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