1. health and fitness

Monograph
Strengthening Maternal and
Child Health Services in Rural Thailand:
Current Status and Future Strategies
Table of contents
Monograph........................................................................................................................i
Strengthening Maternal and Child Health Services in Rural Thailand: Current
Status and Future Strategies............................................................................................i
Contributing Authors....................................................................................................................... ii
Table of contents............................................................................................................ iii
List of Tables.................................................................................................................................... v
List of Figures................................................................................................................................... v
Acknowledgements........................................................................................................................... i
List of Abbreviations......................................................................................................................... ii
List of Abbreviations......................................................................................................................... ii
Executive summary............................................................................................................i
Background...................................................................................................................................... i
Chapter One: Introduction.............................................................................................. 1
Aim..................................................................................................................................................1
Objective......................................................................................................................................... 2
Materials and methods..................................................................................................................... 2
Organization of the monograph........................................................................................................ 3
Chapter Two: Millennium Development Goals................................................................ 4
Millennium Development Goals (MDG) in Thailand............................................................................. 6
MDG achievements and challenges................................................................................................... 3
Poverty, hunger, safe drinking water, sanitation and housing security................................................. 3
Education........................................................................................................................................ 3
Gender............................................................................................................................................. 4
Maternal and child health................................................................................................................. 4
HIV/AIDS, Malaria and other diseases................................................................................................ 4
Environment.................................................................................................................................... 5
MDG Plus targets............................................................................................................................. 5
Improving maternal and child health goal 4 and 5............................................................................... 8
Access to quality maternal health care............................................................................................... 8
Summary......................................................................................................................................... 8
Chapter Three: Health Equity........................................................................................... 9
Universal coverage........................................................................................................................... 9
Morbidity and mortality.................................................................................................................. 10
Equity of access to maternal and child health services........................................................................11
Summary........................................................................................................................................ 12
i
Chapter Four: Primary Care............................................................................................ 13
PHC Independent interventions....................................................................................................... 14
Integrated systems approach........................................................................................................... 16
Nutrition approach.......................................................................................................................... 18
Thai Health care delivery systems for maternal, newborn and child health.......................................... 18
Summary....................................................................................................................................... 20
Chapter Five: Public Policy.............................................................................................. 21
Thailand Health Development and Policy..........................................................................................22
Summary........................................................................................................................................27
Chapter Six: Leadership................................................................................................... 28
Research.........................................................................................................................................32
The influence of the organizational culture (Thai bureaucratic management style) on the
implementation of the Universal Health Care (UHC) policy................................................................33
Summary........................................................................................................................................ 37
Chapter Seven: The Way Forward................................................................................... 38
Improvement in maternal and child health care............................................................................... 39
Health status and outcomes........................................................................................................... 39
Determinants of health..................................................................................................................40
Health system performance............................................................................................................40
Conclusion.....................................................................................................................................40
References....................................................................................................................... 42
ii
List of Tables
Table 1: Thailand’s scorecard on MDG Targets (Goals 1 through 7)....................................................................1
Table 2: Global MDG and Thailand MDG-Plus Targets and Indicators for goals 4 and 5.................................... 6
Table 3: Type of strategy/intervention........................................................................................................ 14
Table 4: Type of policy interventions.......................................................................................................... 26
List of Figures
Figure 1: Example of an integrated system.................................................................................................. 17
Figure 1: Leadership and management in Health Systems.......................................................................... 30
Figure 2: Towards unity for health through sustainable partnerships with key stakeholders.......................... 31
Figure 3: Models for linking research to action............................................................................................32
Figure 4:The framework of accountability relationships..............................................................................33
iii
Acknowledgements
The production of this monograph has been made possible through the support of the University New England,
Australia and Naresusan University Thailand. In 2009, the Thai Australian Health Alliances celebrates five years of
collaborative work building capacity in health serves management, rural health research and capacity building of
education of health professionals between partner organisations in rural Thailand and Australia (Fraser, Briggs D. S.
et al. 2008).
This project was funded following receipt of a competitively available grant of $20,000 from the UNE International Research Linkages and Collaborative Grants Scheme 2008 and a similar contribution in cash and kind by the
Faculty of Public Health Naresuan University Thailand’. Thanks go to the Ministry of Public Health, health professionals, staff and doctoral students of the Faculty of Public Health Naresuan University.
We are grateful for editorial support for this document provided by Professor Niyi Awofeso, School of Population
Health, University of Western Australia.’
iv
List of Abbreviations
AIDS
ANC
ARV
BMN
CDHO
CHD
GDP
ICT
LBW
HIV
HDI
HH
ICPD
IMR
JICA MCH
MDG
MOPH
MMR
NESDP
NHDP
PHC
TBA
U5MR
UHC
UNAIDS
UNFPA
UNICEF
VHC
VHV
WHO
Acquired Immunodeficiency Syndrome
Antenatal care
Anti retroviral
Basic minimum needs
Chief of District Health Office
Community Hospital Director
Gross domestic product
Information and communication technology
Low birth weight
Human Immunodeficiency Virus
Human development index
House hold
International Conference on Population Development
Infant mortality rate
Japan International Cooperation Agency
Maternal and child health
Millennium Development Goals
Ministry of Public Health
Maternal mortality rate
National Economic and Social Development Plan
National Health Development Plan
Primary Health Care
Traditional birth assistant
Under 5 mortality rate
Universal Health Care
Joint United Nations programme on HIV/AIDS
United Nations population fund
United Nations children’s fund
Village health communicators
Village health volunteers
World Health Organization
v
E xecutive S ummary
Background
compared to the United Nations estimate for 2003 of 44
per 100,000 live births (WHO 2005). According to WHO
(2005) the perinatal mortality rate decreased to 8.39 per
1,000 total births. They reported that it is lower than the
national target of 9 per 1,000 total births set for the end of
2006 which Thailand has successfully reduced in children
less than 5 years.
Health system capacity in developing countries is
variable and a number of barriers impede the provision
of primary health care services and subsequent improvement of health and social outcomes. These barriers
include a health system not orientated towards primary
health care and a focus on curative health (Hall and Taylor
2003) in addition to a lack of integration of health services
(Kerber, de Graft-Johnson et al. 2007). The 2010 World
Health Organization report documented adverse impacts
of inadequate, inequitable and inefficient funding on
health systems, particularly in rural areas of developing
nations (WHO, 2010). WHO suggests that improving
health outcomes in developing countries should be entrusted to primary health providers whereby prevention
and promotion efforts are offered as part of a integrated
primary health care approach (WHO 2008). Evidence
shows that a strong primary health care system is associated with improved population health outcomes in OECD
countries that have undertaken reforms in primary health
care services (Macinko, Starfield et al. 2003). Emerging
economies such as Brazil have also remarkable health
improvements through primary health care, despite
structural encumbrances (Macinko, Almeida et al, 2004).
In resource-constrained situations, strengthening primary health care services would be an important step to
take to improve health outcomes. The human dimension
of health care and inadequate tailoring of interventions
to specific communities represents shortcomings in the
improvement of health and social outcomes (WHO 2008).
Reforms that ‘put people first’ require innovative approaches to health care (Macfarlane, Racelis et al. 2000).
For example, the under-five mortality rate fell from
58 per 1000 live births in 1980 to 30 in 1990 and to 23 in
2000 (Hill, Vapattanawong et al. 2006) The improvement
in child survival has been accompanied by a remarkably
small disparity between rich and poor. However the ruralurban differences in health services delivery and outcomes
are mixed. According to a recent study(Limwattananon,
Tangcharoensathien et al. 2010:5) “Child wasting and reported diarrhoea had the narrowest urban–rural disparity. In contrast, low birth weight was more prevalent in
urban than in rural areas by 15%... The urban–rural gap for
MCH service coverage was small. Women living in urban
areas were up to 4% more likely than those in rural areas
to receive prenatal and delivery care from a skilled health
worker, and delivery in a health facility”.
Strengthening maternal and child health services
particularly in rural areas, and primary care unit areas are
key components to ensuring equity in health care and improving health outcomes for the population of Thailand.
The Calcutta Declaration on Public Health recognised the
need for capacity building and expertise in public health
as essential to sustaining partnerships and enhancing
public health development (Regional Conference on Public Health in South East Asia in the 21st Century 2000).
This literature review aims to identify gaps that will
assist an action plan for future improvement of maternal
and child health care in Thailand and is the result of a
collaborative research program between Naresuan University and University of New England. It forms part of
the broader role of the Thai: Australian health academics
alliance. The aim of this program is to develop research
capacity for Thai academics and doctoral students in
the Faculty of Public Health Naresuan University by exchanges between academics. Because Thailand has been
successful in improving MDGs and maternal and child
health, the selection of maternal and child health MDGs
provided the opportunity to shift the research focus from
a purely public health perspective to addressing issues
about health services management. This is consistent
with WHO’s emphasis on system based health research
and the Ministry of Public Health who also wishes to build
capacity in human resources and health systems based
research.
Many constraints face developing countries in the
delivery of maternal and child health services Socioeconomic (Wilkinson and Marmot 2003; Marmot 2005) and
gender disparities (Filmer 2000; Mason and King 2001)
contribute to a disproportionate level of poor health
among the most disadvantaged population. Australian
and international evidence demonstrate that a relationship between the determinants of health with health
status exists, and show a social gradient, with people
at the lower end of the socio-economic or occupational
ladder having poorer health status and outcomes (Black,
Morris et al. 1982; Benzeval, Judge et al. 1995; Turrell and
Mathers 2000). Income, employment conditions, neighbourhood,, personal behaviours, race, stress and social
circumstances all affect health outcomes (Adler, Stewart
et al. 2007).
In comparison to other South East Asian nations,
Thailand is doing relatively well in relation to maternal
and child health. Their success for reducing maternal
mortality rate is attributed to the implementation of
a safe motherhood project that aimed to develop and
strengthen maternal and child health services (WHO
2005). National data for 2003 suggest that the maternal
mortality rate for Thailand is 20.6 per 100,000 live births
In order to overcome current challenges in improving
maternal and child health in Thailand, a review of current interventions and strategies was undertaken by the
Faculty of Public Health at Naresuan University and the
University of New England. This review involved academ-
vi
ics from both universities and Thai public health students
who used the project to develop applied doctoral research
proposals within the Public Health Ministry of Health.
for maternal and child health. The implementation of
a strategic approach underpinned by strong leadership
ensures that changes to public policies are implemented
effectively thus having a significant impact on the health
of the population.
This document provides a review of the current trends
in maternal and child health as well as an analysis of the
impact of interventions and recommendations for the
possible ways forward to strengthen maternal and child
health services in Thailand.
Chapter Five acknowledges that mobilising changes
to policy requires a strong and effective leadership that
engages relevant and appropriate stakeholders in the
reform process. Without effective leadership, many strategies that aim to improve maternal and child health will
not reach their full potential. Addressing cultural aspects
of leadership is an important aspect of organizational
change.. Thailand’s successful approach to reform by implementing universal health care has provided the basis
for considering the resources necessary to support further
health system transformation.
The review is based on material obtained from
published and unpublished literature from the Thai and
Australian perspectives. An iterative process was undertaken to identify gaps in the literature. This involved an
amalgamation of two separate reviews undertaken by
Naresuan University and the University of New England.
The combined document was then refined.
In 2004 Thailand reported that it had almost achieved
all of the Millenium Development Goals (MDGs) set by the
United Nations Millennium Declaration especially those
related to poverty, gender inequality, HIV/AIDs and malaria. There has been a steady progress in the maternal and
child health MDGs. However, geographical disparities in
mortality still exist. The Royal Thai Government considers
the reduction of MDGs an issue of prime importance. They
have invested in developing policies and programs aimed
at improving the quality of services across the country.
This monograph identified in chapter one that despite
progress in the MDGs by Thailand a number of gaps
remain. An improvement in access to quality maternal
health care, especially among selected provinces in Thailand, is necessary to reach the MDGS. Training of health
personnel and improving access to primary health care
services is an important step to improving care.
The final chapter recommends a number of priority
areas. These include strategic direction and applied health
system research. These are as follows:
Health status and outcomes
Improvement in health status and outcomes in maternal and child health care
Improve the training of health service personnel to be
more effective in detecting and responding to childbirth complications
Improve the training of health service personnel to be
more effective in management and leadership
Involve both parents and health personnel in improving health outcomes.
Determinants of health
Improvement in a number of factors outside the
health system
Chapter One highlights the achievements and challenges required to meet the MDGs. The improvement in
access to quality maternal health care, especially among
selected provinces in Thailand, is necessary to reach the
MDGs.
• Proactively involve families and their communities
in participatory research to explore and evaluate
models
• Improve health literacy for women
Chapter Two suggests that promoting fairer access
to health services is a positive step towards improving
health outcomes and reducing inequities. The successful
implementation of Universal Coverage in Thailand reflects
an integrated and coordinated approach from many levels
of government that has the potential for other developing
countries to adopt.
Health system performance
Chapter Three identifies that in Thailand, similar to
other developed countries, there is an under resourced
and unequal distribution of primary health care. There is
a reliance on traditional self-care and non-professional
village health volunteers which influence maternal and
child health outcomes. The literature clearly identifies
that a multi-pronged and multi–level approach is an effective way to improve maternal and child health outcomes.
Two approaches to address delivery of maternal and child
health services in developing countries can be identified.
One approach is that each MDG goal or disease is addressed independently. A second approach is that there is
an integrated approach to addressing each MDG. Despite
the existence of several challenges, Thailand has begun to
implement multiple strategies with some positive results.
These positive outcomes have been underpinned by an
investment in policy changes from the Thai Government.
This monograph provides an overview of current
trends, interventions and strategies in maternal and
child health and emphasises an improvement in access to
quality health care as a necessary investment that is required to improve maternal and child health care. Strong
leadership is an essential element for improving greater
equity in health at all levels of the system that ultimately
affects maternal and child health outcomes. Prioritising
the implementation of the above strategies can be accomplished but will require significant endorsement by
the Thai government.
Improvement of monitoring capacity and the performance of the health system
• Reform of the surveillance system to improve data
• Analyze existing data to develop targeted strategies
The use of a multi-level, multi-systems approach
would strengthen current maternal and child health
systems practices, challenges and solutions identified in
this review. Innovative approaches require an equitable
primary health care system underpinned by strong public
policy and leadership support for organisational change
and implement new programs.
Chapter Four recognises that public policy is an essential element for achieving better health outcomes
vii
C hapter O ne: Introduction
T
Objective
he MDGs to improve maternal health reinforces
decades of international commitment and national efforts to address the problems associated with
reproductive health, safe motherhood, and family
planning. It builds on past global agreements such as the
Program of Action of the International Conference on
Population and Development (ICPD) held in Cairo in 1994,
the Platform of Action of the Fourth World Conference
on Women held in Beijing 1995, and the UN International
Development Targets established in 1995. The global commitment to achieving the MDGs provides a unique opportunity to re-examine, refocus, and scale up resources
and program efforts by donors, governments, and civil
society to improve maternal and reproductive health for
individual and societal well-being (WHO 2006).
In order to explore options available to strengthen
maternal and child health services in Thailand, the objectives of this review is to map the current state of maternal
and child health services in Thailand, identify current
practices in other countries and identify gaps to inform
future investment opportunities.
Materials and methods
This literature review was undertaken as a prelude
to a cross-cultural and interdisciplinary workshop and included stakeholders such as Ministry of Public Health personnel. The workshop aimed to build research capacity of
Thai postgraduate students participating in a forum with
Thai and Australian academics. Gaps in the literature were
identified by small working groups. Through an iterative
progress, over four days, these gaps were worked into
practically applied health service management research
projects for further research in rural Thailand around Child
Maternal Health Care.
The World Health Organization (2008) proposes that
moving towards universal access to health services is a
fundamental step towards promoting health equity. To
move towards universal coverage requires interventions
that that have breadth, depth and height of coverage
(WHO 2008). For example, in relation to maternal and
child health improvement, the New South Wales (Australia) Safe Start maternal and child health policy comprises
three integrated approaches for promoting maternal and
child health and reducing morbidity and mortality (NSW
Department of Health 2009). However, many constraints
face developing countries in the delivery of maternal and
child health services. Socioeconomic (Wilkinson and Marmot 2003; Marmot 2005) and gender disparities (Filmer
2000; Mason and King 2001) contribute to a disproportionate level of poor health among the most disadvantaged population. Australian and international evidence
demonstrates that a relationship between the determinants of health with health status exists, and shows that
people at the lower end of the socio-economic scale have
poorer health (Black, Morris et al. 1982; Benzeval, Judge et
al. 1995; Turrell and Mathers 2000). Income, employment
conditions, gender, neighbourhood,, as well as personal
behaviours, race, stress and social circumstances all affect
health outcomes (Adler, Stewart et al. 2007).
List of projects and workshop participants
1)
The study of factors associated with management of
birth asphyxia in community hospitals in Phitsanulok
Province, Thailand
a)
Academic staff:
i)
b)
2)
i)
Mr. Sutthichai Sirinual
ii)
Mr. Sutas Sitthisastra
The ante-natal care strategic management model for
low birth weight prevention in community hospitals
in Phitsanulok Province, Thailand
a)
Academic staff:
i)
b)
This literature review was the first stage of broad
cross-cultural and interdisciplinary work to build research
capacity at Naresuan University. The literature review provides a basis to develop applied research questions about
maternal child health system that may assist the Ministry
of Public Health and health professionals to improve quality in maternal child health systems.
3)
a)
Dr.PH. students:
i)
Ms. Kornwika Phupongpunkool
ii)
Ms. Jittrakran Sookdee
Aim
b)
Academic staff:
i)
1
Pattama Supannakul, PhD.
Maternal and child health services for teenage pregnancy in Sawankalok District, Sukhothai Province:
Situation analysis
The use of the term ‘indigent’ in this paper refers to
disadvantaged people living in rural areas and those who
live in the border of the country such as ‘hill tribe people’.
To achieve the Millennium Development Goals (MDG)
by strengthening maternal and child health services.
Tavorn Maton, PhD.
Dr.PH. students:
Adjunct Assoc. Prof. Phudit Tejativaddhana,
MD, DHSM.
Dr.PH. students:
i)
Ms. Buaploy Phrom jamg
ii)
Ms. Artitaya Wangwonsin
Chapter One: Introduction
4)
The referral system of maternal and child health services in Phitsanulok Province
a)
Academic staff:
i)
b)
The development of the literature review was an iterative process. Two literature reviews were produced, one
from the Thai perspective and one from a global perspective. These two literature reviews were combined into one
document and reworked by members of the team.
Thanuch Kanoktase, PhD.
