initial costs ran about $1,860,000 and operating costs (including one half the cost of operating the NFPP Information Unit) are about %480,000 per year, excluding administrative overhead. It may prove to be more useful airing several one-minute or two-minute family planning "commercials" per week. This necd not greatly increase the cost of production since broadcasting is free for government purposes.

No evaluative information is available on the "motivation feedback" aspect of training at this time.

Information form Dr. Somsak Varakamin, Assistant Director, National Family Planning Project, MCH Division, MOPH; and project documents. - 94 -

ANNEX XVI

MOBILE VASECTOMY UNITS

PPAT

Project Period: 1974 and ongoing

TARGET POPULATION: Fertile men in rural areas of Nong Khai and Prachinburi during 1974 and in other areas not yet selected in 1975.

I. PURPOSE

To educate and motivate rural men to accept vasectomy for permanent family planning, and to provide free vasectomies to large groups after motivation.

II. METHODS

Once a target area has been selected, a "motivation team!" made up of 5 or 6 members of PPAT staff goes out for 3 - 7 days, spending one day at each village in the area. During the day they educate the villagers about family planning, especially vasectomy, in several ways, including the use of audio-visual equipment, movies, and pcrhaps a local entertain­ ment group singing about family planning.

One month later, the team returns to inform villagers of the date that the mobile vasectomy team will arrive, set up appointments for acceptors to receive vasectomies, answer questions and remotivate. MDs and nurses from local health centers are invited to observe, learn to perform the operations, and participate.

The night before the mobile team is to arrive, a final motivation is given. Some local entertainment group is hired to present a show of song and dance, with family planning messages interspersed. In the two areas of operation during 1974, for instance, a "moran" was presented.

The following day the mobile team of 4 to 8 MDs and nurses from Bangkok locate at a health center or other public building. Acceptors are first given an explanation of how the operation works and how it will affect them. Then the operations are performed and acceptors are given antibiotics, and pain pills, and family planning T-shirts. One MD can perform 25 to 30 operations per day. - 95 -

The teams also provide information on other family planning methods.

The operations and medicine are provided free of charge, although each acceptor is asked to contribute whatever he can afford.

Two teams were sent out during 1974, one to a resettlement scheme in Nong Khai where 125 men were vasectomized (2k days) and one to an area of Prachinburi where 372 men were vasectomized (4 days). Many more vasectomies could have been given but for lack of facilities for sterilizing equipment.

III. COSTS PPAT did not provide a detailed cost breakdown, but has determined that cost per acceptor for all costs, including motivation, is no more than $250 per acceptor. This compares with private clinic charges for vasectomy of $500 in Bangkok and $300 upcountry. I do not have adequate information to provide an accurate cost breakdown, but the types of costs required to field a team would include the following: Motivation Team (5 staff members, 5 villages visited)

Transportation: 2 round trips by van, to carry A-V and other motivational equipment Van (already owned by PPAT) Gasoline (3,200 Km)

Maintenance

Per diem for 5 people, 10 days at villages, 4 days in transit

A-V Equipment (already owned by PPAT)

A-V Equipment maintenance

Motivational materials

Local Entertainment

Moblie Unit:

Trarsportation: 1 round trip by air, 4 MDs, 4 nurses

1 round trip by van to take staff members and equipment to village area, by 2 PPAT assistants, driver - 96 -

Per Diem: 4 MDs, 4 nurses, 2 assistants, 1 driver, 6 days (2 in transit, 4 in service)

Medical equipment and supplies

Information booklets, T-shtrts for accept6rs

Administrative Costs

IV. EFFECTIVENESS

The vasectomy units have had more acceptors than they could handle in both of the areas covered in 1974, but lacked the money, staff, and equipment to do more. 500 acceptors per year are far too few to make any kind of an impact on population growth rate. To meet the Third-Five Year Development Plan's goal of 40,000 sterilization acceptors per year, assuming that 50% are to be vasectomies, the program must be increased 40 times, to about 80 teams fielded per year. If the cost remains $250 per acceptor, this implies a total yearly cost of $5,000,000.

During 1974, MDs and nurses participating in mobile vasectomy units were unpaid volunteers, who received only per diem. PPAT expects it to become more and more difficult finding MD volunteers, because participation in the units requires taking several days off both their day time government jobs and their private clinics, which represents a substantial loss of income. In a private clinic alone,an MD can make at least 500 in an evening. PPAT suggests providing MDs and incentive to participate by paying them perhaps $40 per vasectomy. At this rate, an MD would make $1,000 per day of participation. $40 is too high a price to be passed on to the villager as a charge, so it would have to come out of PPAT's budget, bringing the cost per acceptor up to $290. Cost of 20,000 vasectoaies per year would then be $5,800,000.

