Public health in Thailand, a success story

Thailand has a long and successful history of developing public health.
WHO, World Health Organization, 2007

So many children were dying back then, and we didn't know why.
Phasom Yunranatbongkot, a volunteer for 30 years

These volunteers are the backbone of one of the most successful public health systems in the world. For example, they have contributed to a significant decline in infectious diseases such as HIV, malaria and dengue.
WHO, 2012

Health volunteers in the villages

Let me start by saying something about the health volunteers in the villages, because they are perhaps the most important contributors to improving public health, especially in rural areas, and unfortunately they are not well known.

In English they are called 'Village Health Volunteers' and in Thai, with an abbreviation, อสม, 'oh sǒ mo'. Founded fifty years ago by doctor Amorn Nondasuta (now 83 years old), their number is currently 800.000, or one per twenty households. They can be found in every village (unfortunately I have not been able to find out whether they also function in the cities, perhaps there is a reader who knows or can inquire? I suspect not).

These volunteers ensured that basic health care was distributed more fairly. In a country where power radiates wealth from Bangkok, this is one of the few examples of a relatively self-sufficient, community-based and community-led effective program. The wide-ranging activities of these volunteers clearly show that very many do care and are committed to the general and collective interest of Thailand.

What is Public Health?

Public health is about preventing disease, prolonging life and promoting health through organized community efforts. Be important in that prevention, lifestyle, social and physical environment and health care.

Health care in the narrow sense (hospitals, doctors, operations and pills) is the least important element. In the 19th century, Dutch public health improved by leaps and bounds without the blessings of modern science, but through better prevention, a healthier lifestyle, clean drinking water, better sanitation and, in particular, increasing knowledge among the population. These are the pillars of good public health.

If you were to close all hospitals, the general health of the population would not deteriorate that much, I sometimes jokingly say, but there is a grain of truth in it.

The numbers

Let's call some dry numbers. Child mortality is the most important indicator of good public health (all figures UNICEF, 2011; Thailand saw the fastest decline in child mortality among 30 countries that were roughly equal on the socio-economic ladder).

Infant mortality up to one year (per thousand live births), year and number
1990 29
2011 11

Infant mortality up to five years (per thousand live births)
1970 102
1990 35
2000 19
2011 12

Life expectancy (at birth)
1960 55
1970 60
1990 73
2011 74

Maternal mortality in childbirth (per 100.000 live births)

1990 54
2008 48 (region average: 240)

Any other numbers 

• 96 percent of the population has good drinking water
• 96 percent have adequate sanitary facilities
• 99 percent of all children are vaccinated
• 81 percent of sexually active women use birth control
• 99 percent of all women receive maternity care at least once and 80 percent four times
• 100 percent of all women give birth with expert help
• 1 percent of the children are severely malnourished, 7 percent are moderately malnourished
• 8 percent of children are moderately to seriously overweight
• 47 percent use iodine-containing salt

HIV/AIDS and access to healthcare

Let me add two more important things. Thailand is an example to the world in the prevention, control and treatment of HIV/AIDS. When I came to live in Thailand 14 years ago, I visited a cremation for a young person every month, which has fortunately become a rarity now.

Condoms and HIV inhibitors are easily and cheaply available. The second is that almost every resident of Thailand has had reasonable easy and cheap access to health care in recent years, which was less than half of the population thirty years ago. Many families used to fall into dire poverty due to high medical expenses, fortunately those times are over.

Any other causes of this success story

Thailand has thus made great progress in terms of public health in a relatively short period of time. Foresight, good planning and organisation, facilities reaching the furthest countryside and an impressive system of volunteers are partly responsible for this.

The economic development of recent years is of course also responsible for this progress in public health. It also seems important to me growth of education. Until 1976, 80 percent of all children went to school, but the average number of years in school was only four! Now almost 100 percent of all children go to school and stay there for an average of 12 years (including higher education). An important part of it school curriculum is education in most aspects of health (Sex education unfortunately lags behind, HIV/Aids is treated correctly).

A little more about the health volunteers

This organization, briefly discussed above, has made an important contribution, perhaps the most important, to the improvement of public health, especially in rural areas. Every Thai knows and appreciates them.

They receive two weeks of training, meet monthly, or more often if necessary, and have access to formal health care for consultation and advice. They receive a monthly expense allowance of 700 baht and have free access to health care. The volunteers are often chosen for their heart for the public good, their kindness, their desire to help the needy, in addition to their knowledge of health and disease.

Their tasks are manifold, I will mention the most important ones: prevention, signaling problems, consultation with the formal sector, information and the promotion of a healthy lifestyle. For example, they visit elderly people, people with chronic conditions such as diabetes and HIV, pregnant women and women with newborn children.

They also played an important role in the bird flu epidemic in 2007-8. The fact that volunteers in almost every village quickly detected and reported poultry deaths made Thailand the least affected country in Asia.

Their role in improving public health over the past 50 years has been indispensable and the volunteers are rightly proud of that. And Thailand can be equally proud of what it has achieved in the field of public health in recent decades.

Sources:
Thomas Fuller, Volunteers Forge better Care in Thailand's Villages, NYTimes, Sept. 26, 2011
Arun Boonsang et al., New Primary Health Care in Thailand, Sept. 25, 2013
Sara Kowitt et al., A Qualitivity Study on the Activities of Health Volunteers in Thailand, Mahidol University, Sept. 25, 2012
Komatra Chuensatiansup, MD, PhD, Health Volunteers in the Context of Changes, Ministry of Public Health, Thailand, 2009
Role of Village Health Volunteers in Avian Influenza Surveillance in Thailand, WHO, 2007, with extensive job description of these volunteers
http://www.unicef.org/infobycountry/Thailand_statistics.html