Dr.PH. students:
i)
Ms. Juntima Nawamawat
ii)
Mr. Krisda Lekpetch
Organization of the monograph
Chapter One provides an outline of Thailand’s progress towards the MDGs. The chapter highlights the
achievements and challenges required to meet the MDGs.
5) The ante-natal care system improvement in rural
Phitsanulok Province
a)
i)
b)
Chapters Two to Five provide an overview of the strategies and interventions currently in place in developing
and developed countries to improve maternal and child
health. These encompass health equity, health system
capacity, public policy and leadership.
Academic staff:
Phruttinun Surit, PhD.
Dr.PH. students:
i)
Ms. Wipaporn Sittisart
ii)
Mr. Somnuk Hongyim
Chapter Six presents suggestions for the way forward
to strengthen maternal and child health services in Thailand. These suggestions involve greater investment in education of health professionals to improve maternal and
child health. Better identification of trends for morbidity
and mortality of communicable diseases via the surveillance system would strengthen MCH in Thailand.
The review of the literature included national and
international information obtained from electronic computerised databases, key textbooks, and medical, nursing and healthcare journals. The relevant computerised
literature databases were accessed and combinations
of keywords such as child, maternal, health, mortality
rates, developing countries, developed countries, health
outcomes, Thailand and names of key authors in the field
were entered. The databases searched included the following:
•
Medical Literature Analysis and Retrieval System Online (MEDLINE) (the publicly available
version, known as Pubmed)
•
Cumulative Index of Nursing and Allied Health
Literature (CINAHL)
•
Medscape Professional/Medscape Health
•
Expanded Academic ASAP
•
Proquest
•
Grey literature including Thailand reports
2
C hapter T wo:
Millennium Development Goals
S
ince 2000, the Government and people of Thailand
have joined the international community in pledging their support for the Millennium Declaration
that set out a global agenda for human development. The Millennium Development Goals are a set of
time-bound targets against which governments and the
international community will be assessed (Ahmad OB,
Lopez AD et al. 2000).
2008, an unmet need for contraception in Thailand was
estimated at 3.1%, compared with 11% in 1987, one of the
lowest globally (Ropey, Ross et al. 1996). Contraceptive
use is also low among members of hill tribes, cross-border
migrants and people living in remote areas and in the
southern most provinces (United Nations Development
Program 2002).
At the halfway marks of the MDG for achieving a
two-thirds reduction in child mortality, many countries
are unlikely to reach this target. In Thailand, there is
an encouraging trend that suggests this MDG will be
achieved and that the successful average improvement
in child survival has been accompanied by a substantial
decrease in economic inequality in the under 5 mortality.
Recent studies have not shown significant economic inequality in under-5 mortality reduction (Limwattananon,
Tangcharoensathien et al. 2010). The findings clearly draw
attention to the importance of including an equity dimension in health-outcome monitoring and show how this
can be undertaken in a data-limited setting using routine,
population-based data sources (Wilkinson and Marmot
2003; Marmot 2005). Further research will allow a better
understanding of how Thailand has
achieved this remarkable success.
This will help inform other counMDG Goal 4 and 5 Indicators: Undertries to attain the MDG target and
five Mortality rate males 32, females
reduce health inequalities in paral26 per 1,000 live births; Infant morlel (Vapattanawong, Hogan et al.
tality rate 21.5 per 1,000 live births;
2007).
Proportion (%) of 1 year-old children
Thailand expects to achieve most of the global Millennium Development Goal (MDG) targets well before 2015.
More ambitious national development targets (outlined
in the MDG-plus agenda) have been set and integrated
into national plans. Maternal mortality declined to 22
deaths per 100,000 live births by 2004, while infant mortality declined to 12 deaths per 1,000 live births by 2009
(UNICEF 2010) However, the maternal mortality ratio in
the three southernmost provinces is twice as high as the
national average. A large number of cross-border migrants
have limited access to skilled attendants at delivery; a significant proportion of them deliver with traditional birth
attendants (United Nations Development Program 2002).
Thailand has seen an impressive improvement in maternal and
child health as a result of implementation of targeted interventions that encompass policy, public
health, clinical and educational
investments. Such investments
include universal vaccination and
immunized for measles 94; MMR
prenatal care, targeted prevention
Over the past five decades there
13.2 per 100,000 live births; Births by
programs, expansion of free access
have been substantial improveskilled attendant 94.5%.
to antiretroviral drugs, monitoring
ments in the health of Thai children,
of human development, and investwith reductions in the under-five
Data source: WHO. Basic Indicators: Health
Situation in South-East Asia, World Health
ment in safe motherhood. Howevmortality rate (U5MR) from above
Organization, South-East Asia Region, 2004.
er, indicators suggest that although
160 per thousand in the 1950s and
maternal mortality in Thailand
60s to below 40 per thousand by
is decreasing some inconsisten1990 (WHO 2006; Ministry of Public
cies in data remain. The maternal mortality rate (MMR)
Health 2007). As of 2009 the mortality rate was 13.5 per
continues to be high in some provinces and the infant
thousand (World Bank 2010). A further 24% reduction
mortality rate (IMR) requires a further reduction to meet
from 1990 to 2002 puts Thailand well on track to achieve
the additional indicators for the Millenium Development
the Millennium Development Goal (MDG) of a two-thirds
Goals (MDGs) that were developed for specific use in the
reduction in U5MR between 1990 and 2015 (Ministry of
Thai context. Thailand also is required to improve timely
Public Health 2007).
access to quality essential maternal and child health serThailand’s progress is in stark contrast to many other
vices. While successful progress towards the MDGs has
countries, particularly those in sub-Saharan Africa and
occurred, there has recently been a slowing in attainment
southern Asia where varied progress towards this target
of the MDG goals.
has led to doubt as to whether the goal can be achieved
The total fertility rate, which reached replacement lev(WHO 2002; Thailand National Statistical Office 2006;
el in the early 1990s, declined to approximately 1.7 children
United Nations Economic and Social Commission for Asia
per woman in 2005, a drop associated with an increase in
and the Pacific (UNESCAP) 2007). As the MDGs focus on
the contraceptive prevalence rate. However, there is still a
average levels, one unanswered question is whether the
high unmet need for contraception among young people,
success in reducing the average U5MR has been accompawith 46.8 per cent of induced abortions reported in Thai
nied by a reduction in the disparity in child health between
hospitals occurring among women younger than 25. As at
subgroups of the Thai population. This notion is in line
3
Chapter Two: Millennium Development Goals
• Respect for nature: Prudence must be shown in
the management of all living species and natural
resources, in accordance with the precepts of sustainable development. Only in this way can the immeasurable riches provided to us by nature be preserved
and passed on to our descendants.
with global calls for routine monitoring of equity in health
outcomes (WHO 2006; United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) 2007).
Many other countries provide examples of increasing life
expectancy and decreasing child mortality while inequalities between the rich and the poor remain (Thailand) or
worsen (WHO 2000). Although Thailand has experienced
substantial economic growth over the past two decades
(with some interruption due to the 1997 economic crisis),
income inequality persists at a relatively high level (WHO
2000). One common way of measuring inequality is the
use of the gini coefficient. ‘The coefficient varies between
0, which reflects complete equality and 1, which indicates
complete inequality’ (World Bank 2011). Thailand’s gini coefficient is 0.42. This is about average for the SEA region.
(World Bank 2009) A critical question is what the impact
of income inequality is on child mortality. Although Thailand might be, on average, set to meet the MDGs for child
health, as in other countries, it is likely that relatively
deprived segments of the population might be lagging
behind (Wilkinson and Marmot 2003; Marmot 2005).
• Shared responsibility: Responsibility for managing
worldwide economic and social development, as well
as threats to international peace and security, must
be shared among the nations of the world and should
be exercised multilaterally. As the most universal and
most representative organization in the world, the
United Nations must play the central role.
The MDGs eight ambitious goals to be achieved by
2015 are drawn directly from the actions and targets contained in the Millennium Declaration. The eight MDGs
contain 18 targets monitored through 48 indicators.
Goal 1: Eradicate extreme poverty and hunger
Millennium Development Goals (MDG) in
Thailand
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower women
The United Nations Millennium Declaration was
adopted by 189 nations during the United Nations Millennium Summit in September 2000. The declaration sets
forth fundamental and universal values of people-centred
and sustainable human development that briefly are as
follows:
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Goal 7: Ensure environmental sustainability
• Freedom: Men and women have the right to live
their lives and raise their children in dignity, free from
hunger and from the fear of violence, oppression or
injustice. Democratic and participatory governance
based on the will of the people best assures these
rights.
Goal 8: Develop a global partnership for development
• Equality: No individual and no nation must be denied the opportunity to benefit from development.
The equal rights and opportunities of women and
men must be assured.
• Solidarity: Global challenges must be managed in
a way that distributes the costs and burdens fairly in
accordance with basic principles of equity and social
justice. Those who suffer or who benefit least deserve
help from those who benefit most.
• Tolerance: Human beings must respect one another, in all their diversity of belief, culture and language.
Differences within and between societies should
be neither feared nor repressed, but cherished as a
precious asset of humanity. A culture of peace and
dialogue among all civilizations should be actively
promoted.
4
Chapter Two: Millennium Development Goals
Table 1 provides a description of Thailand’s scorecard on the MDG targets.
Table 1: Thailand’s scorecard on MDG Targets (Goals 1 through 7)
Goal
Scored
Remark
1. Halve, between 1990 and 2015, the
proportion of people living in extreme
poverty
Already
achieved
Poverty incidence reduced from 27.2% in 1990 to 9.8%
in 2002.
2. Halve, between 1990 and 2015, the
proportion of people who suffer from
hunger
Already
achieved
Proportion of population under food poverty line
dropped from 6.9% to 2.2% between 1990-2002, and
the prevalence of underweight children under five
dropped from 18.6% to 8.5% between 1990-2000.
3. Ensure that by 2015, boys and girls
alike, will be able to complete a full
course of primary schooling
Highly likely
Gross enrolment ratio and the retention rate indicate
that it is likely that Thailand will achieve universal
primary education well ahead of 2015.
4. Eliminate gender disparity in primary
and secondary education, preferably by
2005, and in all levels of education no
later than 2015
Already
achieved
Thai girls and boys have had equal education
opportunity. There is a small gender gap at the
primary level. Girls are outnumbering boys in higher
education.
5. Reduce by two thirds, between 1990
and 2015, the under-five mortality ratio
Not
applicable
Given the low starting point in 1990, this target is
considered not feasible and therefore not applicable.
6. Reduce by three-quarters, between
1990 and 2015, the maternal mortality
ratio
Not
applicable
7. Have halted by 2015 and begun to
reverse the spread of HIV/AIDS
Already
achieved
Yearly new infections have dropped by over 80% since
1991. HIV continues to spread among some groups.
Young people continue to be vulnerable.
8. Have halted by 2015 and begun to
reverse the incidence of malaria and
other major diseases
Already
achieved for
malaria
Achieved for malaria. The disease is an area-specific
problem, and has been effectively managed.
9. Integrate the principles of sustainable
development into country policies
and programs and reverse the loss of
environmental resources
Potentially
Principles of sustainable development, partnership
and public participation have been integrated into
country policies and programs. But reversing the loss
of environmental resources is still Thailand’s greatest
challenge.
10. Halve by 2015 the proportion of
people without sustainable access to safe
drinking water and basic sanitation
Already
achieved
Very close to universal access.
11. By 2020 to have achieved a significant
improvement in the lives of at least 100
million slum dwellers (globally)
Likely
Most Thai people, including slum dwellers, have
secure tenure. Various measures have been
implemented and more are underway to improve the
slum livelihood.
Given the low starting point in 1990, this target is
considered not feasible and therefore not applicable.
Source: United Nation Development Programme. One United Plaza. New York. pp3-4
5
Chapter Two: Millennium Development Goals
Thailand will achieve most if not all of the MDGs well
in advance of 2015(United Nations Development Program
2004). Poverty has already been reduced by two thirds
since 1990. The proportion of underweight children has
fallen by nearly half. Universal access to primary school
education is likely to be achieved within a few years. Malaria is no longer a problem in most of the country. Yearly
new HIV infections have been reduced by over 80 percent
since 1991, the peak of the epidemic. Great strides are being made towards gender equality.
and meeting basic human needs of the entire population. There are several on-going government programs,
for example, debt reduction schemes, the Village Fund,
microcredit schemes, low-cost housing and the universal
health care scheme, contributing further to this success.
The next challenge lies in targeting people in very remote
areas and reaching out to elusive or difficult-to-reach
population groups such as the elderly, people with disabilities, homeless people, people living with HIV/ AIDS,
and migrants. Another challenge is to enhance the costeffectiveness of intervention needs.
This success can be attributed to a powerful mix of
national harmony, astute policy-making, strengthening
of democratic governance, industriousness of Thai people, rapid economic expansion, public investment in social
services for all, and advantageous historic and geopolitical circumstances.
Education
The current Thai government recently announced
that Thailand’s mandatory education of nine years, required by the National Education Act, will be expanded
to twelve years and fifteen years. Having achieved nearuniversal primary education, Thailand is focusing on expanding secondary enrolment and upgrading the quality
of education, both of which are instrumental not only for
deepening human development, but also for enhancing
national competitiveness. The greatest challenge lies
in improving quality. The prevailing situation indicates
weakness in both skills (e.g. Mathematics, Science and
English) and creative and critical thinking, which are
the basis for meaningful “learning” for people of all ages.
Research indicates that while substantial progress has
been made in diminishing rural urban differences in entry
to secondary school, there remains some inequalities especially for boys of the North and girls in the Northeast
regions of Thailand (Pattaravanich, Williams et al. 2005).
Between 1990 and 2001, the Human Development
Index (HDI) in Thailand rose steadily from 0.705 to 0.768.
At present, Thailand belongs to the group of countries
with medium-level human development outcomes, with
a rank of 74th among 175 countries. In general, Thailand
has proven to be resilient in weathering storms and adept
at repositioning itself in a fast-moving world. The financial crisis in the late 1990s eroded, but did not reverse, the
remarkable progress in human development. Since then,
assiduous macroeconomic and domestic reforms have
again poised Thailand for impressive growth, as demonstrated by the 6.7 percent gross domestic product (GDP)
growth in 2003.
In retrospect, the most influential development
of the 1990s was the democratization of development
and strengthening of civil society. The 1997 Constitution
opened enormous opportunities for further democratization of and progress in human development especially
in health and education. The shift in the institutional approach extends to the 8th and 9th National Economic and
Social Development Plans, which embrace the principles
of “people-centred development” and “sufficiency economy” providing broad-based strategies for human development, poverty reduction and reducing vulnerabilities to
external shocks.
It is important to focus education reform on the curriculum, learning process and teacher development to
achieve interactive and student-centred education. Information and communication technology (ICT) is expected
to bridge the urban-rural gap and help prepare Thai students and the community to participate in a knowledge
based society. However, several infrastructural challenges
exist which hamper effective use of ICT (Usun 2009). Usun
(2009) suggests that lack of power, telephone, internet
access as well the costs and lack of adequately trained
staff in ICT constitute barriers to implementation and use.
Expanding learning opportunities outside the classroom
and life skills development add to the quality agenda. Education is an important social determinant of health and it
has been shown that improving the quality of education
and increasing the educational opportunities between
the rich and the poor can potentially improve the health
status of the poor (von dem Knesebeck, Verde et al. 2006;
Limwattananon, Tangcharoensathien et al. 2010).
MDG achievements and challenges
Thailand’s Millennium Development Goals scorecard
is impressive. As Table 11 shows the targets for poverty,
hunger, gender, HIV/AIDS, malaria and access to water
have already been achieved, more than ten years ahead
of schedule, and it is likely that the education goal will be
achieved soon. Targets that are likely or have the potential
to be reached include reversing the spread of tuberculosis,
improving the lives of slum dwellers, integrating principles of sustainable development into national policies and
reversing the loss of environmental resources.
Gender
Thailand has a mixed experience with gender equality.
The labour market is open, and Thai women participate
actively in both the agricultural and non-agricultural
sectors. However, women have fewer opportunities for
career advancement, in part due to their dual role and
excessive responsibility at home, where they both provide
family care and share financial responsibility (Bhongsvej
2004). In addition, little progress has been made with
regard to women’s participation in electoral politics at
national and local levels. To rectify this, the National
Poverty, hunger, safe drinking water,
sanitation and housing security
Several decades of extensive rural development
programs undertaken by various government and nongovernment agencies in Thailand have resulted in overall
achievement in reducing poverty, improving nutrition,
6
Chapter Two: Millennium Development Goals
Environment
Women Development Plan sets ambitious targets and
places strong emphasis on gender education and the empowerment of women. Widespread abuse and domestic
violence constitutes a horrific violation of the rights and
dignity of women (Ellsberg, Jansen et al. 2008). This problem requires renewed and urgent action.
Balancing economic growth is one of Thailand’s greatest challenges. Thailand is party to key international treaties, has enacted important national environmental laws,
and has integrated environmental concerns into national
policies and programs. Although there have been encouraging signs that the rate of forest degradation, water
contamination, air pollution and other instances of environmental damage have slowed, this improvement is still
inadequate to offset the accelerating rate of growth and
resource depletion. A policy package is needed to promote
sustainable development, including a shift from a natural
resource and production-based economy to a knowledgebased economy; a better environmental governance system based on a well-informed public; and more stringent
enforcement of existing environment laws.
Although there are equal numbers of male and female
students at all levels of education, opportunities for
training is more limited for women than men. More than
70% of female workers in industries such as agriculture,
manufacturing, commerce and services have lower skill
levels therefore have less earning ability (Bhongsvej 2004).
Maternal and child health
Thailand has made steady progress in maternal and
child health. For example vaccination and pre-natal
care, is universal. Lack of adequate health care is evident
primarily in the remote and mountainous Northern provinces and in the Southern most provinces. Improving the
overall quality of services is another policy priority because many health personnel have not received adequate
training in the assessment or detection of maternal risks
or pregnancy complications (United Nations 2004). This
calls for upgrading the expertise of health personnel and
implementing a family centred strategy that focuses on
the family and community levels (United Nations 2004).
According to the United Nations Report (2004) engaging
every family will help to improve the quality of life for children and adults.
MDG Plus targets
Building on the achievement of reaching most of the
MDGs, Thailand has introduced the concept of “MDG Plus”,
a set of tailor-made and ambitious development targets
going well beyond the international MDG targets.