Of the two groups vasectomized during 1974, no acceptor had fewer than 4 children. Thus even if vasectomies were widely accepted, they could not in themselves bring about a lowering oZ the growth rate to national target levels, unless fathers with fewer children can be motivated to accept.

Still, this i3 a step in increasing villagers' knowledge about, access to, and acceptance of vasectomy and family planning in general.

Information from Dr. Pisut Utamote, Executive Director PPAT. - 97 -

ANNEX XVII

USE OF MIDWIVES TO INJECT DEPO-PROVERA

MCH/MOPH with assistavze from British Council, UNFPA, and Pop. Council

PROJECT PERIOD: 1975 - 1976

TARGET POPULATION: 1,200 depo-provera acceptors throughout the country, 600 serviced by midwives, 600 by MDs.

I. PURPOSE

To determine the feasibliity of using midwives to inject depo-provera (a three month contraceptive injection), to make this popular form of birth control more readily accessible to the rural people.

II. W-THODS

Fifty government midwives working in different areas of rural Thailand have been trained to inject depo-provera. Their use of the contraceptive with 600 acceptors will be compared with 600 acceptors receiving depo-provera from fifteen MDs, to determine the midwives' ability to give the injection, educate the acceptors about its side-effects and treat them, and provide follow-up. If the evaluation prcves their service is as good as the MDs', midwives may be allowed to inject depo-provera nationally. The fifty midwives received three days of training at Chulalongkorn Hospital, which included motivation, treatment of side-effects, follow-up, and reporting. Midwives received manuals for their reference.

New acceptors must meet the conditions of a check list which is exactly like the checklist for pill acceptors with two additional conditions: 1. They must have at least two children 2. They must be under 45 years old.

Midwives keep follow-up cards on each acceptor, which gives the date when another injection should be given. If acceptors do not return on expected dates, midwives are expected to find out why.

Midwives have medicine to treat side-effects, but if there are problems beyond their scope they are to make referrals to the first class health centers. -98. -

Midwives are not expected to have than any difficulty in finding many more the 600 acceptors required for this study. Thailand one of the already has highest acceptor rates for depo-provera, and that Thai villagers it is well-known prefer injections to other forms of medicine because they are considered more potent. The service charge is $15 per injection, or $60 per year, the same price as a year's supply of pills. At the end of the test period, in about 14 months, MCH Division, and the Population MOPH Council will prepare an evaluation oriented the quality of service towards midwives are able to give to depo-provera acceptors. It will not deal with side-effects or other medical problems of this method.

III. COSTS The major cost is the training. Training of 50 midwives at Hospital for Chulalongkorn 3 days, including travel, per diem, written material, and provision of lecturers cost approximately $800 per person, $4,000 altogether. Check,: lists and follow-up forms are the same as those used for acceptors, with two extra pill check points added, so new forms did not need to be printed. The cost per depo-provera injection is $14, just under of $15, so that the the acceptor charge supply cost is covered by the income. Cost of medicines to treat side-effects and charges to acceptors of these medicines are not considered here. - 99 -

Cost of expansion nationwide:

Training could'be given at provincial level by PC1O staff with assistance from MCH Bangkok staff. (Assume 5,000 midwives)

Per diem @%60/day x 3 days x 5,000 s 900,000 Transportation @ A60/round trip x 5,000 300,000 Written materials @ A5/person x 5,000 25,000 Div. of MCH Trainer -- One/Province: Transportation @ 91,000 round trip x 70 70,000 Per diem @ 9100/day x 3 days x 70 21,000

Miscellaneous administrative costs $500 x 70 35,000

Total Training 1,351,000

Training cost per midwife 270.2

Initial Supply of Depo-Provera (1st year) Assuming an average of 30 acceptors per midwife, $.14 x 4 x 5,000 x 30 8,400,000 TOTAL COST 9,751,000

IV. COMMENTS Given the rural Thai preference for injections, depo-provera has the potential for wide acceptance if it is made readily available to villagers. The fact that there are sid3-effects may even be in its favor, since it shows that the medicine is working, as long as the side-effects can be treated. If depo-provera becomes popular and is available only from the government midwives, a secondary effect may be to bring more people in to the health centers, thereby presenting an opportunity for increased contact between health personnel and villagers and increased services.

