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Print version ISSN 0042-9686
Bull World Health Organ vol.86 n.1 Genebra Jan. 2008
Thailand's unsung heroes
The success of primary health care programmes in Thailand over the past three decades can be attributed not only to medical advances but to the role of community health volunteers. Buddhist monks and their temples have been strongly involved in health promotion and education, particularly in remote, rural communities.
It's 06:30 and the grounds of the Wat Kae Nok temple are already full of people of all ages, exercising not only for their spiritual needs but also for a physical work out.
Every morning and evening, the large shaded grounds of the temple in Thailand's Nonthaburi province are reserved for health promotion activities. The young do aerobics while most of the elderly practise Tai Chi with long sticks to energize mind and body before going back to their usual duties.
Suparat Chanakit, a 57-year-old woman, is among them. She and her family usually come to exercise at the temple since it is walking distance from her home. If time allows, she practises meditation at the weekends.
"Last year I still had to sit in a wheelchair when going out with my family. But look at me now. I feel much better and stronger when coming here to exercise and meditate at the temple. It keeps me away from illness and medication," says Chanakit, who had been using a wheelchair due to a heart condition and a problem with her legs.
Wat Kae Nok is among hundreds of Buddhist temples nationwide participating in Thailand's Health Promotion Temple project. This campaign was initiated in 2003 by the Public Health Ministry as part of the Healthy Thailand agenda aimed at highlighting the importance of physical and mental well-being of the population. It currently covers over 800 temples.
Temples are regarded as an ideal place to run health promotion activities since the majority of Thais are Buddhists and since temples and monks have such a strong influence on the Thai people and their way of life.
Buddhist temples have traditionally been centres for community activities, including education, health care and cultural events. Thirty years ago, when primary health care had just started in Thailand, Buddhist monks dubbed the "bare-headed doctors" were trained in diverse community health-care techniques.
One such technique was to advise communities on how to use over-the-counter drugs. For example, monks showed farmers the correct medicines to take for anaemia and taught people living in remote areas about the dangers of buying sets of unnamed tablets known as "ya-chood" that were sold illegally, but which were highly popular.
The involvement of monks in primary health care was seen as a way of restoring their original community function, after successive governments had dominated such community activities for decades. More than 200 000 monks and some 30 000 temples across the country became an integral part of the so-called Folk Doctor movement in the 1980s.
But due to a shift to urban lifestyles that embraced Western medicine and conventional health systems during the 1990s, the monks and their temples played a less important role in health-care services and treatment, according to Pra Sopit Kittithada, abbot of Wat Chalermprakiat, another temple in Nonthaburi province.
"Access to medical health care is better than before. It is understandable why people go to see doctors and get free treatment at hospitals instead of relying on traditional herbal medicine provided by monks and folk doctors," the abbot says. "That's why [we] monks had to review our role and see if there was some other thing we could do to help the community."
Sopit Kittithada believes that the Health Promotion Temple campaign is important because it promotes well-being and helps to revive the role of religion in the community.
In 2001, the temple received donations of five million Thai baht (US$ 147 000) to build a community clinic to give some 2000 community residents access to basic health care. Retired doctors and nurses volunteered to work at the primary care unit, which is now under the supervision of the Public Health Ministry.
During the past three decades, medical services were the focus of public health. That emphasis recently started to shift to health promotion and disease prevention, and the monks saw an opportunity to do something for the community.
The importance of communities was firmly placed on the international health agenda in the Declaration of Alma-Ata in September 1978. The idea was to achieve universal health care or health for all by the year 2000 and primary health care was indicated as a key strategy.
Primary health care was defined as the first level of contact that individuals have with the national health system, from which they could be referred to further levels of specialization. It was envisaged as essential health care based on sound scientific evidence and community participation.
Thanks to Thailand's shift towards health promotion and disease prevention, monks and temples are adjusting their roles and communities are being encouraged to get involved.
Dr Amorn Nondasuta, Chairman of the Committee on the Promotion and Development of Health Security Responsibility of Local Administrations, is in charge of the primary health care programme in Thailand. He says the idea that communities should get involved in health care was perhaps the greatest achievement of the health for all campaign, not least because the stated goal of universal access to health care by the year 2000 was not attained.
"Although we cannot achieve all the goals of the health for all declaration, we have been successful in our strategy of creating health volunteers to restore the original community function and in developing it further based on different backgrounds and culture. As a result, the primary health care system today is deeply rooted in local communities," Nondasuta says.
Volunteers receive incentives for their unpaid work such as free medical care for their families. They receive training on basic medical care skills and once they understand these concepts they can work well as health communicators, taking care of their own families and their neighbours.
Trained volunteers have made their contribution to achieving health for all in a variety of ways. For example, they promoted the use of water-sealed latrines to improve sanitation. As a result, such latrines have become common in villages across the country.
Volunteers were also instrumental in the dramatic decline of protein-calorie malnutrition in preschool children in the past 20 years. Thanks in part to their efforts, the problem has become insignificant, says Nondasuta.
The provision of essential drugs is another key component of primary health care in Thailand. The Public Health Ministry allocates a budget for drugs to local communities to ensure that stockpiles are available when needed and to introduce those communities to the basics of financial management of health services. The communities are responsible for managing how their drug funds are spent.
Thailand has also initiated a system under which primary health care staff working in communities may refer patients for specialist medical care in large well equipped hospitals.
Policy-makers included the community drug fund and the specialist referral system in the universal health-care scheme, which has provided free medical treatment for the majority of Thailand's 64 million people since January 2001.
But the work of volunteers is one element of the primary health care system that makes Thailand stand apart. At present there are more than 800 000 health volunteers working to promote primary health care for different communities across the country. They have played a crucial role in controlling many communicable diseases such as HIV/AIDS and newly emerging diseases for example severe acute respiratory syndrome (SARS) and avian flu.
Thailand's strong communications network of health volunteers helped to reduce the number of new HIV/AIDS cases from 100 000 in 1995 to 13 936 in 2007 according to the country's Ministry of Public Health. Thailand has not reported a human case of avian influenza for nearly two years.
Volunteer participation has become such a mainstay of community involvement in Thailand that it has been incorporated into development strategies of both governmental and nongovernmental organizations. It was incorporated into 2001 national health legislation and into the recent reform of the country's national health system.
To implement the Healthy Thailand agenda, Nondasuta believes it is essential to extend the concept of volunteerism to cover every family and says that a focus on younger generations and utilization of mass media, especially community radio, will help promote health education in the community.
"Children and youth should be encouraged to run health programmes for their communities as they are key factors that lead to behavioural change. The ultimate aim is to achieve an active role of the people in nurturing and safeguarding their own health," he says.
Training and spiritual guidance are also necessary to keep them with the system, he adds.
"The road to health development in our country may not always be rosy. There are ups and downs to be expected. But with faith in what we're doing, we can overcome obstacles and look forward to sustainable health-care development in the long run," Nondasuta says.