MDG Plus sets out more ambitious targets than the international MDG targets. For example, already by the year
2000 Thailand reached the international MDG poverty
target of halving, between 1990 and 2015, the proportion
of people living in poverty. In response, Thailand is now
setting an MDG Plus target of reducing the proportion of
poor people to below 4 percent by 2009. If successful, this
will represent a stunning four-fifths reduction in the proportion of people living in poverty since 1990, six years in
advance of 2015. Also, given the likely achievement of universal primary education, Thailand has set an MDG Plus
target of universal secondary education by 2015. Having
made great strides in achieving gender equality in education, Thailand sets a more appropriate gender target of
doubling the proportion of women in the national parliament, local government bodies and executive positions
in the civil service by 2006. The MDG Plus framework is a
tribute to Thailand’s can-do and results-based approach
to human development.
HIV/AIDS, Malaria and other diseases
Through strong and sustained political action, Thailand mobilized a broad-based response to the HIV/AIDS
epidemic. The result is a significant slowing of the spread
of HIV/AIDS in Thailand. However, HIV/AIDS remains a
major challenge. HIV is a moving target in terms of geography, and is spreading unchecked among some groups,
including injecting drug users, men who have sex with
men and informal commercial sex workers. New vulnerability has been recognized in industrial hubs, border areas,
youth, and mobile population groups such as migrants,
seafarers and construction workers. In response, Thailand
is revitalizing its multi-sectoral response, and shifting the
focus of prevention towards young people in general and
specific vulnerable groups. In addition, as antiretroviral
(ARV) drugs become more affordable, Thailand is committed to expanding free access to these drugs to improve the
health and well-being of those living with HIV/AIDS. Like
most developed and urbanized societies, Thailand’s major
health risks have shifted from communicable to non-communicable diseases. Malaria and tuberculosis (with the
exception of HIV/AIDS co-infection) have been effectively
contained within the border areas and are no longer life
threatening diseases. Cancer and heart disease are major
causes of death. In response to these new challenges,
Thailand’s health strategy has shifted to preventive care
and health promotion that emphasizes multi-sectoral
collaboration at national and community levels with individuals taking responsibility of life style .
Most of the MDG Plus targets are taken from already
agreed national plans and strategies. For example, targets
pertaining to maternal and child health, HIV/AIDS, malaria and lower secondary education are set for 2006, the
end point of the 9th National Economic and Development
Plan. Others targets have been set by recent government
decisions or sector-specific strategies, such as the reduction of poverty and the increase in the share of renewable
energy. Finally, a few targets, such as region specific reductions in maternal and child health, have been agreed
on in the context of this MDG Report. Table 2 provides a
full account of all MDG Plus targets. The MDG Plus targets
make this Report a valuable tool for policy dialogue, agenda setting, advocacy and monitoring of human development in Thailand. It brings together all current human
development-related targets and adds new ones, into one
consolidated framework. The Report further strengthens
Thailand’s results-based and target-oriented approach to
development, creating a broad accountability framework
against which performance of the Government and its
partners will be assessed.
7
Chapter Two: Millennium Development Goals
Table 2: Global MDG and Thailand MDG-Plus Targets and Indicators for goals 4 and 5.
Goal
MDGs goal 4
MDGs goal 5
Targets
Indicators
Global MDG
Reduce by two-thirds,
between 1990 and 2015, the
under-five mortality rate
(U5MR).
• Under-five mortality rate
• Infant mortality rate
• Proportion o f 1-year old children
immunized against measles
Thailand MDG+
Reduce infant mortality rate
(IMR) to 15 per 1,000 live births
by 2006.
Reduce by half the U5M in
highland areas, selected
northern provinces and three
southernmost provinces
between 2005-2015.
• IMR in highland areas, northern
provinces and three southernmost
Provinces U5M in highland areas,
selected Northern provinces and three
southernmost provinces
Global MDG
Reduce by three-quarters,
between 1990 and 2015,
the maternal mortality ratio
(localized to MMR in high income
OECD in 2000).
• Maternal mortality ratio
• Proportion of births attended by
skilled health personnel
Thailand MDG+
Reduce MMR to 18 per 100,000
live births by 2006.
Reduce by half MMR in highland
areas, selected Northern
provinces and 3 Southernmost
provinces between 2005-2015
• MMR in highland areas, northern
provinces
and 3 southernmost provinces
Source: United Nation Development Programme. One United Plaza. New York.
MDG Plus indicators for goal 4 and 5
ity information for more advanced monitoring that may
be missing from the original MDG indicators. Second, it
ensures that the scope of monitoring progress is expanded to measure the benefits to all members of Thai society.
Third, it accounts for differences in geographic coverage,
as aggregated national indicators may cover up serious
regional and ethnic disparities. The MDG Plus indicators
provide an important tool for consolidated and broadbased monitoring of human development in Thailand, at
both national and sub-national levels (see Table 2).
Between 1989 and 1995-1996, the infant mortality rate
(IMR) declined from 38.8 to 26 per 1,000 live births representing a drop of about one third. Progress was slightly
more rapid in urban areas. At the beginning of 2001 the
IMR was estimated at 22 and the Ministry of Public Health
plan is aiming to reduce this to 15 by 2006. The under-five
mortality rate (U5MR) dropped as a result of better health
care and improving socio-economic situations. Although
trend data cannot be analysed due to a switch from a
manual to an on-line registration system during 1996-97,
comparable data collected between 1990-1995 shows that
the U5MR dropped from 12.8 to 11.6 per 1,000 live births
over that period. The apparent increase of the U5MR
to16.9 per 1,000 live births in 1998 is believed to be the result of technical change in the method of data collection
rather than a real increase.
The expanded set of indicators have been developed
and agreed on through a long and detailed consultative
process among line Ministries, the Office of the National
Economic and Social Development Board, the National
Statistical Office, academic institutions and civil society
organizations. This process provided an invaluable opportunity to discuss data deficiency and gaps, conflicting
data sets, and the need for improvements in collection
and analysis. Most infant deaths occur in the perinatal period, the time from late pregnancy up until the first seven
days of life. In this period, the health of an infant is largely
determined by that of the mother, especially maternal nutrition. Therefore, progress on reducing infant mortality
The MDG Plus framework also includes an expanded
set of indicators for the monitoring of human development in Thailand. The MDG Plus framework improves
on the original MDG indicators in three important ways.
First, it ensures that the indicators take into account qual-
8
Chapter Two: Millennium Development Goals
is closely tied to maternal health and other development
concerns including poverty and hunger. The conditions
of pregnancy and childbirth continue to effect infants
who survive the first days of life. Most deaths during the
neonatal period, or the first month of life, were related to
pregnancy, childbirth, congenital diseases and chromosome irregularities. After that, the first month of birth,
parasitic infection and AIDS were the primary causes of infant death, making both child-care practices and progress
on HIV/AIDS and other major diseases, important factors
in infant health. When children get older, other causes of
death become significant. These include drowning, traffic accidents and other types of diseases such as AIDS,
dengue fever, parasitic infections, congenital diseases,
chromosome irregularities and malnutrition.
targets have been set to reduce IMR to 15 per 1,000 live
births by 2006, and to reduce by half between 2005-2015
in the U5MR in highland areas, selected northern provinces and the southernmost provinces. In order to meet
these targets to improve MCH it is important to proceed
to reach the MDGs and MDG plus.
Summary
Despite progress in the MDGs by Thailand a number
of gaps remain. An improvement in access to quality maternal health care, especially among selected provinces
in Thailand, is necessary to reach the MDGS. Training of
health personnel and improving access to primary health
care services is an important step to improving care.
Improving maternal and child
health goal 4 and 5
Despite some inconsistency, all data sources support
the same trend that maternal mortality rates declined by
about two thirds in the decade from 1990 to 2000. The
MMR dropped from 36 per 100,000 live births in 1990 to
an all-time low of 14 per 100,000 live births in 1999. The
increase to 17.6 per 100,000 live births in 2001 and 24 per
100,000 live births in 2002 is a result of an endeavour to
expand the coverage and improve the technical aspects
of data collection. With this in mind the Ministry of Public
Health set a target of 18 per 100,000 live births by 2006,
as on MDG Plus target. The leading causes of maternal
death were haemorrhage, hypertension, sepsis and amniotic fluid embolism. Largely due to the Government’s
Safe Motherhood Programme, the proportion of births
attended by health personnel increased from 91 percent in
1990 to almost full attendance in 2001.
Access to quality maternal health care
Every Thai woman should be able to access prenatal
and maternity care. Women should make at least four
prenatal visits, which are considered sufficient to ensure
the well-being of both the mother and the baby. There
are difficulties accessing primary health care in the North
due to the mountainous terrain. In the southernmost
provinces, complexities based on gender, culture, religion
and language can make access to use of primary health
care difficult. This explains the higher MMR in these two
areas. There is room for quality improvements in maternal
health care. An immediate priority is to ensure that pregnant women do not suffer from iron/folate deficiency.
Anaemia among pregnant women has steadily dropped
from 19 percent in 1990 to 12 percent in 2001. The Ministry
of Public Health target is to keep iron/folate deficiency
among pregnant women to less than 10 percent by 2006.
A lack of an appropriately trained workforce coupled with
a lack of health system infrastructure are barriers that
hinder access to quality maternal health care (Koblinsky,
Matthews et al. 2006; Maternal and Newborn Health
2008). Additional training would ensure that auxiliary
health personnel could become more skilful in anticipating and responding to childbearing complications.
Given the low baseline of 12.8 per 1,000 live births
in 1990, the reduction in child mortality by two thirds by
2015 to 4.3 per 1,000 live births was not feasible. MDG Plus
9
C hapter T hree: Health Equity
T
he concept of health equity conveys a sense of
fairness and is an ethical value (Leeder 2003). It is
understood within the literature as an absence of
systematic differences by population and by group
implying that there are no differences in health outcomes
(Macinko and Starfield 2002). Thus, equity refers to a fair
distribution of resources to address health disparities that
are associated with an underlying social disadvantage or
marginalisation in society (Harris, Sainsbury et al. 1999;
Leeder 2003). Although the health sector has no control
over the causes of inequities, the health sector can take
some actions to address inequities in health (WHO 2008).
While disparities still exist, universal coverage provides a
foundation on which to address inequalities. For instance
a study in 2003 (Veugelers and Yip 2003) identified that
those with a low income used a disproportionate amount
of health services to improve their health and contributed
to a reduction in mortality. Yet, the under utilization of
specialist services by those with a lower income compared
to those with a higher income potentially contributed to a
widening of the socioeconomic gap.
Thailand successfully implemented a universal coverage scheme in Thailand in 2002 that encompassed
a number of reforms such as policy and legislative
changes as well as long term funding reforms (Hughes
and Leethongdee 2007). The universal health scheme
(30-baht health care) initially implemented in 2002 was
financed by general tax revenue for 45 million of its people
(Tangcharoensathien, Tantivess et al. 2002). However, in
October 2006, The General Surayud Chulanont Interim
Government, abolished the 30-baht fee and made the
health care program completely free (The Nation 2006;
Yiengprugsawan, Carmichael et al. 2010). Since then,
there has been no copayment for health services by this
scheme. A capitation contract model has been adopted
to purchase ambulatory and hospital care, and preventive
care and promotion, including reproductive health services, from public and private service providers. The policy
aims at promoting governmental and non-governmental
sectors to provide services equally and evenly in their respective area. Various payment mechanisms employed in
Thailand (capitation, case basis, fee for service) have been
evaluated and will be the basis for designing an effective
and efficient policy. Although the universal health scheme
replaced previous health care arrangements, there still
remains the Civil Servant Medical Benefit Scheme and Social Security Scheme that runs in parallel to the universal
scheme. Consolidating these programs into one may help
to enhance access and equity of services (Thoresen and
Fielding 2011)
The World Bank (World Bank 2006 p.141) suggests
that inequalities in health care use in many developing
countries arise due to a number of constraints in the
ability of individuals to achieve good health. The World
Bank (World Bank 2006p. 29) indicates that inequalities
manifest in a number of dimensions including health,
education and income creating a cyclical effect where
the dimensions interact and reinforce one another. For
instance, poor health can affect an individual’s capacity
to earn an income, their performance at education facilities, or their capacity to participate in community activities (World Bank 2006:29). The continual reproduction of
these cyclical effects translates into inequalities in other
dimensions of life. Gwatkin et al. (2007 p. 7) has identified
the existence of a health gradient that increases as economic circumstances gets better. He states that:
‘The health of the poor is notably worse than that of
the better-off’ and ‘The poor use health services less, have
less adequate health-related behaviors, and are disadvantaged with respect to other determinants of health
status.’
Social and economic difficulties coupled with women’s
lack of empowerment, poor education and employment
opportunities poses barriers to improving maternal and
child health in developing countries. These barriers and
constraints pose difficulties in terms of ensuring equitable
health services. For instance Navaneetham & Dharmalingam (2002) suggested that education for females was
a strong predictor of maternal health services. Similarly
a study by Erci (2003) identified that low education was
a barrier to the use of antenatal services decreasing the
use of and initiation of prenatal care. Lower education has
been shown to increase the risk of perinatal death (Shah,
Shah et al. 2000). Thus, many interventions are required
to address health inequities.
The potential impact of universal coverage on maternal and child health services depends on the three key
aspects: awareness of entitlement on the part of intended
beneficiaries of services; the response of health care providers to capitation; and the capacity of purchasers to
monitor and enforce contracts.
Morbidity and mortality
Within Thailand, there remain some disparities in
MCH health outcomes despite the health reforms undertaken and the successful reduction of child mortality
inequalities by half between the richest and poorest populations between 1990 and 2000 (Vapattanawong, Hogan
et al. 2007). UNICEF (2008) indicates that disparities are
present between the rich and poor in Thailand for nutrition, child health, maternal and newborn health. They
also indicate that disparities for nutrition are worse for
those living in rural areas.
Universal coverage
Although developed countries have implemented universal coverage, there remains some level of inequalities.
For instance in Australia, disparities remain for Indigenous
people who can expect a life expectancy of approximately
17 years lower than non-indigenous people and who have
a increased risk of poor health outcomes (AIHW 2008).
10
Chapter Three: Health Equity
Current evidence shows that there is an association
between socioeconomic status and mortality of children
in developing countries of which the nature and magnitude vary by country (Rutstein 2000; Wagstaff 2000). For
instance the maternal mortality ratio for Sub Saharan Africa was estimated to be almost twice that of South Asia,
four times that of Latin America and almost 50 times that
of industrialised countries (Ronsmans and Graham 2006).
The effectiveness of health intervention studies that show
reductions in inequalities are limited. A study from Matlab
in Bangladesh (Razzaque, Streatfield et al. 2007) reported
that the mortality gap between rich and poor increased
initially and then narrowed due to the intensiveness of the
intervention. Similarly, Koenig et al (2001) provided evidence that measles vaccination in Bangladesh exerted a
narrowing of the differentials in childhood mortality risks
between rich and poor. In Thailand, it was documented
that delays in seeking, reaching or getting good care in
the southernmost provinces negatively impacted upon
maternal mortality following emergency obstetric care
(Liabsuetrakul, Peeyananjarassri et al. 2007).
ban women. Houweling (2007) suggests that use of both
public and private services is lowest among the poorest,
especially in regards to professional delivery care. However, use of health care services is low in many countries. It
is reported that women in Nigeria showed a poor pattern
of health seeking and preferred to have birth deliveries at
home by unskilled or traditional attendants (Osubor, Fatusi et al. 2006). Similarly, a study in Tanzania (Mpembeni,
Killewo et al. 2007) showed that almost half of respondents delivered their babies at home by untrained attendants. Many factors influence health seeking behaviours
including knowledge and acceptance of maternal health
services (Lubbock, Stephenson et al. 2008) as well as socioeconomic differences (Makinen, Waters et al. 2000). A
study by Somyod et al (2006) found that antenatal care
is heavily influenced by such factors as wealth and education. In poor households, women are far less likely to use
antenatal care than women are in well-off households.
The report notes that women with secondary schooling
are two to three times more likely to have antenatal care
than women with no education (Somyod S, Rungrat P et
al. 2006). A study undertaken in Nicaragua (Lubbock, Stephenson et al. 2008) suggests that for improvements in
maternal and child health to occur, interventions should
be multi-level that includes individuals, households’ and
community.
Equity of access to maternal and
child health services
Chapter Three highlights some of the factors that
influence the equitable delivery of maternal and child
health services. These factors include fragmentation of the
workforce, an under resourced and unequal distribution
of primary health care services as well as geographical
barriers, access to transportation and poverty. Other
factors identified in the literature that are not specific
to Thailand reflect inequalities in relation to education,
income and housing characteristics (Wagstaff 2002).
Summary
Promoting fairer access to health services is a positive
step towards improving health outcomes and reducing
inequities. The successful implementation of universal
coverage in Thailand reflects an integrated and coordinated approach from many levels of government that
has potential for other developing countries to adopt.
However, ensuring that the gap between rich and poor
does not increase will require substantial commitment to
intensive and long-term interventions. Underpinning this
to reducing the gap is the need to build capacity to generate evidence and translate it into action (Prakongsai,
Limwattananon et al. 2009).
Evidence supports variations in access to maternal
health care within and between developing countries.
For instance, a systematic review identified that urban
women were more likely to deliver in medical settings
with the assistance of skilled health workers than rural
women(Say and Raine 2007). Research suggests that
where countries have higher levels of government
participation in health financing, there appears to be
a higher utilisation rate of skilled birth attendants and
caesareans (Kruk, Galea et al. 2007). Greater levels of
health spending in relation to caesarean services, is
to some extent, shown in a study that showed access
to caesareans varied between countries. The authors
identified that the poorest countries had little access
to caesareans whereas the richest countries were over
the maximum recommendation of caesareans for the
population (Ronsmans, Holtz et al. 2006). These studies
highlight a multitude of factors operate at different levels
to produce inequities and variation in access to maternal
and child health services. Nevertheless primary care
practitioners in Thailand believe that the PHC system is
largely equitable (Pongpirul, Starfield et al. 2009)
Ensuring that timely effective obstetric and newborn
care is available to women could reduce the associated
risks and complications that lead to perinatal death (Ngoc
et al. 2006). A study (Bulatao and Ross 2002) that investigated access to maternal health service in 49 countries
identified that 39% of women in rural areas estimated to
have adequate access to services compared to 68% of ur-
11
C hapter F our: Primary Care
P
level through lack of accessible, well functioning, staffed
and resourced facilities, and at the policy and systems
level through poor planning, management and supervision, and lack of political commitment (Maternal and
Newborn Health 2008). In many developing countries,
complications of pregnancy and childbirth are the leading causes of death among women of reproductive age.