Motivation of new acceptors for this method, as for other methods, will depend mainly on the midwife, through her contact with villagers, explain­ ing the method and its advantages. Unless midwives themselves are supervised ind motivated regularly and frequently, large increases in acceptance rates can-nn be expected.

Information from Dr. Somsak Vorakamin, Assistant Director, National Family Planning Project, MOPH - 100 -

ANNEX XVIII

TAME ON DOCTORS

Tambon doctors, like tambon chiefs (kamnans) and (rillage headmen (puyaibans) are representatives of the Ministry of Interior at the local level. There is one TD for every tambon in Thailand, approximately 5,000. Their duties are to report to the District Health Officer (DHO) on the general health situation in their tambon, to accompany the police to all murders which occur in their tambon and file a report on them, and di.stribute government home remedies to the villagers. They are expected to have other full time occupatiols.

Once a month the TDs meet with the DHO at the district office to receive information, report any unusual health problems, and receive their honoraria of 200 to $300. The DHO visits the tambons and meets with them regularly, perhaps once or twice a month. They receive some supplies and remedies from both MOI and MOPH.

Tambon doctors are selected by the kamnans and puyaibans on the basis of previous medical experience if possible. For instance, former army medics are considered prime choices. There are 2,000 former medics in Thailand, and the MOI tries to replace retiring TDs with these people if they are available. (Retirement age is 60). Because selection is based on medical experience, some 25 to 30 percent of TDs are injectionists or "quacks". All TDs are male at this time.

The only training program for all tambon doctors took place between 1969 and 1971. They were trained at Bangkok in groups of 60, receiving. 15 days of instruction in first aid, identification of diseases, basic treatment and prevention. Tambon doctors recruited since then have been given no formal training, just a manual from the MOPH. In Chonburi, Korat, and perhaps some other provinces, however, TDs are receiving further short term training in conjunction with integrated health services projects.

Tambon doctors are members of the Tambon Council, along with the kamnan, some teachers and puyaibans. This Council develops the yearly Tambon Development Plan and implements it through the use of the tambon's share of local tax collections and grants from the Provincial Administration or MOI. Developaent projects are typically construction or improvement of roads, bridges, irrigation canals, or water systems, or similar projects. (Local tax collections are not used to pay local officials honoraria).

Information based on conversation with Niphon Bunyapatara, Chief of Technical Service Division, DOLA, MOI. 1/30/75 - 101 -

In practice, most tambon doctors attend to the health problems of very few villagers and do minimal reporting. (If they are injectionists, they may see many patients, but their services are neither free nor legal). They are often well-known and respected in their coimunities, however,and have the potential for encouraging an interest in improving health knowledge and conditions through their positions on the tambon councils. - 102 - ANNEX XIX

MDORANDUM

TO: Mr. Roger Ernst, Director DATE: February 3, 1975

FROM: Vivikka Molldrem, Health

SUBJECT:. DAP Review: Role of Private Sector in Delivering Thailand's Health Delivery Capabilities

REF: STATE 022348 (Para 2, Page 3)

I. EXISTING PRIVATE HEALTH SECTOR

The private sector pr7esently provides about 85 per cent of all health care in Thailand, and given inadeque.te government health services in rural areas coupled with a high population growth rate, that percentage is likely to increase.

In Bangkok, provincial capitals, and other municipalities, much of the private service is rendered by physicians in private clinics, usually moonlighting from their regular government hospital positions. (Of 4,124 MDs in 1973, only 277 were completely in private practice). In rural areas, however, there are very few MDs (214 assigned to MOPH rural health centers as of 1972). Private sector health care is provided by drug stores, injectionists or "quacks", traditional midwives, herbalists, and government health service personnel in private clinics. The MOPH estimates that in 1973 there were about 35,000 indigenous/folk doctors and 19,000 "traditional midwives", but some provincial health staff argue that there is at least one of each in every village. The MOPH also estimates that there are 6,313 modern and 7,495 traditional drug stores in Thailand, but because of the laxity of control on distribution of medicintes and drugs, there are probably many more.