Women’s lifetime risk of maternal death is almost 40
times higher in developing countries than in developed
ones: one woman in every 1,800 will die from pregnancyrelated complications in developed countries, while in
developing countries the lifetime risk is one in 48 (UNICEF
2009). The major problems of MCH worldwide are high
rates of maternal and infant deaths, inadequate ANC, low
birth weight, under nutrition, and sexually transmitted
infections (STIs) especially HIV/AIDS.
rimary health care is an important component of
improving maternal and child health outcomes.
The term maternal and child health (MCH) is widely
used by many national and international organizations for the set of services related to maternity and basic
childhood health care such as deliveries and immunizations (National Center for Health Statistics 2002). (Some
discussion of the origin of Primary Health Care, especially
related to the Alma Ata declaration is pertinent here.
Primary health care is seen as a broad process in terms
of its original definition. Increasing countries are viewing
targeted primary care for specific services as being more
achievable. Maternal health encompasses all activities
such as antenatal care (ANC), delivery care, postnatal
care and maternal complication care provided to women
during pregnancy, delivery and post-partum period. On
the other hand, child health care includes all medical assistances such as vaccination, illness treatment, management of conditions related to under nutrition and mortality reduction for babies right after birth up to the age of
five (NIPORT 2005).
Two approaches to address delivery of maternal and
child health services in developing countries can be identified. One approach is that each MDG goal or disease is
addressed independently. A second approach is that there
is an integrated approach to addressing each MDG. Table
3 illustrates some of the interventions that are classified
into these two distinct approaches. The following section
discusses these approaches.
MCH is an area of serious concern in developing
countries. Rates of morbidity and mortality in pregnant
women, mothers and newborns remain high, particularly
among poorer groups. They occur at the service delivery
12
Chapter Four: Primary Care
Table 3: Type of strategy/intervention
Type
Strategy/Intervention
Definition
Independent
interventions
Oral rehydration Immunisation
Fortification of food
Insecticide treated nets
Hygiene – hand washing, cleansing birth
canal, neonatal skincare
These interventions are focused on disease
or illness
Antenatal care – screening and treatment
for bacterial infections, STIs
Focused on ensuring mothers are adequately
free of infection,
Assistance at birth
Improve quality of care
Contraceptive use
Education
Direct payment to households
Increase uptake of services
Participatory women’s intervention
Integrated
packages
Clinical care
Outpatient services
Outreach services
Maternal and child services used as entry
point
Communicable disease control, health
education, nutrition promotion
Community based package
Antenatal and newborn care
Antenatal and postnatal visits
Source: Adapted from the following: (Bustreo, Harding & Axelsson 2003; Campbell & Graham 2006; Ekman, Pathmanathan &
Liljestrand 2008; Haws et al. 2007; Rosato et al. 2008; Travis et al. 2004)
PHC Independent interventions
Single strategies such as the promotion of infection
control procedures, for example, hand washing can reduce childhood deaths. Studies (Luby, Agboatwalla et al.
2005; Aiello, Coulborn et al. 2008) in developing countries
have shown that using soap for hand washing can prevent death of children from diarrhoea or respiratory tract
infections. Equally, improving access to immunisation can
prevent disease and reduce the burden of disease in developing countries. For instance immunizing for pertussis
has been shown to reduce disease burden in children
(Preziosi, Yam et al. 2002). Childhood vaccine preventable
disease interventions are a cost effective measure and
can contribute to a significant reduction in mortality of
children less than five years (Brenzel, Wolfson et al. 2006).
Independent interventions address individual issues.
For example, Baqui et al (2008) undertook a RCT of service delivery strategies in rural Bangladesh to promote
birth and newborn care preparedness. They found that
there was a reduction of neonatal mortality in a home
care model. The home care model successfully referred a
third of neonatal cases and treated more than a third of
cases with antibiotics. In contrast a study by Blum (2006)
identified several major constraints during home birth
deliveries that may prevent the provision of skilled care.
These constraints included poor transportation, inappropriate environment for home delivery, insufficient supplies
and equipment, lack of security, inadequate training and
medical supervision. They found that attending births in a
facility provided an environment that was clean and safe
with adequate supplies. Most women who give birth and
can afford it prefer professionally provided options (Koblinsky, Matthews et al. 2006).
Other preventative interventions such as antenatal
screening for syphilis infection remain inconsistent between countries (Saloojee, Velaphi et al. 2004). Unlike
developed countries, developing countries are unable
to afford frequent repeated screening programs due to
resource constraints (Sankaranarayanan, Budukh et al.
13
Chapter Four: Primary Care
2001). Access to preventative measures such as antiretrovirals to prevent mother to child transmission of HIV(De
Cock, Fowler et al. 2000), or to condoms to prevent
transmission of STIs (Hearst and Chen 2004) or unwanted
pregnancies (Brown 2001) in developing countries remain
variable despite the effectiveness of these interventions.
Although there has been an increase in combination HIV/
AIDS antiretroviral therapy in developing countries (WHO
2005), high rates of transmission of mother to child HIV
infection continue to occur. For instance, the UNAIDS
estimates that the number of children under the age of 15
living with HIV has increased from 1.6 million in 2001 to 2.0
million in 2007 with the majority of infections occurring in
sub-Saharan Africa (UNAIDS 2008). The use of condoms
in developing countries have been shown to be effective
in terms of cost (Ainsworth and Teokul 2000) however,
their use is inconsistent and is susceptible to changes of
dominant social norms (MacPhail and Campbell 2001).
because of convenience or funding requirements instead
of tailoring packages to local issues. A study by Jahn et
al. (2000) assessed the performance of maternity care
in Nepal. They identified that maternity care had a limited effectiveness due to deficiencies from preventative
services to hospital based obstetric care. They propose a
two pronged approach to improve maternity care that addressed preventative services to hospital based obstetric
interventions. In Thailand, all pregnant women receive a
MCH Booklet and Pregnancy Pathway at their first antenatal visit. Almost all of the mothers (98.9%) reported that
they utilized the MCH Booklet to record their antenatal
and postpartum care received. Apparently, 61% of postpartum mothers received complete standard postpartum
care; at least 3 visits by trained medical and health personnel (doctor/nurses/midwifes). A slightly higher percentage
(62.5%) of infants received childcare from a professionally
trained health care provider (Institute for Population and
Social Research 2004).
The variation in the use of antibiotics to treat bacterial infections in developing countries ranges from being
widely available to tightly restricting use. For instance,
the decline in maternal mortality in Bangladesh has anecdotally been attributed to the wide availability of over
the counter antibiotics (Costello, Azad et al. 2006). On
the contrary, the tight control of antibiotic use through
prescriptions is problematic due to the lack of availability
of the drug, poor quality and difficulty in access to a pharmacy (Pecoul, Chirac et al. 1999). In developing countries
often, drugs are available without prescription. Evidence
based prescribing guidelines in developing countries is one
intervention that has been successful in addressing some
of the variation in essential use (Hogerzeil 2004). Other
interventions that have been used effectively include
pharmacy and therapeutic committees and targeted
training of health workers (Laing, Hogerzeil et al. 2001).
Promotion of safe abortions is an important component of improving maternal health care. Almost 97% of
abortions occur in developing countries of which over half
occur in Asia (Grimes, Benson et al. 2006) among women
aged 15-30 (Shah, Shah et al. 2000). A study by Singh
(2006) of abortion related hospital admissions estimates
an average of 5.7 per 1000 women occur in developing
countries excluding China. By comparison, very few
unsafe abortions occur in developed countries (Sedgh,
Henshaw et al. 2007). A study in India (Coyaji 2000) investigated the feasibility of medical abortion. The results
indicated that the use of medical abortions proved effective, acceptable and feasible. To ensure safe abortions
occur require changes at policy level, training for service
providers, service delivery points for appropriate services
as well as public awareness of the available services (Berer
2000).
Integrated systems approach
A review of community-based interventions recommends an integrated approach to safe motherhood and
newborn health (Bhutta, Darmstadt et al. 2005). Integration of interventions can be of three types: one point of
service delivery, the creation of links between different
levels of the health service and coordination between
activities necessary for health system delivery (Ekman,
Pathmanathan et al. 2008; Lawn, Rohde et al. 2008).
Improving health outcomes through an integrated system requires a staged implementation of strategies that
are finely tuned to the capacity of the health system and
requires many changes to occur at a district and national
level (Ekman, Pathmanathan et al. 2008). As an example,
Sri Lanka has implemented an integrated package that
has a government and a private component whereby the
provision of a continuum of care starts at the time of marriage (see Figure 1).
Strategies to improve maternal and child health
care in developing countries require the support of communities to participate and utilise health services. The
use of volunteers to stimulate community participation
has been shown to be successful in many countries and
growing evidence suggests that the use of volunteers is a
way to address inequities and effectiveness of programs
(Tien, LeBan et al. 2000). For instance, a primary health
program undertaken in the Lao’s People Democratic
Republic (Perks, Toole et al. 2006), reported improved
access and utilization of services, a decrease in maternal
mortality ratio and lower infant mortality rate as well as
improved infant feeding practices. However, confirmation
of cost effectiveness of the training of volunteers is yet to
be demonstrated (Sibley and Ann Sipe 2004). Similarly,
a participatory intervention with mothers on birth outcomes undertaken in Nepal reduced neonatal mortality
(Manandhar, Osrin et al. 2004).
Complex issues such as maternal empowerment,
sociocultural taboos, behavioural practices such as health
care seeking practices all disadvantage inadequate health
care during pregnancy and childbirth and all affect maternal and child health outcomes (Bhutta and Soofi 2008).
A study undertaken in Turkey by Celk & Hotchkiss (2000)
have identified that education had a significant impact on
the use of health care. They found that women who had
at least five years of education were more likely to use
Preventative interventions have been shown to be
cost effective at an integrated level (Adam, Lim et al.
2005). However, the evidence base for guiding the implementation of intervention packages to improve maternal
and child health are lacking. Haws et al. (2007) systematically reviewed the evidence of 41 integrated interventions.
They found that interventions were bundled together
14
Chapter Four: Primary Care
Figure 1: Example of an integrated system
vider and recipients and clearer health service systems.
The public sector is the main service providers while the
private for profit and not for profit sector participated in
the pluralistic health service system. Meanwhile, many
people still depended on traditional ways of self-care.
In Thailand, trained health personnel, doctors, nurses
and midwives provide most of the care. According to
the WHO World Health Atlas (2004) the ratio of health
personnel to population in Thailand was as follows: doctor 0.3:1,000, dentist 0.07:1,000; pharmacist 0.17:1,000,
nursing and midwifery personnel 1.52:1,000.. In Thailand
there are 70 agencies responsible for health personnel
production, of which 13 are under the Ministry of Education, 43 are under the Ministry of Public Health, 3 under
Ministry of Defence, 1 under the Ministry of Interior, and
finally there are 10 agencies in the private sector, including the Thai Red Cross Society. A registration mechanism
is in place for the accreditation of all doctors, nurses and
midwives; however, at the time of this report, periodic
updating is not mandatory.
Source: Accelerating progress towards achieving maternal and
child health MDGs 4 and 5 in South East Asia (WHO 2009)
prenatal care than those who had no education. They suggest that improving educational opportunities for women
would improve the use of maternal health care services.
They also found that women who were pregnant with
their first child were more likely to use prenatal care than
women who had given birth more than twice. However,
they found that Kurdish women were less likely to use
prenatal care services compared to other ethnic groups.
The effect of living in particular parts of Turkey was also
associated with pre-natal care use. Subsequently, Celik
& Hotchkiss (2000) propose that ethnicity, location and
parity levels have been shown to be predictors of maternal care and can affect health outcomes.
Primary health care, especially in the area of maternal
and child health care, in Thailand is mostly provided by
non-professional village health volunteers. There are only
about 7000 doctors in Thailand that are geographically
distributed inequitably, yet the estimated population of
Thailand as of midyear 2009 is 63 million (Institute for
Population and Social Research 2009). Despite the fact
that 80% of the population are engaged in agriculture
in rural areas, most of the doctors reside and practise in
Bangkok, the capital. To redress this geographical inequity the government has implemented some supply and
demand incentives to retain doctors in rural areas (Wibulpolprasert and Pachanee 2008) The Ministry of Public
Health in Bangkok consists of six provincial health offices
that include maternal and child health care centres. These
maternal health care centres have about 100 beds, many
midwives and some doctors. The fee in Australian dollars
for a normal childbirth including a three-day hospital
stay is about $12 to $20. They also offer a 2-year training
program in midwifery. Underneath the Provincial Health
Office are District Health Offices followed by town health
centres at the sub-District level and Village Health Volunteers (VHV) plus Village Health Communicators (VHC) at
the village level. For villagers, the closest available medical professionals are 1 or 2 midwives working in the town
health centres. Their day-to-day primary health care heavily depends on VHV and VHC. The ratio of health professionals to population in 1997 has been improved. The ratio
of doctor, dentist, pharmacist, nurse, health personnel
to people were 1:3649; 1:17711; 1:10178; 1:1073, and 1:1282,
respectively. The total health expenditure during 20002005 period, has been 6.09-6.14 as a percentage of GDP
(Ministry of Public Health 2007).
Nutrition approach
Interventions to improve maternal, neonatal and
child nutrition are an important part of improving maternal and child health outcomes. According to Mora &
Nestel (2000) promotion of maternal nutrition should
occur during a woman’s life cycle instead of focusing on
pregnancy. They propose the use of a package of interventions that involves ten actions that range from education
to access to services. However, implementation would
require overcoming a number of challenges. Preventing
neonatal death from nutritional deficits involves the use
of interventions that target early initiation and exclusive
breastfeeding (Edmond, Zandoh et al. 2006). Duration
of exclusive breastfeeding for a period of six months has
shown to reduce morbidity and reduced gastrointestinal
infection (Kramer and Kakuma 2004).
Thai Health care delivery systems for
maternal, newborn and child health
There are multiple sectors responsible for maternal
and child health. Three are most obvious, the most important one is the Ministry of Education, which has 8 medical
schools and is responsible for the overall skills and quality of the health providers. The second is the Ministry of
Defence, the Royal Thai Air Force and the Royal Thai Navy,
who along with other units at the provinces provide maternal and newborn care. The third is the MOPH , which
provides specialist newborn health care policy and etc.
The health service system in Thailand has evolved
from self-reliance, in the past using local wisdom for curative care and health promotion to a system that depends
on modern medical and health service approaches. In
the new system, new approaches include the creation of
various disciplines of health personnel as well as the procurement and development of health care technologies.
As a result, there are clear designations of provider, pro-
15
Chapter Four: Primary Care
and plays an important role in maternal and child health.
The main donors that are interested in supporting maternal and child health programs in Thailand include UNICEF,
UNAIDS, UNFPA, JICA and WHO.
This risk might affect clinical practices and the quality of
services provided by contracted hospitals to beneficiaries.
There a number of challenges that currently impede
the delivery of maternal and child health services in Thailand. These include:
At present, there are standard guidelines for provision
of maternal and child health services at every level of government health facilities. The majority of maternal and
child health services are delivered throughout the country
by government agencies at all levels of the health care
system. At the village level, there is a primary health care
unit, where village health volunteers assist in providing
advice and referring cases to health centres. The hospital
component complements the MCH services system at the
community level and consists of a network of community
hospitals at district level, provincial, regional hospitals,
MCH hospitals, and university hospitals. All levels are
linked together by an established referral system. Currently 92.2% of pregnant women receive at least 4 antenatal care visits. Most antenatal care is provided in hospitals
and/or health centres by medical and health personnel
(doctor/nurses/ midwives). In government hospitals, antenatal care services are free of charge. Services provided
at antenatal clinics include: routine physical examination;
voluntary counseling and testing of HIV and thalassemia;
tetanus toxoid vaccination; health education, provision of
folic acid and iron supplement.
1) Improving quality of MCH care in thePrimary Care
Unit (PCU)
2) The integrated management of MCH such as antenatal care, child care services
3) Education prospective of MCH for health providers (doctors/ nurse/ midwifes and public health
workers)
4) Referral system especially linkage between PCU
and community hospital
5) Risk management skills for PCU health personnel
Summary
In Thailand there is an under resourced and unequal
distribution of primary health care services. The health
workforce includes a range of professional and non
professionals who provide health related activities in
the public, private sector and communities (Pagaiya
and Noree 2009). The literature clearly identifies that a
multipronged and multi–level approach is an effective way
to improve maternal and child health outcomes. Despite
the existence of several challenges, Thailand has begun to
implement multiple strategies with some positive results.
These positive outcomes have been underpinned by an
investment in policy changes from the Thai Government.
The following chapter discusses policy issues.
The average number of bed-days in hospital for birth
is two days for both mother and newborn. Usually the
mother is discharged if the newborn is sick and requires
hospitalization beyond two days. Some hospitals have
tried to set up a place for mothers to stay while their sick
babies are being treated, to help promote breastfeeding
for sick babies, and to educate mothers about essential
newborn care.
Thailand has traditionally focused on preventive public health measures, such as sanitation, clean water supplies and vaccinations, as the most cost-effective means
of improving the general health status of the population.
These public initiatives have led to considerable improvements over the last decade and required collaboration
between government and the private sector. The government launched a massive public education exercise in the
mid-1990s to raise the public’s understanding of the risk
of HIV/AIDS and the rate of infection appears to have stabilized. Private health services provided treatments to infected patients and participated in the prevention of HIV/
AIDS and NGOs such as the Population and Community
Development Association helped promote condom usage
and family planning for the public (World Bank 2007; Limwattananon, Tangcharoensathien et al. 2010).
The health services system in Thailand is changing
rapidly, particularly in the social security scheme. This has
emphasised quality and efficiency since its establishment
in 1991 with a scheme applying capitation payment to
fund providers-so called main contractors-prospectively.
Although the payment mechanism is beneficial to the
overall system administration and helps contain operating costs of the Social Security Office, the capitation
payment makes contracted hospitals at risk of financial
burden of medical care offered to social security patients.
16
C hapter F ive: Public Policy
H
ealth policy and strategy are key elements of the
Thailand Government approach to implementing activities aimed at making the people healthy
involving all concerned, using the ‘all for health’
approach. A good understanding of health policy and
strategy is essential, as they can potentially have either
a positive or negative effect on the health and well-being
of all Thai people. According to the 1997 Constitution of
Thailand (The 1997 Constitution was revoked by the Announcement of the Democratic Reform Council, dated
19 September 2006; and the development of a new constitution in 2007), the highest ranked public law of the
country, had provisions guaranteeing rights and freedom
of the people in physical, mental and social aspects that
cannot be violated. The state has the duty to protect such
rights and freedom. The constitution specified the peoples’ rights related to health in six aspects as follows:
five sections and are classified into two groups: policies
on establishing a health service system that is accessible,
efficient and of good standard, and policies for creating
the environments that are conducive to healthy living and
health promotion.
The 2007 Constitution of Thailand contains the
framework for formulating health development policies
and strategies of the country, with a linkage to the national development strategies. As a result, the The Tenth
National Economic and Social Development Plan, 20072011: has been formulated.
Thailand Health Development and Policy
Within the framework of the Tenth National Economic and Social Development Plan, 2007-2011, the development of public health policies and initiatives have
included specific factors that will help to strengthen the
health system. These include consideration of various
economic indicators, putting into place appropriate laws
and regulations and addressing socio-cultural factors
(WHO 2007).
1. Right to know about the impact on human
health, the environment and quality of life.
2. Right to express opinions about the impact on
health, the environment and quality of life.
3. Right to take part in decision-making, to benefit
from, to protect/promote natural resources and
the environment that will have an impact on human health and quality of life.
The Ministry of Public Health (MOPH ) is responsible
for the organization, management and administration of
public health services in the country, focusing on provincial and rural areas. At the central level, the Office of the
Permanent Secretary is responsible for policy and planning, manpower development and health administration
through the supervision of the provincial health offices
(headed by the Chief Provincial Medical Officer). Policy
making and technical supports were provided by technical units at the central level. Nutrition Division was one
of the technical units in the Department of Health, established as early as 1951 (Wibulponprasert 2007).
4. Right for at least 50,000 eligible voters to collectively sign a proposition to legislate a law on
health, according to the fundamental state policy,
to the parliament for consideration.
5. Right to receive health care in an equal, universal,
and equitable manner.
6. Right to join in examining for health consumer
protection purposes through an independent
consumer protection agency.
Prior to Primary Health Care (PHC) implementation,
the health care system in the rural areas could cover at
most about 20% of the population. Limited access due to
geographical barriers, transportation access and poverty
all added to barriers to successful health services. In the
fifth National Economic and Social Development Plan
(NESDP) (1982-1986), PHC was fully implemented nationwide (Thailand Health Research Institute 1998; Wibulponprasert 2007). Major efforts in improving rural health
services included the expansion of district hospitals,
increased number of Tambon health centres and trained
manpower. The most striking effort in manpower expansion was the creation of village level health volunteers,
starting with two distinct types of volunteers: Village
Health Communicators (VHC) and Village Health Volunteers (VHV). Village volunteers were identified by using
sociograms or other agreed mechanism, and were trained
to work in their own community. The level of training
and assigned responsibility differs. The VHC was to communicate health information between health personnel
and the community, while the VHV was trained to provide
simple, first aid care, including prescribing medicine listed
According to the 2007 Constitution, the fundamental state policies were provided with the intention for
the state to provide basic services to the people and all
governments are required to implement for national development purposes. They are regarded as fundamental
policies of the country, not of any particular government.
The government has to report to Parliament on what it
will do in administering the country accordingly. The
fundamental state policies are divided into 4 elements:
(1) public administration, justice, security and foreign affairs; (2) politics, administration, natural resources and
environment; (3) social administration, and (4) economic
development. The government is required to report on
the implementation of the fundamental state policies
to the Parliament once a year. Health policies are mainly
under the fundamental social state policies and some are
under another two elements of the state policies. Such
health policies are considered the foundation for the state
to improve the Thai people’s health status. They cover
17
Chapter Five: Public Policy
on the essential drug list. During the first two decades,
the ratios were: VHC:HH (Household) = 1:10-20; VHV :
HH = 1:100-200 and VHV:VHC =1:10. In recent years, VHV
consist of men and women over 30 years of age who are
interested in health care and who receive 15-day intensive
training. Each VHV has several VHC as assistance. For the
past 20 years the Thai government has taken the policy
of “2 children per family” via contraception since abortion
is prohibited by law in Thailand. VHV plays an important
role in educating villagers in the area of contraception.
Lately the population increase rate has become too low
(Wibulponprasert 2007).
and village self-managed primary health centres. Basic
Minimum Needs (BMN) approach for improving quality of
life was implemented nationwide in the 6th NESDP (19871991). The health insurance scheme has been an important
health financing strategy in an effort to increase health
coverage. The coverage of all types of health insurance
has increased from 32.9% in 1991 to 79.7% in 2000 (MOPH,
2000). There have been four major types, namely, public
assistance to the indigents (low income, children aged
0-12, elderly, community leaders and health volunteers,
novices and monks, and the disabled), health welfare for
the state employees (civil servants, state enterprise employees and their families), compulsory health insurance
(social security and workman compensation funds), and
voluntary health insurance (health card project and private health insurance). The public assistance to the indigenous hill tribe population has increased markedly during
the latter half of 1990s from 16.6% to 44-45%, and in 2000
decreased to 40.8%. Some of the nutrition activities, such
as iron supplementation also benefited from this allocation (Ministry of Public Health 2007).
Essentially, the VHC/VHV are community people who
serve as ‘mobilizers’ and are not paid workers or extended
health personnel. These volunteers communicate and
mobilize the community people in preventive and promotion of health care through activities, such as growth
monitoring, encouraging mothers to bring children for
immunization, and identifying pregnant women and encouraging them to attend antenatal care. Retention rates
of volunteers were low in the early stage of implementation. Additional training and refresher courses were
supported by the government budget and community
contribution. After two decades, all volunteers are now
upgraded to VHV, with the provision of additional training.
Recognition, peer acceptance and respect from the community assists in retention. The government provides free
medical services to the family (Thailand Health Research
Institute 1998; Wibulponprasert 2007). Annual selection
of the best performers at district, provincial and national
level is another activity for heightening their recognition.
The success of the volunteer system depends a great deal
on monitoring progress, providing on-spot training of
specific skills and motivation, and assisting in resolving
problems in the implementation (Wibulponprasert 2007).
In practice, monthly or bimonthly meetings between
health officers (‘facilitator’) and mobilizer/volunteers and
community leaders/ group are essential for effective supervision. The implementation of the community-based
nutrition improvement activities depended largely on
strong community participation, facilitated by facilitator
from health and other sectors. Facilitator has different
tasks of interface with mobilizer and community leaders.
With community leaders, the focus of the interface was
to help the community to define problems and plan for
solution. The interface between facilitator and mobilizer
focuses on specific skills training, supervision and quality
assurance.
For the health facilities, by the year 2000, there were
92 general hospitals at the provincial levels, 716 district
hospitals (coverage 89.7% of district), 9,704 (Tambon)
health centres and almost 70,000 village primary health
care centres (inclusive of urban and rural areas)(Ministry
of Public Health 2007). The ratio of health professionals to
population in 1997 has also been improved, with the ratio
of doctor, dentist, pharmacist, nurse, health personnel
to people being 1:3649; 1:17711; 1:10178; 1:1073, and 1:1282,
respectively. The health budgeting during 1969-2000,
has been 2.7-7.5% of fiscal budget in Thailand, or 0.4-1.1%
of GDP. The allocation has decreased slightly during economic crises, from 7.2% of fiscal budget in 1998 to 6.9% in
1999, 6.8 and 6.5% in 2000 and 2001 (Ministry of Public
Health 2007). In 1999, immunization covered over 94% for
all, except measles, which remained at 86.4%. The coverage of clean drinking water was 95.5 and sanitary latrine
of 98.2%, both in 1999 (Ministry of Public Health 2007). The
health care system for the coming two decades will meet
the expectation of the Thai society’s need for health. It
will consist of three components: health service system,
alternative medicines, and self-care and family care. Thus,
the health service system will no longer be the sole health
care system as it was in the past. The current thinking is
to provide integrated care in managing the health care
system that focuses on health promotion and decentralizing health care by promoting community involvement.
The direction is to use primary care as the central core
since integration of health services and interface between
the health service system and community will be crucial in
health promotion.
Specific programs that are strengthened through
primary health care include maternal and child health
and family planning, nutrition, environmental health, and
control and eradication of communicable diseases. Coordination is emphasised between university and health
training institutions and the MOPH in health manpower
development in Thailand. In the third NESDP, the national
family planning program was one of the most successful
population control programs in the world. Contraceptive
prevalence in 2009 has been maintained as high as about
71.5% compared to a regional average of 57.2% (WHO
2009).
Public policies are an important component of the
health sector. According to the World Health Organization (2008) policies must be in place to address health
systems, public health and intersectoral collaboration in
order to improve primary health care in developing countries. The World Health Organization (2008) point out
health system policies that are related to essential drugs,
technology, human resources and so forth, are necessary
to support primary health care and universal coverage
reforms. Despite the effectiveness of national policies to
Other health development projects included the
health card project (a form of voluntary health insurance),
18
Chapter Five: Public Policy
lower the cost and safety of medicines (Hogerzeil 2004)
implementation has been variable across countries (Reidenberg 2007). Laing and colleagues (2001) have identified a number of strategies that have proven effective
and includes among many the use of standard treatment
guidelines, essential medicines list and training of health
workers. While evidence suggests that Thailand’s National
Medicinal Drug Policy has improved the accessibility and
quality of essential drugs there remains some irrational
use of drugs and a lack of uptake of traditional medicines
(Phanouvong, Barraclough et al. 2002)
health issues or provide a favourable result in terms of
health outcomes. Engaging the private sector to improve
maternal and child health outcomes can be an effective
strategy. Bustreo and colleagues (Bustreo, Harding et al.
2003) reviewed the available evidence on private sector
utilization and quality of care. They reported that a number of approaches have shown some success in improving
maternal and child health outcomes. These approaches
are summarized in Table 4. They suggest that a strategic
approach to engaging the private sector is likely to exert
significant influence on maternal child outcomes. From
a global perspective, collaborating with other sectors to
improve access to clean water for instance could reduce
diarrhoea in children thus preventing the death of many
children (von Schirnding 2002).
Investment in human resources for instance could improve maternal and child health outcomes. For instance,
a cross-country study (Anand and Bärnighausen 2004)
explored the link between human health resources and
health outcomes. They found that the density of human
resources such as doctors and nurses’ account for variation in the maternal, infant and under five mortality rates
across countries. Understaffed developing country health
systems as a result of international migration of staff (Alburo and Abella 2002; Martineau, Decker et al. 2004) may
compromise the capacity to deliver health care. Ensuring
adequately skilled health professionals are available, may
require a range of interventions to be available. Stilwell
(2004) suggests that interventions need to be strategic
and improve data collection, address financial and non
financial incentives as well as negotiate agreements
with other countries. Opportunities, favourable working
conditions, as well as reorganization of staffing structure
and skills are further strategies that could be employed to
address the workforce shortages in developing countries
(Marchal and Kegels 2003). Other strategies such as support in the form of professional development and continuing education have been identified as essential for patient
safety (MacKinnon 2008).
Table 4: Type of policy interventions
Effective public health policies encompass a range
of interventions that guide the prioritisation of health
problems to disease prevention and promotion of health
(WHO 2008). Despite evidence of the contribution that
information makes to the reduction of maternal mortality
inadequate data collection on levels and trends for maternal mortality is still absent in some developing countries
(Graham 2002). Evidence from some countries such as Sri
Lanka, Thailand and Malaysia showed that collection of
data mobilized the government to take action and successfully reduced maternal mortality (Graham and Hussein 2006). Thailand’s success in reducing child mortality
is the result of the implementation of multiple strategies
and policy changes that have targeted inequalities (Vapattanawong, Hogan et al. 2007). Health system reforms
that can effectively change how resources are distributed
may be successful in effecting positive health outcomes.
However, many barriers prevent the implementation of
public policies such as the inability to mobilize resources
adequately, development of ill informed strategies and
incompleteness of data (De Brouwere, Tonglet et al. 1998).
Type of strategy
Definition
Contracting
Private entities can provide
specified services
Commercialization
Private entity agrees to
expand delivery of health
services to specific target
groups in exchange for
increase in profitability
Regulation
Setting rules related to the
provision of child health
services
Information
dissemination
Providers are trained
Education of individuals and
households
Source: Adapted from:(Bustreo, Harding & Axelsson 2003)
As discussed in Chapter Two, the successful implementation of Thailand’s Universal Health Coverage has
improved health service equity. Additionally there has also
been a positive impact on the efficient delivery of health
services. A study undertaken by Puenpatom & Rosenman (Phanouvong, Barraclough et al. 2002) reviewed the
technical efficiencies of 92 hospitals prior to and during
the implementation of universal coverage. They found
that small general hospitals were the most efficient followed by large general hospitals and regional hospitals
during the transition period. More recently research has
been undertaken in Thailand to explore the role of the
community hospital doctor. This has found a duality of
role between clinician and manager (Taytiwat, Briggs et
al. 2010). Further, research has developed a key set of
competencies required for the primary health care unit
and community hospital health service managers which
has been developed into a curriulum for rural health servicer managers by the Faculty of Public Health, Naresuan
University. Thailand (Yanggratoke, Briggs et al. 2010),
The ‘health in all polices’ intervention is based on the
notion that health can be improved through policies that
are controlled by sectors other than health, such as education, gender inequality or safety of food (WHO 2008).
The WHO (2008) suggests that policies that have intersectorial collaboration can mobilize communities around
19
Chapter Five: Public Policy
Another country, Cuba, has successfully demonstrated health status improvements such as a reduction in
infant mortality by implementing a strategic approach to
address public health issues (Cooper, Kennelly et al. 2006).
The strategic approach included a high quality primary
care network and public health system, education of the
workforce and a local biomedical research infrastructure.
In setting up the public health infrastructure, there was
an initial focus on basic health improvements such as
sanitation and immunisation, followed by a reorientation towards primary health care. A surveillance system
to ensure timely and accurate data provides information
on mortality and mortality by cause and province. In
terms of maternal and child health, Cuba established a
supportive network of community orientated services in
collaboration with governmental sectors and community
organizations. Cuba has demonstrated success by implementing a strategic approach. However, the dominance
of a ‘vertical’ or single approach to health in other countries often prevents horizontal or integrative approaches
from implementation. For instance, a study by Behague &
Storeng (2008) interviewed professionals from 16 developing countries and found that being sensitive to advocacy
practices meant a focus on vertical (single interventions)
approaches instead of a more strategic approach using
horizontal (integrated interventions) approaches. They
also identified that many professionals, in order to secure
funding or secure their academic reputations focus on
experimental research that evaluates clinical interventions or vertical elements of larger health packages or
programs. Hence, a strong leadership and an effective
government underpin a strategic approach to improving
health outcomes.
Policies not only need an evidence base, but also information that can assist in the allocation of resources,
services and health status (WHO 2008). However, overcoming constraints may be complex to optimal policy
implementation. An evaluation of the implementation of
a hospital information system in South Africa identified
that inadequate infrastructure, application and organization of the implementation process were some of the
reasons that the project failed (Littlejohns, Wyatt et al.
2003). Although investment in health systems is central
to ensuring an improvement in health outcomes, the ability of developing countries to invest in infrastructure will
depend on that country’s priorities and wealth (McKee,
Suhrcke et al. 2009). Many developing countries do not
have the same level of resources or capacity to repeat or
sustain models of health care used in developed countries
(Sankaranarayanan, Budukh et al. 2001).
Summary
Public policy is an essential element for achieving better health outcomes for maternal and child health. The
implementation of a strategic approach underpinned by
strong leadership ensures that changes to public policies
are implemented effectively this facilitates their impact
on the health of the population. The following chapter
discusses the importance of leadership.
20
C hapter S ix: Leadership
L
eadership involves not only managing people but
also resources. Ledlow and Coppola (2009) suggest
that good leaders manage resources and motivate
individuals towards the leaders vision and the organization’s mission as well as build strong and effective
relationships with others. The World Health Organization
(2008) suggests that an effective government with strong
leadership is vital for improving maternal and child health
and achieving success in reaching the MDG. While good
leaders empower, good managers are necessary to identify and achieve the organisational objectives and ensure
effective use of resources (WHO 2007). However, ineffective leadership, governance and management capacity
is a limitation in many low-income countries. A review
of Pakistan’s maternal and child health policy (Siddiqi,
Haq et al. 2004) identified that to ensure improvement
in maternal and child health services Ministries of Health
need a sustained governance and evidence base to ensure
effective implementation of policies. Conversely, the
migration of professionals limits the ability to undertake
and implement research or participate in global health
governance aspects (Sitthi-amorn and Somrongthong
2000). Initiatives to support and facilitate research skills
have had some success in some countries. For example,
Thailand’s International Health Policy Program successfully trained 36 professionals who all returned to serve
in the Ministry of Health and some Universities (Pitayarangsarit and Tangcharoensathien 2009). The evaluation
showed a zero attrition rate and no international loss of
professionals who participated in the scheme. Another
initiative to enhance management leadership is the use
of a capacity building approach. Briggs et al (Briggs, Tejativaddhana et al. 2010) utilised a ‘bottom up approach’
to translate local Thai health managers knowledge and
skills into operational use. A duality of roles is required
with balancing between clinical and management roles.
(Taytiwat, Briggs et al. 2010) This has been reinforced by
participants defining a curriculum for rural health service
management in Thailand specifying necessary competencies (Yanggratoke, Briggs et al. 2010).
munity participation at all levels has been ineffective. In
Australia, the SHAPE declaration provides guidance on
how health reform should occur and about the central
importance of health managers, government and communities to this process (Briggs 2008).
Public Health has been the predominate paradigm in
developing health services in most countries and can be
credited with successful foundations and rapid improvements in health outcomes achievements up to the present. However, with the rapid development of a systems
approach to health service delivery, the move to devolved
decentralised delivery at the district level and the need
for across sector engagement; demands different skills,
experiences, and capability in managing health systems.
Filerman (2003) ‘emphasises that the core competencies essential for managerial positions are not the same as
public health competencies. General management competence and public health competence are both essential
and they are complimentary, but they should not be confused’ (Health Systems Trust 2008:21). General management competence alone is not adequate; broad contextual
health system understanding is fundamental to effective
management of health systems (Briggs 2008). Education, training and continuing professional development
in health management should be viewed as an important
additional qualification and experience and a pre-requisite
to advancing leadership in primary health care.
WHO suggests that strengthening health management and leadership requires a framework of adequate
numbers of health managers, with appropriate competencies working within functional support systems, in
enabling work environments. This framework described
in Figure 1 is said to be capable of use to map current activities, undertake needs assessment, plan leadership and
management development, solve particular countries
leadership and management problems and monitor and
evaluate strengthening activities (WHO 2007). The WHO
document goes on to espouse principles and make recommendations for future action that include:
High quality health management is central to successful health reform and health care delivery. Health
management should be an important profession and it
is essential to build both capacity and qualifications in
health managers that will lead to improved health care
outcomes and at the same time deliver improved health
system performance.