II. PRESENT GOVERNMENTAL INTERACTION WITH PRIVATE SECTOR

There has been little attempt on the part of the. government to control the illicit flow of drugs, practice of intdigenous practitioners, or moonlighting activities of health center personnel. There seems to be a tacit acceptance that this kind of health care is better than none at all. Until recently, there has been no attempt to identify, direct or retrain these ptactitioners either. Beginning with the WHO Chonburi Project and the UNFPA Accelerated MCH Development Project, however, a number of traditional midwives have been provided shoft-term training in proper methods of delivery and some "tambon doctors" of the Ministry of Interior (25 to 30 per cent of whom are quacks) have been given training in first-aid and simple medical care on a trial basis. The DEIDS project plans to do the - 103 ­

same, and the MOPH through its proposed Integrated Health Services Project hopes to provide training to indigenous midwives and tambon doctors all over the country during a five year period.

The Ministry is not yet willing to recognize and in that way legitimize quacks, except in a few cases.

The Malaria Eradication Program many times identifies and recruits quacks as malaria volunteers, to take blood smears and distribute suppression pills, because they are well-known in their villages and are knowledgeable about the village health situation. The Non Thai District pilot project in Korat plans to experiment usiug quacks as "village health comnunicators" to become the "eyesand ears" of the local health center personnel. These and the tambon doctor program are the only cases I know of which recognize quacks.

The MOPH is now experimenting in severa areas with a relatively new concept in utilizing village resources, the recruitment of "village health communicators" and "village health volunteers". The idea of using volunteers seems to be based on the success of the malaria volunteer program in surveillance and reporting of malaria cases. There are now about 8,000 malaria volunteers operating countrywide. A network for rapid delivery of malaria smears has been set up through cooperation with local baht-bus companies. The general health service volunteers have been or are now operating in Wat Bot District of Pitsanuloke, Saraphi District of Chiang Mai, Non Thai District of Korat, and Lampang (DEIDS), but I have as yet been unable to find any indication as to their effectiveness in changing villagers' health attitudes and practices. Nevertheless, the MOPH hopes to expand the village volunteer program countrywide over a three-year period.

III. VILLAGE FINANCIAL CAPABILITY

Villagers have the capability to support local practitioners through fees, and sometimes quite well. One injectionist in a high malaria (but low income) area claimed he saw at least 12 persons per day and net $5,000 per month. Fee is apparently charged according to service, not according to income of the patient, thus access to private health care is easier for the wealthy than for the poor. To divert the money presently supporting quacks and other local practitioners to support a government­ recognized and lcenced practitioner is only feasible if that practitioner is allowed to perform the same services, and if villagers are dissatisfied with present services. The government is not yet willing to license persons with significantly less training than MDs to perform these services (although BEP paramedics are hesitatingly allowed to do so). According to several KAP health surveys which have been taken, villagers have rather poor health education and are fairly well satisfied with their present services. - 104 -

On the other hand, villagers have been willing to contribute supplies and labor to construct health facilitics. About 60% of the second class health centers in Korat were built entirely with village resources. Five Child Nutrition Centers ir Saraphi District, Chiang Mai, were built entirely with local resources and salaries of aides paid by local tuition fees. Second class health centers may receive $7,000 to $8,000 per year in local charges - not nearly enough to pay a sal~ry, but sufficient to purchase most medical supplies. Thus there is some, very limited, financial capability or. the village level for projects which the villagers feel they need.

IV. LOCAL GOVERNMENT FINANCIAL CAPABILITY

Local government's capability to tax is completely controlled by Bangkok. At the tambon level, basically the only revenue is 80% land taxes collected locally, plus some minor slaughtering and signboard fees. This revenue is too little to finance even a single development project, so for annual funds for road or irrigation construction or improvement or similar projects a tambon must request a grant from the Provincial Administrative Organization or DOLA. Funds are very1 tight at this level and health is generally given lower priority to infrastructural improvement.

The Governor of the province, however, has a much larger resource base. While mo3t of his locally-derived revenues must go to already established programs such as police, education, sanitation, roads, etc., there is some flexibility and allocations can be made to health if it is a political priority. For instance, in Korat the Governor ha3 provided funds for retraining of all health personnel in multi-purpose health .service over the past four years. Many provincial governors have provided a mobile health unit to service remote areas (using personnel from MOPH but supplying a vehicle and maintenance).

Decentralization of MOPH

For what it is worth, staff members of the PCMO's office in Korat feel that the recent MOPH organization represents a real decentralization of power. The PCMO has authority over all aspects of health service, therefore planning and coordination among them is possible. Each province now prepares its own health'plan, based on its own health needs and staff capabilities.

WHO Assessment

USOM requested participation of Dr. Peter Kunstadter to address this aspect of health care as member of WHO Coun%:ry Program planning exercise currently ir process. Dr. Kunstadter reports little emphasis given by the assecsmnt team to linkage of private aad public health sectors.