In developing countries this approach reflects high
level WHO concern to see a greater emphasis placed on
health management (WHO 2005:3; WHO 2007). Often the
existing health management interventions and capacity
building is time limited, it is not sustained with continuing
professional development, and it is often poorly resourced
in uncertain environments (WHO 2005; WHO 2007).
●
Support the use of the framework in countries
to share practical experiences and findings
●
Encourage networks of leadership and management resource institutions and individuals active in the field
●
Creating a clearing house/knowledge centre
● Catalyse the harmonization and alignment of
development
■
partners with country health systems, and
assistance to countries in
■ mobilising resources for strengthening
leadership and management
●
In health systems in developed countries, there is
an increasing recognition that health reform through
restructure without effective health manager and com-
Further development of tools for leadership and
management
●Strengthening
21
Chapter Six: Leadership
Figure 3: Towards unity for health through
sustainable partnerships with key
stakeholders.
Figure 2: Leadership and management in
Health Systems
1
Policy
Makers
3
2
Health
Managers
People
Needs
Based
Health
System
Health
Professionals
Source: WHO/HSS 2007
Communities
Most health systems are based on principles of equity and universal access and have identified at a national
level, major health needs and disadvantaged and marginalised groups who need greater access to and attention
from health systems. All too often these well intended
principles and identified needs get lost in an internalised debate between health providers, government and
policy makers about how best to structure and control
the organisational arrangements of the health system.
In many cases communities, patients and clients have
become disengaged from important debates about their
health system. Boelens (2000) partnership pentagon (see
Figure 2) encourages sustainable partnerships between
a number of key stakeholders. These include policy makers, health managers, health professionals, academic
institutions and communities with the aim of reducing
fragmentation in service delivery. Boelen (2000) suggests
that to create unity, political, scientific and organisational
conditions, as well as alliances and synergies need to be
identified and developed. It is important that in any approach to further develop the health management profession and to strengthen health systems should be an
inclusive approach that takes notice of citizens, patients,
health professionals and communities. It is important in
both research and practice to listen to the voices of these
groups and to place their concerns and needs at the centre of our deliberations. This is particularly important not
just to improve health outcomes and to ensure effective
use of resources, but to ensure transparent accountability
and good governance.
Academic
Institutions
5
4
Source: (Boelen 2000)
22
Chapter Six: Leadership
Research
Figure 5:The framework of accountability
relationships
Contingent with this approach is a well structured
research agenda that has as its objective the development
and advancement of health management through a collaborative approach that aligns researchers with research
users. This approach attempts to develop research capacity and capability at the same time engaging with health
professionals in addressing identified health system
problems. This is described as Model D below in Figure 3
and forms the basis of this current research project in Maternal and Child Health.
The state
Politicians
Citizens/clients
Figure 4: Models for linking research to action
Nonpoor
Poor
Policymakers
Providers
Frontline
Organizations
Source: World Bank 2004,49; ODE-AusAID 2008,7.
The Alliance for Health Systems Research in its 2004
Report on Strengthening Health Systems recommends
amongst other recommendations the adoption of more
innovative applications of the knowledge management
revolution and that ‘the health systems research community should challenge itself to explore problem-oriented
alliances with other disciplinary and topic-based groups
who share the same concerns of strengthening health systems’ (Health Systems Trust 2004:vii). The Working Group
on Challenges in Global Health (JCEI 2009) suggests that:
‘in addition to looking for additional resources
to meet challenges that there is also a critical
need to use existing resources more efficiently
and more effectively with creative thinking on
ways to achieve better health outcomes with the
resources we already have and encourag[ing]
stakeholders ….to drive their own planning and
implementation processes’ (Health Systems
Trust 2008:33).
Source: (Lavis, Lomas et al. 2006),(WHO 2008)
This approach has the dual benefit of developing the
capacity of researchers, students and practicing health
professionals and of translating knowledge into operational use. The accountability framework proposed by the
World Bank (see Figure 4) and drawn on by the 2008 Report
of the Humanitarian Policy Group Overseas Development
Institute, London on behalf of AusAID, Office of Development Effectiveness, brings into context the importance of
community and care recipients as discussed above. These
different models described above provide a basis on which
to consider how maternal and child health leadership,
management and knowledge translation might all work
together. The main theme running through the three
models is integration and fits very nicely with the integrative concepts proposed by Bolean (2000) which would be
useful framework model to consider.
The influence of the organizational culture
(Thai bureaucratic management style)
on the implementation of the Universal
Health Care (UHC) policy
Carney (2006) points out that organizational cultural dimensions are crucial for the effectiveness of the
implementation of the UHC policy and they should be
understood and identified. The UHC policy was one of
the tools of the Thaksin Government to reform public
administration. Primary care development is designed
to achieve the ‘modernisation’ of the national health
system (Meads, Iwami et al. 2005:253). Modernisation
is defined by Meads, Iwami and Wild (2005:257) , as ‘decentralisation, regulation, governance, partnership, and
stewardship’. These form the framework of New Public
Management (NPM) (Dunleavy and Hood 1994), although
this conceptual structure is not the focus of this study. The
framework is intended to promote the transition from
working in a bureaucratic culture to a more managerial
culture (Painter 2005).
23
Chapter Six: Leadership
According to Painter (2005:7), the administrative
reforms of the Thaksin Government used the ‘model of
executive government’, which mimics the NPM’s language. However, Painter contends that NPM was used
in a ‘symbolic role’ by the government (Painter 2005:24).
Much of the language of the reform programs is ‘managerialist’ in tone. Painter (2005:3) argues this reform is ‘best
understood as a politicisation programme rather than as
a managerial one’. He points out the managerial reform
of the Thaksin Government ‘is being deployed in order to
redistribute bureaucratic power to the political executive’
(Painter 2005:4).
The autocratic management style is present not only
at the national level, but also at the local level. The Working Group on Quality of Life and Health Development
(2004) report that, in some districts, the health centre
staff were not consulted about the decision to upgrade
their primary care units. The decision for upgrading those
health centres rested on two heads – the CHD and CDHO.
As a result, there was conflict between the health centre
staff and the CHD and CDHO. This disagreement impacted on the effectiveness of primary health services delivery
and management at front-lined health services ultimately
affecting the implementation of the UHC policy.
Bowornwathana and Poocharoen (2005) criticise this
reform because it was not true decentralisation, rather it
is a shift of power away from bureaucratic channels to a
consolidation and centralisation of power of the political
executives, especially that of the Prime Minister (Bowornwathana 2004; Painter 2005). Moreover, Pathmanand’s
report (2001:39) shows that despite the Thaksin Government offering a social programme which included ‘cheap’
health care as their election strategy, once in power, they
concentrated on economic development with big capital
investment rather than establishing capacity development and democratisation.
Chungsathiensup (2002) argues lower-ranked workers in the Thai public health system dare not question or
challenge staff in positions senior to them. This fits very
well with Thai culture which avoids confrontation (Cooper
and Cooper 1992; Holmes and Tangtongtavy 1995). Lowerranked staff deal with the power differential by deferring
and waiting for orders to act (Bloor and Dawson 1994).
The management of the Thai public health system rests
on patronage and the attendant power ritual (Chungsathiensup 2002).
Samudavanija (1987) argues the Thai bureaucracy is
hierarchically organised, and reflects the differentials in
status and power rather than a rational division of labour
or chain of command. This situation is based on personal
relations of patronage and dependency, in which deference and loyalty are more important than merit (Samudavanija 1987). The security of the bureaucracy members
is the priority rather than functional rationality (Painter
2005). Dixon (2005) reports the failure of performancebased reform in Thailand because of the highly-centralised
control of budgeting by the Bureau of Budget in relation
to other public agencies. In addition, Gamage and Suksomchitra (2004) report this style of management has led
to failure in the Thai education system.
Jindawattana and Pipatrojanakamol (2004) reveal
the top-down approach of the Government on the implementation of the health care reform by showing that the
Government rushed into the implementation of the UHC
policy without true participation from stakeholders and
communities. Furthermore, Na-Ranong and Na-Ranong
(2002) report the MoPH implemented the initial phase of
the UHC policy, so health providers from other ministries
had no chance to participate in making decisions. It reflects the authoritarian management style of the MoPH.
The MoPH was seen as using its power to only protect
funding for its own health facilities and for solving internal MoPH problems. There was a lack of a clear direction
for the decentralisation policy.
Hofstede (1991) suggests the management culture
can be analysed by considering the following attributes:
i) power distance; ii) collectivist culture; iii) uncertainty
avoidances; and, iv) gender. Thai culture has dominance
with high power distance. Thais accept wide differences
in power in their organizations (Komin 1990) and subordinates are unlikely to approach and contradict their bosses
directly (Thanasankit and Corbitt 2000). According to
Thanasankit (2002), high power distance results in a hierarchical organizational structure for most organizations
across Thailand and the leaders of the organizations are
viewed as father figures. Due to paternalism and dependence, the flat management structure approach is not
effective and does not accelerate decision-making in Thai
organizations (Rohitratana 1998), where decision-making
commonly does not have a team approach (Thanasankit
and Corbitt 2000), but is authoritarian (Holmes and Tangtongtavy 1995). In addition, the leader’s role is perceived as
that of a controller rather than a colleague (Thanasankit
2002).
In addition, the report of the Working Group on Quality of Life and Health Development (2004) shows that
there is a lack of coordination between the Community
Hospital Director (CHD) and Chief of District Health Office
(CDHO).. This was seen as a result of the rushed implementation of the top-down policy. Consequently, the roles and
responsibilities of both organizations in implementing
the UHC policy are ambiguous. The health centres report
to the district health office while the community hospitals
hold the funding. When the community hospitals assign
funding to the health centres the CDHO needs to approve
the activities to be performed by the health centre staff. If
the CDHO wants to develop some health promotion and
disease prevention activities for the community the CHD
has the authority and responsibility to allocate per capita
funding for these activities, not the CDHO. Some CHDs
have not provided funding to the CDHOs to carry out
such activities, and these preventative health activities
emphasised in policy have not been implemented. Some
CDHOs are not satisfied that they have no part in the
management of the funding. This conflict and confusion
has impacted on health centre staff; they feel as if they
have two managers – the CHD who provides funding to
them and the CDHO responsible for their career path.
The authoritarian management style creates a ‘superior-inferior’ concept, which is already dominant in Thai
culture (Rohitratana 1998:190). Hallinger and Kantamara
(2000) explain this results in an acceptance that decisionmaking should be made by leaders who are in positions of
24
Chapter Six: Leadership
authority and discourages subordinates ‘to dare to make
mistakes, or to take initiative’ (Thanasankit and Corbitt
2000). Furthermore, Komin (1990) and Thanasankit
(2002) demonstrate that power in Thai society is constructed by position, title and status related with position
and rank, rather than by personality or education.
tratana 1998). The patronage system embraces this value.
Samudjavanija (1987) states it is difficult to separate the
emotional relationships between superiors and inferiors
(a characteristic of Thai culture) and the rational relationships which the bureaucrats need to function efficiently.
Evans, Han and Madison (2006) point out that there
must be an appropriate preparation for organizational and
community development. Bowornwathana (2004:248)
argues reform requires ‘cultural change’ and a long-term,
rational strategy. Rural health care reform will only be effective if the CHDs and their stakeholders understand, in
depth, how organizational culture and traditional cultural
norms influence their strategic involvement and the implementation of organizational change in the Thai social
system (Hallinger and Kantamara 2000; Carney 2006).
Thais have an intensely collective culture, which
constructs and locates the context for change in group or
social interests rather than individual interests. They look
primarily to their referent social groups in order to make
sense of their role in change (Holmes and Tangtongtavy
1995). Thais are likely to express their view or opinion
as a group rather than as individuals (Thanasankit and
Corbitt 2000). Decision-making, management and promotion are based on group performance (Hofstede 1991).
Moreover, Thai culture values trust and relationships
(Thanasankit and Corbitt 2000). Thanasankit and Corbitt
(2000) argue personal relationships are stronger than
work relationships and relationships between superiors
and subordinates are considered to be equivalent to family relationships.
Participatory negotiation based leadership rather
than a short term performance focus or top bureaucratic
structure is now favoured among many international
organizations (Platteau and Abraham 2002). In many
countries, it constitutes a key element for reforms (Devas
1997) however, the struggle for influence and resources
add to the complexities surrounding leadership and governance. New mechanisms for multi stakeholder dialogue
(Anderson and McDaniel 2000) that engages various
key stakeholders at the centre of governance would ultimately strengthen and realign capacity to address major
health issues. Although the values of participation and accountability help to establish local needs and preferences,
they are exclusive of the poor because of the domination
by local elites and can only be overcome by effective
counteracting pressures (Devas and Grant 2003). Recent
research (Devas 2005) identified that having a multi-level
model of governance that includes local (community) and
an extensive (metropolitan) level would provide accountability to community members and opportunities for the
poor to have their voice heard.
The high level of avoidance, which results from uncertainty in how to respond to a given situation, can be
demonstrated by the way that ‘Thais are strongly socialised to conform to group norms, traditions, rules and
regulations’ (Hallinger and Kantamara 2000:192). Thais
base their relationships on trust and emotion. The high
level of feminine qualities lead Thais to place a high value
on stability and harmony in social relationships and avoid
conflict as much as possible (Hallinger and Kantamara
2000; Thanasankit and Corbitt 2000).
Thanasankit (2002) argues the four attributes of Thai
values described by Hofstede (1991) are not sufficient to
frame all aspects of culture that influence management.
He explores four other Thai values: i) Pu Yai or decisionmaking power; ii) Kreng Jai or consideration; iii) Face Saving; and, iv) Bun Khun (Thanasankit 2002:32-33). Pu Yai is a
superior or power figure who normally has the authority
to make decisions; this is similar to the concept of ‘power
distance’ described by Hofstede (1991). Kreng Jai refers to
feelings of being considerate or reluctant to impose upon
another person (Klausner 1981) and this value can be observed in the actions of all superiors, equals and inferiors.
Face Saving leads Thais to avoid conflict and criticism at all
times. Thais also try to avoid making others lose face at all
costs. However, this value discourages subordinates from
challenging their bosses. Last, Bun Khun is described by
(Holmes and Tangtongtavy 1995:30) as:
Summary
Mobilising changes to policy requires a strong and
effective leadership that engages relevant and appropriate stakeholders in the reform process. Without effective
leadership, many strategies that aim to improve maternal
and child health will not be as successful. Addressing
cultural aspects of leadership is an important component
that needs consideration in organizational change. Thailand’s successful approach to reform has provided the basis for potentially renegotiating the resources necessary
to support further health system transformation.
… indebted goodness, [and] is a psychological
bond between someone who, out of sheer
kindness and sincerity, renders another person
the needed help and favour, and the latter’s
remembering of the goodness done and his
ever-readiness to reciprocate the kindness.
Thais believe in Bun Khun (Thanasankit 2002). It is a
reciprocal relationship between two people to respect and
do favours for each other. This can help create a friendly
social relationship. However, this connection can be
exploited and used to obtain power in Thai society (Rohi-
25
C hapter S ix: Leadership
Q
uality of MCH services is a cause for serious
concern in many developing countries. Rates
of morbidity and mortality in pregnant women,
mothers and newborns remain shockingly high,
particularly among poorer groups. They occur at service
delivery level through lack of accessible, well functioning,
staffed and resourced facilities, and at policy and systems
level and through poor planning, management and supervision, and lack of political commitment. In Thailand, despite improvements MCH problems pose a serious threat
to the improvement of the overall health status of the
country and thereby can negatively affect socio-economic
development. According to the World Bank (World Bank
2009) Thailand has reduced maternal mortality ratio from
51 per 100,000 live births in 2005 to 48 per 100,000 live
births in 2008; the infant mortality rate from 14.00 per
1,000 live births in 2005 to 12 per 1,000 live births in 2009
and under 5 mortality rate from 16 per 1000 in 2005 to
14per 1,000 in 2008
This monograph has provided a snapshot of interventions that are currently utilised in various countries to
improve maternal and child health outcomes. Interventions have been identified within four areas namely health
equity universal coverage, health systems capacity, public
policy and leadership. One of the major themes identified
in this review is the prerequisite to improving maternal
and child outcomes that includes building capacity, particularly, training and education of health professionals,
and managerial and research capacity. Improvement in
these three areas would enhance the implementation of
interventions.
Thailand has shown that effective interventions can
improve maternal and child health and ensuring that this
improvement is sustained will necessitate a strengthening
of interventions. Identifying whether an independent or
integrated group will be implemented will require a deep
understanding of local issues, for example which issue has
the most importance and what resources will be required.
In other words, what capacity has the health system to
ensure that a strategic approach to improving maternal
child health outcomes is available? The development and
implementation of collaborative networks could help to
mobilize communities around a particular health issue.
Thailand has made great strides in reducing maternal
and child mortality over the past two decades. It is important, however, not to be complacent and to recognize
that in the recent past progress has tended to slow down
(particularly in the case of maternal mortality) and that
there are still very large geographical disparities in mortality. Only if the current trends continue will Thailand
be on track to achieve MDGs 4 and 5. Therefore, it is essential to strengthen MCH interventions, particularly in
the rural areas, and to back this up with systemic reforms
that ensure equal access to quality MCH services across
the whole of Thailand. In paying close attention to solving problems related to the vital interests of the people,
the Government cannot de-emphasize the importance
of ensuring the health of the people, particularly accessibility to essential quality MCH services among the most
vulnerable populations, i.e. women and children from the
poorest areas and households, or the emphasis on quality
of MCH services in primary care units.
Supporting a strategic approach to the implementation of interventions is policy reinforcement. This will require policy that supports the use of a range of strategies
including essential medicines, human resources, information and collaboration with other sectors. Ensuring the
availability of adequate human resources including skilled
professionals that are supported by a range of professional development and continuing education programs
would be a valuable investment. Reorganization of staffing structures could be employed to address any identified
workforce issues.
The following recommendations are based on the
maternal and child survival status, MCH current situation
and are keys to reaching MDGs 4 and 5 and the targets set.
It should be noted that the appropriate MCH interventions
and related institutional reforms all relate specifically to
health services, and can have a very substantial impact
on maternal and child mortality, but they need to be
complemented in other sectors, such as family planning,
health education, training health personal and health
care service systems, all of which indirectly affect levels
of morbidity and mortality among women and children.
The administrators should have programs that promote
the MCH protocol such as providing conferences, meetings, and training about the MCH protocol to give health
personnel the chance to be exposed to this new protocol.
Finally, the administrators should promote and provide
strong support policy and necessary equipment on a
regular basis.
26
Chapter Seven: The Way Forward
The MDGs indicate that a reduction is required in child
mortality by two thirds by the year 2015. MDG Plus targets
have been set to reduce the infant mortality rate (IMR)
to 15 per 1,000 live births by 2006, and to reduce by half,
from 2005-2015, the Under 5 Mortality Rate in highland
areas, selected Northern provinces and the southernmost
provinces. In order to meet these targets, priority needs
identified in this literature review needs to be given to the
following areas:
of life for children and adults. A strong emphasis
on gender sensitivity is crucial for the strategy to
be successful
2.
Improve health literacy for women
a.
Improvement in maternal and
child health care
Women with lower education levels have higher
maternal health risks and require special attention. Village health volunteers can play an
important role in ensuring that these women
have necessary and timely information and take
appropriate actions to protect and improve their
health and well-being.
Health status and outcomes
Health system performance
Improvement in health status and outcomes in maternal
and child health care by:
Improvement of monitoring capacity and the performance of the health system by
1.
1.
Improving the training of health service personnel
to be more effective in detecting and responding to
childbirth complications
a.
2.
a.
Health personnel require additional training in a
number of areas. These include as follows: micro
skills in project planning, implementation and
evaluation, health micro skills in diagnosis and
reporting of disease or illness.
Improving the training of health service personnel to
be more effective in management and leadership
a. Ensuring that health service personnel have
adequate maternity care skills will have an immense impact on the well-being of both the
mother and the baby. In addition, maternity
care should not be left entirely to health service
personnel. It should be a shared responsibility
with parents-to-be. Health service personnel
must regard maternity and family education as
an important part of their work.
3.
2.
Thailand has taken the important first step to fill
data gaps regarding births and deaths, in order
to understand the threats to people of all age
groups. A team of health and civil registration
experts are collaborating to overhaul the birth
and death diagnosis and the registration system. In addition to this broad-based effort, the
Ministry of Public Health is building capacity to
monitor the situations of high-risk groups, i.e.
highland children, children in the northern and
southern provinces.
Analyze existing data to develop targeted strategies
a. A review of the maternal mortality data is to
be conducted to examine the causes of death
at both the national and regional levels, and in
higher risk areas, i.e. the more remote provinces.
The review will aim for a better understanding of
the situation and help in the planning of appropriate actions suitable to each area/population
group.
Greater investment in training for health personnel
4. Improve the training of health service personnel to
be more effective in management and leadership
Conclusion
This monograph has provided an overview of current
trends interventions and strategies in maternal and child
health and has emphasised that an improvement in access to quality health care is a necessary investment that
is required to improve maternal and child health care. As
demonstrated in this monograph, a strong leadership is an
essential element for improving greater equity in health
at all levels of the system that ultimately affects maternal
and child health outcomes. Prioritising the implementation of the above strategies can be accomplished but will
require significant endorsement by the Thai Government.
a. A more effective management system underpins a strategic approach to the implementation
of effective interventions. Develop skills in curriculum development and implementation.
Determinants of health
Improvements in a number of factors outside the health
system include:
1.
Reform of the surveillance system to improve data
Proactively involve families and their communities in
participatory research to explore and evaluate models
A multilevel and multi-pronged approach can address
many of the practices, challenges and solutions identified
in this review. Innovative approaches require an equitable
primary health care system underpinned by strong public
policy and leadership support to prolong any strategies
implemented.
a. Improving childrens’ well-being requires an
integrated strategy and pro-active intervention at both the community and family levels.
The Government is preparing an integrated
family-centred strategy to engage every family
in harnessing their energy to improve the quality
27
References
Adam, T., S. S. Lim, et al. (2005). “Cost Effectiveness Analysis of Strategies for Maternal and Neonatal Health in Developing
Countries.” BMJ 331(7525): 1107-.
Adler, N., J. Stewart, et al. (2007). Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the US The
John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.
Ahmad OB, Lopez AD, et al. (2000). “The decline in child mortality: a reappraisal.” Bull World Health Organ 78: 1175-1191.
Aiello, A. E., R. M. Coulborn, et al. (2008). “Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A
Meta-Analysis.” Am J Public Health 98(8): 1372-1381.
AIHW (2008). Australia’s Health 2008. Canberra, AIHW.
Ainsworth, M. and W. Teokul (2000). “Breaking the Silence: Setting Realistic Priorities for AIDS Control in Less-Developed
Countries.” The Lancet 356(9223): 55-60.
Alburo, F. A. and D. I. Abella (2002). Skilled Labour Migration from Developing Countries: Study on the Philippines. Geneva,
International Migration Programme, International Labour Office.
Anand, S. and T. Bärnighausen (2004). “Human Resources and Health Outcomes: Cross-Country Econometric Study.” The
Lancet 364(9445): 1603-1609.
Anderson, R. A. and J. McDaniel, R.R. (2000). “Managing Health Care Organizations: Where Professionalism Meets Complexity Science.” Health Care Management Review 25(1): 83.
Baqui, A. H., S. E. Arifeen, et al. (2008). “Effect of Community-Based Newborn-Care Intervention Package Implemented
Through Two Service-Delivery Strategies in Sylhet District, Bangladesh: A Cluster-Randomised Controlled Trial.”
Lancet 371: 1936-1944.
Behague, D. P. and K. T. Storeng (2008). “Collapsing the Vertical-Horizontal Divide: An Ethnographic Study of EvidenceBased Policymaking in Maternal Health.” American Journal of Public Health 98(4): 644.
Benzeval, M., K. Judge, et al. (1995). Chapter 1 Introduction. Tackling inequalities in health and agenda for action. M. Benzeval, K. Judge and M. Whitehead. London, Kings Fund Publishing: 1-9-.
Berer, M. (2000). “Making Abortions Safe: A Matter of Good Public Health Policy and Practice.” Bulletin of the World Health
Organization 78: 580-592.
Bhongsvej, M. (2004). Women and Men:Moving towards a Partnership of Equals in Development. Washington, DC, World
Bank.
Bhutta, Z. A., G. L. Darmstadt, et al. (2005). “Community-Based Interventions for Improving Perinatal and Neonatal Health
Outcomes in Developing Countries: A Review of the Evidence.” Pediatrics 115(2): 519-617.
Bhutta, Z. A. and S. Soofi (2008). “Community-Based Newborn Care: Are We There Yet?” The Lancet 372(9644): 1124-1126.
Black, D., J. N. Morris, et al. (1982). Inequalities in Health. The Black Report. Great Britain, Penguin Books.
Bloor, G. and P. Dawson (1994). “Understanding professional culture in organizational context.” Organization Studies 15(2):
275-295.
Blum, L. S., T. Sharmin, et al. (2006). “Attending Home vs. Clinic-Based Deliveries: Perspectives of Skilled Birth Attendants in
Matlab, Bangladesh.” Reproductive Health Matters 14(27): 51-60.
Boelen, C. (2000). Towards unity for health: Challenges and Opportunities for Partnership in Health Development. Geneva,
World Health Organisation.
Bowornwathana, B. (2004). “Thaksin’s model of government reform: Prime ministerialisation through “a country is my
company” approach.” Asian Journal of Political Science 12: 135-153.
Bowornwathana, B. and O. Poocharoen (2005). “Managing reforms: The politics of organizing reform work.” Public Organization Review: A Global Journal 5: 233-247.
Brenzel, L., L. J. Wolfson, et al. (2006). “Vaccine-Preventable Diseases.” Infectious Diseases.
Briggs, D., P. Tejativaddhana, et al. (2010). “The Thai-Australian Health Alliance: Developing Health Management Capacity
and Sustainability for Primary Health Care Services.” Education for Health 10: 457.
Briggs, D. S. (2008). “The Shape Declaration on the organisation and management of health services: A call for informed
public debate. .” Asia Pacific Journal of Health Management 3(2): 10-13.
Brown, A. D. (2001). Sexual Relations Among Young People in Developing Countries: Evidence from WHO Case Studies,
Dept. of Reproductive Health and Research, World Health Organization.
Bulatao, R. A. and J. A. Ross (2002). “Rating Maternal and Neonatal Health Services in Developing Countries.” Bulletin of the
World Health Organization 80: 721-727.
28
Bustreo, F., A. Harding, et al. (2003). “Can Developing Countries Achieve Adequate Improvements in Child Health Outcomes
Without Engaging the Private Sector?” Bulletin of the World Health Organization 81: 886-895.
Carney, M. (2006). “Understanding organizational culture: The key to successful middle manager strategic involvement in
health care delivery.” Journal of Nursing Management 14: 23-33.
Celik, Y. and D. R. Hotchkiss (2000). “The Socio-Economic Determinants of Maternal Health Care Utilization in Turkey.” Social Science & Medicine 50(12): 1797-1806.
Chungsathiensup, K. (2002). Knowledge and power in health bureaucratic practices: A cultural analysis of Thai public
health administration (in Thai). Nonthaburi, Health System Research Institute, Ministry of Public Health.
Cooper, R. and N. Cooper (1992). “Working with Thais.” European Business Review 92(2): viii-x.
Cooper, R. S., J. F. Kennelly, et al. (2006). “Health in Cuba.” Int. J. Epidemiol. 35(4): 817-824.
Costello, A., K. Azad, et al. (2006). “An Alternative Strategy to Reduce Maternal Mortality.” The Lancet 368(9546): 1477-1479.
Coyaji, K. (2000). “Early Medical Abortion in India: Three Studies and Their Implications for Abortion Services.” JournalAmerican Medical Womens Association 55(3 ): 191-194.
De Brouwere, V., R. Tonglet, et al. (1998). “Strategies for reducing maternal mortality in developing countries: what can we
learn from the history of the industrialized West?” Tropical Medicine & International Health 3(10): 771-782.
De Cock, K. M., M. G. Fowler, et al. (2000). “Prevention of Mother-to-Child HIV Transmission in Resource-Poor Countries:
Translating Research Into Policy and Practice.” JAMA 283(9): 1175-1182.
Devas, N. (1997). “Indonesia: What do we mean by Decentralization?” Public Administration and Development 17( 3): 351-367.
Devas, N. (2005). “Metropolitan Governance and Urban Poverty.” Public Administration and Development 25(4): 351-361.
Devas, N. and U. Grant (2003). “Local Government Decision-Making - Citizen Participation and Local Accountability: Some
Evidence from Kenya and Uganda.” Public Administration and Development 23(4): 307-316.
Dixon, G. (2005). “Thailand’s quest for results-focused budgeting.” International Journal of Public Administration 28(3,4):
355.
Dunleavy, P. and C. Hood (1994). “From old public administration to new public management.” Public Money Manage 14: 3.
Edmond, K. M., C. Zandoh, et al. (2006). “Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality.” Pediatrics
117(3): e380-386.
Ekman, B., I. Pathmanathan, et al. (2008). “Integrating Health Interventions for Women, Newborn Babies, and Children: A
Framework for Action.” The Lancet 372(9642): 990-1000.
Ellsberg, M., H. A. F. M. Jansen, et al. (2008). “Intimate Partner Violence and Women’s Physical and Mental Health in the
WHO Multi-Country Study on Women’s Health and Domestic Violence: An Observational Study.” The Lancet
371(9619): 1165-1172.
Erci, B. (2003). “Barriers to Utilization of Prenatal Care Services in Turkey.” Journal of Nursing Scholarship 35(3): 269-273.
Evans, F., G. Han, et al. (2006). Healthcare Reform and Interest Groups: The Case of Rural Australia. Lanham, University
Press of America.
Filerman, G. L. (2003). “Closing the management competence gap.” Human Resources for Health Affairs 1(7).
Filmer, D. (2000). “The Structure of Social Disparities in Education: Gender and Wealth.” World.
Fraser, J., Briggs D. S., et al. ( 2008). “A Thai-Australian Rural Health Service Management and Medical Education Study
Tour: Workplace Changes After a Year.” Asia Pacific Journal of Health Management 3(1): 33-39.
Gamage, D. T. and P. Sooksomchitra (2004). “Decentralisation and school-based management in Thailand.” International
Review of Education 50: 289-305.
Graham, W. J. (2002). “Now or Never: The Case for Measuring Maternal Mortality.” The Lancet 359(9307): 701-704.
Graham, W. J. and J. Hussein (2006). “Universal Reporting of Maternal Mortality: An Achievable Goal?” International Journal
of Gynaecology and Obstetrics 94(3): 234-242.
Grimes, D. A., J. Benson, et al. ( 2006). “Unsafe Abortion: The Preventable Pandemic.” The Lancet 368(9550): 1908-1919.
Gwatkin, D. R., S. Rutstein, et al. (2007). Socio-economic Differences in Health, Nutrition, and Population within Developing Countries, Washington, DC, World Bank.
Hall, J. and R. Taylor (2003). “Health for All Beyond 2000: The Demise of the Alma-Ata Declaration and Primary Health Care
in Developing Countries.” The Medical Journal of Australia 178(1): 17-20.
Hallinger, P. and P. Kantamara (2000). “Educational change in Thailand: Opening a window onto leadership as a cultural
process.” School Leadership & Management 20(2): 189-205.
Harris, E., P. Sainsbury, et al. (1999). Perspectives on Health Inequity. Sydney, The Australian Centre for Health Promotion.
29
Haws, R. A., A. L. Thomas, et al. (2007). “Impact of Packaged Interventions on Neonatal Health: A Review of the Evidence.”
Health Policy Plan.: czm009.
Health Systems Trust (2004). Strengthening Health Systems: The Role and Promise of Policy and Systems Research, Alliance for Health Policy and Systems Research.
Health Systems Trust (2008). District Management Study: A National Summary Report-A review of structures, competencies and training interventions to strengthen district management in the national health system of South Africa,
Department of Health South Africa.
Hearst, N. and S. Chen (2004). “Condom Promotion for AIDS Prevention in the Developing World: Is It Working?” Studies in
Family Planning 35(1): 39-47.
Hill, K., P. Vapattanawong, et al. (2006). “Epidemiologic transition interrupted: a reassessment of mortality trends in Thailand, 1980–2000.” Int J Epidemiol: 1093.
Hofstede, G. (1991). Cultures and Organizations: Software of the Mind. Maidenhead, McGraw-Hill.
Hogerzeil, H. V. (2004). “The Concept of Essential Medicines: Lessons for Rich Countries.” BMJ 329(7475): 1169-1172.
Holmes, H. and S. Tangtongtavy (1995). Working with the Thais: A Guide to Managing in Thailand. Bangkok, White Lotus.
Houweling, T. A. J., C. Ronsmans, et al. (2007). “Huge Poor-Rich Inequalities in Maternity Care: An International Comparative Study of Maternity and Child Care in Developing Countries.” BULLETIN-WORLD HEALTH ORGANIZATION
85(943/944): 745.
Hughes, D. and S. Leethongdee (2007). “Universal Coverage In The Land Of Smiles: Lessons From Thailand’s 30 Baht Health
Reforms.” Health Affairs 26(4): 999-1008.
Institute for Population and Social Research. (2009). “Thailand Population.” Retrieved 9th July 2009, from http://www.ipsr.
mahidol.ac.th/ipsr/.
Institute for Population and Social Research, M. U. (2004). “Mahidol Population Gazette.” 13 1.
Jahn, A., D. Lang, et al. (2000). “Maternity Care in Rural Nepal: A Health Service Analysis.” Tropical Medicine & International
Health 5(9): 657.
JCEI (2009). Global Action for Health Systems Strengthening: Policy recommendations to the G8.Report by the Task Force
on Global Action for Health Systems Strengthening, Japan Centre for International Exchange.
Jindawattana, A. and S. Pipatrojanakamol (2004). Policy development: Universal Health Coverage in Thailand (in Thai).
Proceedings of the Universal Health Coverage National Conference, Royal River Hotel, Bangkok, Health System
Research Institute, Ministry of Public Health.
Kerber, K. J., J. E. de Graft-Johnson, et al. (2007). “Continuum of Care for Maternal, Newborn, and Child Health: From Slogan
to Service Delivery.” The Lancet 370(9595): 1358-1369.
Klausner, W. J. (1981). Reflections on Thai Culture: Collected Writing. Bangkok, Suksit Siam.
Koblinsky, M., Z. Matthews, et al. (2006). “Going to Scale with Professional Skilled Care.” The Lancet 368(9544): 1377-1386.
Koenig, M. A., D. Bishai, et al. (2001). “Health Interventions and Health Equity: The Example of Measles Vaccination in Bangladesh.” Population and Development Review: 283-302.
Komin, S. (1990). Psychology of the Thai People: Values and Behavioural Patterns. Bangkok, National Institute of Development Administration (NIDA).
Kramer, M. S. and R. Kakuma (2004). “The Optimal Duration of Exclusive Breastfeeding: A Systematic Review.” Adv Exp Med
Biol 554: 63-77.
Kruk, M. E., S. Galea, et al. (2007). “Health Care Financing and Utilization of Maternal Health Services in Developing Countries.” Health Policy Plan. 22(5): 303-310.
Laing, R. O., H. V. Hogerzeil, et al. (2001). “Ten Recommendations to Improve Use of Medicines in Developing Countries.”
Health Policy and Planning 16(1): 13-20.
Lavis, J. N., J. Lomas, et al. (2006) “ Assessing country-level efforts to link research to action.” Bulletin World Health
Organization 84, 620-628.
Lawn, J. E., J. Rohde, et al. (2008). “Alma-Ata 30 Years on: Revolutionary, Relevant, and Time to Revitalise.” The Lancet
372(9642): 917-927.
Ledlow, G. and N. Coppola (2009). Leadership Theory and Influence. Health Organizations: Theory, Behaviour and Development. J. Johnson. Sudbury, Massachusetts, Jones and Bartlett Publishers: 167-191.
Leeder, S. (2003). “Achieving Equity in the Australian Healthcare System.” Medical Journal of Australia 179: 475-478.
Liabsuetrakul, T., K. Peeyananjarassri, et al. (2007). “Emergency obstetric care in the southernmost provinces of Thailand.”
International Journal for Quality in Health Care 19(4): 250-256.
30
Limwattananon, S., V. Tangcharoensathien, et al. (2010) “Equity in Maternal Child Health in thailand.” Bulletin of the World
Health Organization 88, 420-427.
Littlejohns, P., J. C. Wyatt, et al. (2003). “Evaluating Computerised Health Information Systems: Hard Lessons Still to be
Learnt.” BMJ 326(7394): 860-863.
Lubbock, L. A., R. B. Stephenson, et al. (2008). “Utilization of Maternal Health Care Services in the Department of Matagalpa, Nicaragua.” Revista Panamericana de Salud Pública 24(2): 75-84.
Luby, S. P., M. Agboatwalla, et al. (2005). “Effect of Handwashing on Child Health: A Randomised Controlled Trial.” The Lancet 366(9481): 225-233.
Macfarlane, S., M. Racelis, et al. (2000). “Public Health in Developing Countries.” The Lancet 356(9232): 841-846.
Macinko, J. and B. Starfield (2002). “Annotated Bibliography on Equity in Health, 1980-2001.” International Journal for Equity
in Health 1(1): 1.
Macinko, J., B. Starfield, et al. (2003). “The Contribution of Primary Care Systems to Health Outcomes within Organization
for Economic Cooperation and Development (OECD) Countries, 1970-1998.” Health Services Research 38(3): 831865.
MacKinnon, K. A. (2008). “Labouring to Nurse: The Work of Rural Nurses who Provide Maternity Care.” Rural and Remote
Health 8(1047).
MacPhail, C. and C. Campbell (2001). “‘I Think Condoms are Good but, aai, I Hate Those Things’: Condom Use Among Adolescents and Young People In a Southern African Township.” Social Science & Medicine 52(11): 1613-1627.
Makinen, M., H. Waters, et al. (2000). “Inequalities in Health Care Use and Expenditures: Empirical Data from Eight Developing Countries and Countries in Transition.” Bulletin of the World Health Organization 78(1): 55-65.
Manandhar, D. S., D. Osrin, et al. (2004). “Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes in
Nepal: Cluster-Randomised Controlled Trial.” The Lancet 364(9438): 970-979.
Marchal, B. and G. Kegels (2003). “Health Workforce Imbalances in Times of Globalization: Brain Drain or Professional Mobility?” The International Journal of Health Planning and Management 18(S1): S89-S101.
Marmot, M. (2005). “Social Determinants of Health Inequalities.” The Lancet 365(9464): 1099.
Martineau, T., K. Decker, et al. (2004). “Brain Drain of Health Professionals: From Rhetoric to Responsible Action.” Health
Policy 70(1): 1-10.
Mason, A. D. and E. M. King (2001). Engendering Development`Through Gender Equality in Rights Resources, and Voice. A
World Bank Policy Research Report World Bank.
Maternal and Newborn Health. (2008, accessed 8 Oct 2009). “The State of the Worlds Children 2008: Child Survival.” from
http://www.eldis.org.
McKee, M., M. Suhrcke, et al. (2009). “Health Systems, Health, and Wealth: A European Perspective.” The Lancet 373(9660):
349-351.
Meads, G., M. Iwami, et al. (2005). “Transferable learning from international primary care developments.” International
Journal of Health Planning and Management 20(253-267).
Ministry of Public Health (2007). Thailand Health Profile 2005-2007, Ministry Public Health.
Mora, J. O. and P. S. Nestel (2000). “Improving Prenatal Nutrition in Developing Countries: Strategies, Prospects, and Challenges.” Am J Clin Nutr 71( 5): 1353S-1363.
Mpembeni, R., J. Killewo, et al. (2007). “Use Pattern of Maternal Health Services and Determinants of Skilled Care during
Delivery in Southern Tanzania: Implications for Achievement of MDG-5 Targets.” BMC Pregnancy and Childbirth
7(1): 29.
Na-Ranong, V. and A. Na-Ranong (2002). The evaluation of the implementation of the UHC policy (2001─2002) (in Thai).
Bangkok, Thailand Development Research Institute.
National Center for Health Statistics (2002). Health, United States, 2002 Hyattsville, MD, Public Health Service.
Navaneetham, K. and A. Dharmalingam (2002). “Utilization of Maternal Health Care Services in Southern India.” Social Science & Medicine 55(10): 1849-1869.
NIPORT (2005). Bangladesh Demographic Health Survey 2004. Mitra and Associates and ORC Macro. Dhaka, Bangladesh,
The Institute.
NSW Department of Health (2009). NSW Health/Families NSW Supporting Families Early Package –Maternal and Child
Health Primary Health Care Policy. North Sydney, NSW Department of Health.
Osubor, K. M., A. O. Fatusi, et al. (2006). “Maternal Health-Seeking Behavior and Associated Factors in a Rural Nigerian
Community.” Maternal and Child Health Journal 10(2): 159-169.
Pagaiya, N. and T. Noree (2009). Thailand Health Workforce: A Review of Challenges and Experiences. Washington, World
Bank’s Human Development Network.
31
Painter, M. (2005). Managerial reform and political control: The case of Thaksin and the Thai bureaucracy. Hong Kong, City
University of Hong Kong: 1-29.
Pathmanand, U. (2001). “Globalization and democratic development in Thailand: The new path of the military, private sector, and civil society.” Contemporary Southeast Asia 23(1): 24-42.
Pattaravanich, U., L. Williams, B. , et al. (2005). “Inequality and Educational Investment in Thai Children*.” Rural Sociology
70(4): 561.
Pecoul, B., P. Chirac, et al. (1999). “Access to Essential Drugs in Poor Countries: A Lost Battle?” JAMA 281(4): 361-367.
Perks, C., M. J. Toole, et al. (2006). “District Health Programmes and Health-Sector Reform: Case Study in the Lao People’s
Democratic Republic.” Bulletin of the World Health Organization 84: 132-138.
Phanouvong, S., S. Barraclough, et al. (2002). “Improving Primary Health Care in Thailand: The Role of the National Medicinal Drug Policy.” Australian Journal of Primary Health 8(2): 24-30.
Pitayarangsarit, S. and V. Tangcharoensathien (2009). “Sustaining Capacity in Health Policy and Systems Research in Thailand.” Bulletin of the World Health Organization 87: 72-74.
Platteau, J. P. and A. Abraham (2002). “Participatory Development in the Presence of Endogenous Community Imperfections.” Journal of Development Studies 39(104-136).
Pongpirul, K., B. Starfield, et al. (2009). “Policy characteristics facilitating primary health care in Thailand: A pilot study in
transitional country.” International Journal for Equity in Health 8(1): 8.
Prakongsai, P., S. Limwattananon, et al. (2009). “The equity impact of the universal coverage policy: lessons from Thailand.”
Advances in Health Economics and Health Services Research 21: 57-81.
Preziosi, M.-P., A. Yam, et al. (2002). “Epidemiology of Pertussis in a West African Community Before and After Introduction
of a Widespread Vaccination Program.” Am. J. Epidemiol. 155(10): 891-896.
Razzaque, A., P. K. Streatfield, et al. (2007). “Does Health Intervention Improve Socioeconomic Inequalities of Neonatal,
Infant and Child Mortality? Evidence from Matlab, Bangladesh.” International Journal for Equity in Health 6(1): 4.
Regional Conference on Public Health in South East Asia in the 21st Century (2000) “Calcutta Declaration on Public Health.”
World Health & Population 3, 0-0.
Reidenberg, M. M. (2007). “World Health Organization Program for the Selection and Use of Essential Medicines.” Clin Pharmacol Ther 81(4): 603-606.
Rohitratana, K. (1998). The role of Thai values in managing information systems: A case study of implementing an MRP
systems, Proceedings of the Fifth International Working Conference of IFIP WG 9.4 ─ Implementation and Evaluation of
Information Systems in Developing Countries, Bangkok, International Federation for Information Processing.
Ronsmans, C. and W. J. Graham (2006). “Maternal Mortality: Who, When, Where, and Why.” The Lancet 368(9542): 1189-1200.
Ronsmans, C., S. Holtz, et al. (2006). “Socioeconomic Differentials in Caesarean Rates in Developing Countries: A Retrospective Analysis.” The Lancet 368(9546): 1516-1523.
Ropey, B., J. Ross, et al. (1996). Meeting unmet need: New strategies. Population Reports, Series J No. 43, Johns Hopkins
School of Public Health, Population Information Program, Baltimore.
Rutstein, S. O. (2000). “Factors Associated with Trends in Infant and Child mortality in Developing Countries During the
1990s.” Bulletin of the World Health Organization 78: 1256-1270.
Saloojee, H., S. Velaphi, et al. (2004). “The Prevention and Management of Congenital Syphilis: An Overview and Recommendations.” Bulletin of the World Health Organization 82: 424-430.
Samudavanija, C. (1987). The bureaucracy. Government and Politics of Thailand. S. Xuto. Oxford, Oxford University Press:
75-107.
Sankaranarayanan, R., A. M. Budukh, et al. (2001). “Effective Screening Programmes for Cervical Cancer in Low-and MiddleIncome Developing Countries.” Bulletin of the World Health Organization 79: 954-962.
Say, L. and R. Raine (2007). “A Systematic Review of Inequalities in the Use of Maternal Health Care in Developing Countries:
Examining the Scale of the Problem and the Importance of Context.” BULLETIN-WORLD HEALTH ORGANIZATION
85(943/944): 812.
Sedgh, G., S. Henshaw, et al. ( 2007). “Induced Abortion: Estimated Rates and Trends Worldwide.” The Lancet 370( 9595):
1338-1345.
Shah, N. M., M. A. Shah, et al. (2000). “Searching for Socioeconomic Risk Factors in Perinatal Mortality in Kuwait: A Case
Control Study.” Social Science & Medicine 51(4): 539-550.
Sibley, L. and T. Ann Sipe (2004). “What can a Meta-Analysis tell us about Traditional Birth Attendant Training and Pregnancy Outcomes?” Midwifery 20(1): 51-60.
Siddiqi, S., I. U. Haq, et al. (2004). “Pakistan’s Maternal and Child Health Policy: Analysis, Lessons and theWay Forward.”
Health Policy 69(1): 117-130.
32
Singh, S. (2006). “Hospital Admissions Resulting from Unsafe Abortion: Estimates from 13 Developing Countries.” The Lancet 368(9550): 1887-1892.
Sitthi-amorn, C. and R. Somrongthong (2000). “Strengthening Health Research Capacity in Developing Countries: A Critical Element for Achieving Health Equity.” British Medical Journal 321(7264): 813.
Somyod S, Rungrat P, et al. (2006). Factors affecting ANC in the south of Thailand.
Stilwell, B., K. Diallo, et al. (2004). “Migration of Health-Care Workers from Developing Countries: Strategic Approaches to
its Management.” Bulletin of the World Health Organization 82: 595-600.
Tangcharoensathien, V., S. Tantivess, et al. (2002). “Universal Coverage and Its Impact on Reproductive Health Services in
Thailand.” Reproductive Health Matters 10(20): 59-69.
Taytiwat, P., D. Briggs, et al. (2010). “Lessons from understanding the role of community hospital director in Thailand: clinician versus manager.” The International Journal of Health Planning and Management.
Thailand Improving Maternal, Newborn and Child Health in the South East Asia REgion.
Thailand Health Research Institute (1998). “Health Examination Survey of Thai productive age population –1996/97.” 55.
Thailand National Statistical Office. (2006). “Statistics: Survey of Population Change.” Retrieved accessed 20 June 2006,
from http://www.nso.go.th/eng/stat/popchang/popchg.htm,.
Thanasankit, T. (2002). “Requirements engineering – exploring the influence of power and Thai values.” European Journal of
Information Systems 11: 128-141.
Thanasankit, T. and B. Corbitt (2000). “Cultural context and its impact on requirements elicitation in Thailand.” The Electronic Journal on Information Systems in Developing Countries 1(2): 1-19.
The Nation (2006) “The Nation. Bt30 health fee may be scraped; The Nation. .” Thailand Development Indicators.
Thoresen, S. and A. Fielding (2011). “Universal health care in Thailand: Concerns among the health care workforce.” Health
Policy 99(1): 17-22.
Tien, M., K. LeBan, et al. (2000). Community Workers Incentives and Disincentives: How They Affect Motivation, Retention, and Sustainability. Working Draft.
Turrell, G. and C. Mathers (2000). “Socioeconomic Status and Health in Australia.” Medical Journal of Australia 172: 434- 438.
UNAIDS (2008). Report on the global AIDS epidemic: Executive Summary. Geneva, Joint United Nations Programme on
HIV/AIDS (UNAIDS).
UNICEF (2008). Maternal, Newborn and Child Survival, UNICEF.
UNICEF. (2009). “Statistics by Area: Maternal Health.” Retrieved May, 2009, from http://www.childinfo.org/delivery_care.
html
UNICEF (2010). Levels and Trends in Child Mortality :Report 2010 New York, UNICEF: 24.
United Nations (2004). Thailand Millennium Development Goals Report
Bangkok, Thailand, Office of the National Economic and Social Development Board United Nations Country Team in Thailand.
United Nations Development Program (2002). Human development report. New York, Oxford University Press: 12-13.
United Nations Development Program (2004). MDG Plus: A Case Study of Thailand. New York, UNDP: 16.
United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) (2007). Reduce Child Mortality. Bangkok, Thailand.
Usun, S. (2009). “Information and Communications Technologies (ICT) in Teacher Education (ITE) Programs in the World
and Turkey: (a comparative review).” Procedia - Social and Behavioral Sciences 1(1): 331-334.
Vapattanawong, P., M. C. Hogan, et al. (2007). “Reductions in child mortality levels and inequalities in Thailand: analysis of
two censuses.” The Lancet 369(9564): 850-855.
Veugelers, P. J. and A. M. Yip (2003). “Socioeconomic Disparities in Health Care Use: Does Universal Coverage Reduce Inequalities in Health?” J Epidemiol Community Health 57(6): 424-428.
von dem Knesebeck, O., P. E. Verde, et al. (2006). “Education and Health in 22 European Countries.” Social Science & Medicine
63(5): 1344-1351.
von Schirnding, Y. (2002). “Health and Sustainable Development: Can We Rise to the Challenge?” The Lancet 360(9333):
632-637.
Wagstaff, A. (2000). “Socioeconomic Inequalities in Child Mortality: Comparisons Across Nine Developing Countries.”
BULLETIN-WORLD HEALTH ORGANIZATION 78(1): 19-29.
Wagstaff, A. (2002). “Poverty and Health Sector Inequalities.” Bulletin of the World Health Organization 80: 97-105.
33
WHO (2000). The world health report 2000—Health systems: improving performance. Geneva, Switzerland, World Health
Organization: 3.
WHO (2002). World Health Report 2002. Geneva, World Health Organization.
WHO. (2004). “World Health Atlas.” Retrieved 14 March, 2011.
WHO (2005). Making Health systems Work. Working Paper No.1.: Strengthening management in Low - Income Countries.
Department of Health Systems Policies and Operations. Evidence and Information for Policy. Geneva, World
Health Organization.
WHO (2005). Progress on Global Access to HIV Antiretroviral Therapy: An Update on “3 by 5”. Geneva, UNAIDS.
WHO (2005). “Thailand Improving Maternal, Newborn and Child Health in the South-East Asia Region 2004.” Retrieved 12
October, 2009, from http://www.searo.who.int/.
WHO (2006). “Improving maternal, newborn and child health in the South-East Asia Region.” 77-78.
WHO (2006). World Health Report 2006. Geneva, World Health Organization.
WHO (2007). Report on an International Consultation on Strengthening Leadership and Management in Low-Income
Countries. Geneva, Accra, Ghana Department for Health Policy, Development and Services Health Systems and
Services, World Health Organization.
WHO. (2007). “Trends in Policy Development “ Retrieved 15 March, 2011.
WHO (2007). WHO Towards Better Leadership and Management in Health: Report on an International Consultation on
Strengthening Leadership and Management in Low Income Countries. Accra, Ghana, World Health Organization: 29.
WHO (2008). Call for Proposals. Supporting National Processes for Evidence-Informed Policy in the Health Sector of Developing Countries Geneva, Alliance for Health Policy and Systems Research, World Health Organization.
WHO (2008). Primary Health Care : Now More than Ever. Geneva, World Health Organization: 119.
WHO (2009). Accelerating progress towards achieving maternal and child health MDGs 4 and 5 in South East Asia. New
Delhi, World Health Organisation.
WHO (2009). “World Health Statistics.”
WHS09_Full.pdf.
Retrieved 23 November, 2009, from http://www.who.int/whosis/whostat/EN_
Wibulpolprasert, S. and C.-A. Pachanee (2008). “Addressing the Internal Brain Drain of Medical Doctors in Thailand: The
Story and Lesson Learned.” Global Social Policy 8(1): 12-15.
Wibulponprasert, S. (2007). Thailand health profile 2005-2007. Bangkok, Thailand, Express transportation organization:
288-290.
Wilkinson, R. and M. Marmot, Eds. (2003). Social Determinants of Health: The Solid Facts. Denmark, World Health Organization.
Working Group on Quality of Life and Health Development (2004). 30-Baht for all diseases project: Analysis of the efficiency
and accessibility of health care for grass-roots people (in Thai). Bangkok, Advisory Committee for the National
Economic and Social Development Board.
World Bank (2006). World Development Report 2006: Equity and Development. Washington, World Bank 336.
World Bank (2007). The National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-2011: Key
Contents. Washington, Department of Disease Control, Ministry of Public Health United Nations Development
Programme.
World Bank (2009). World Development Indicators Online. Washington, DC, Development Data Group, The World Bank.
World Bank (2010). Level & Trends in Child Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for
Child Mortality Estimation New York, United Nations Children Fund: 24.
World Bank. (2011). “Measuring Inequality.” Retrieved 15th April, 2011, from http://go.worldbank.org/3SLYUTVY00.
Yanggratoke, S., D. Briggs, et al. (2010). “The Thai–Australian Alliance: Developing a Rural Health Management Curriculum
by Participatory Action Research.” World Health & Population 11(3): 5-16.
Yiengprugsawan, V., G. A. Carmichael, et al. (2010). “Has universal health insurance reduced socioeconomic inequalities in
urban and rural health service use in Thailand?” Health & Place 16(5): 1030-1037.
34
Contributing Authors
Thailand
Adjunct Associate Professor Phudit Tejativaddhana MD, DHSM, MPA (1st Class Honours), FCHSM
Dr Phrutthinun Surit PhD
Dr Nithra Kitrrerawuttiwong PhD
Australia
Dr Karin Fisher PhD
Dr David Briggs PhD
Professor John Fraser MD
Professor Mary Cruickshank PhD
Contributing Editor
Professor Niyi Awofeso, School of Population Health, University of Western Australia’
‘This work was produced by the School of Health, University of New England Armidale, Australia as an output
from collaborative research between the School of Health UNE and the Faculty of Public Health, Naresuan
University, Thailand. Copyright rests with that School and apart from use required by that School and by the
Faculty of Public Health Naresuan University Thailand, any requests or enquiries concerning reproduction and
rights should be directed to that School.
Acknowledgements:
Thank you to the doctor, nurse and patients for their permission to use the photograph on the front cover of
this monograph.
Copyright:
School of Health
Faculty of the Professions
University of New England
Armidale NSW Australia
Published in 2011
ISBN: 978-1-921597-30-5