Primary Health Care a Continuing Challenge

8/6/2019 Primary Health Care a Continuing Challenge

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Publication No. SResearch for PHC Model Dc"'cir;pillcittChantaburi Prov'ince

A,-i*.Atr l"ruining {.*::=ss l{rrFci:*i:r1 I Ieal{h {l::r* E}r:e.:tEt}t!rrtrtr&::hidol L.' nir crsiq: . =9.E::ai irtnd

ISBI{ 9?4-58{r-211-8


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Bangkok, Thailand : May l, 1987


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T-TII lll l an effort to design a workable model for Primary Health Care service delivery,the ASEAN Training Centre for Primary Health Care Development in cooperation with MahidolUniversity, the Ministry of Public Health, other concerned ministries, and the Japan InternationalCooperation Agency launched the Research for Primary Health Care Model DevelopmentProject in Chantaburi Province.The thrust of the Primary Health Care Model Development Chantaburi Province projectis on the identification, training and fielding of a group of young, energetic, civic-minded anddedicated Thai university graduates. These graduates, having been awarded the title GraduateHealth Volunteer will operationalize the model.The project will enable the Centre to test the viability of different strategies towardan effective Primary Health Care Delivery programme and at the same time identify the limi-tations of these strategies while determining their replicability across the country. The projectwill also highlight the role and potential of developing leadership skills in health and communitvdevelopment, in the graduate health volunteers (GHV).It is our hope that the GHV will significantly contribute to the resolution of manyobstacles that have impeded the full development of primary health care in Thailand. Byselection of graduates from various universities and degree programs, future leaders from all

professional walks will become knowledgeable of the intricacies of health delivery. The GHVwill likely. be sympathetic to health issues and policies as they become the nations decisionmakers. Thus not only health professionals, but lawyer, teachers and engineers will be ableto make worthy contributions to health care problems in the future. This however, is longterm benefit of the program. More current benefits of the GHV are as follows :l) Increasing the number of health workers in rural areas, thereby decreasing thedisparity between urban and rural health status. As an indicator of the differential in urbanand rural health status, current infant mortality statistics show 45,/1000 death rate for Thailand,while only l3l1000 for Bangkok.2) The GHV is a low cost answer to the problems of financial constraints coupledwith manpower shortages. With ll million people in Thailand living below the poverty line,it is an insurmountable task to supply adequate health services nationwide. Through the GHV,basic services, such as maternal health, immunizations and sanitation will be within the financialreach of the nation's poor. The GHV, a cadre of new university graduates has been assembledand trained in an effort to assuage the perennial problems in primary health care delivery thathave beleaguered the country for the past several decades.In object optimism, I dare say that the Graduate Health Volunteers are Thailand'sanswer to the World Health Organization's challenge of Lead-ership Development for HealthFor All.

Krasae Chonawongse, M. D., Dr. P. H.DirectorATC/PHCMav L 1987


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I operation staff of the Research on Primary Health Care Model DevelopmentProject - Chantaburi Province wish to acknowledge the invaluable cooperation and assistancerendered to them by the following :- The provincial governor, the provincial chief medical officer and his personneland the various related government agencies in Chantaburi Province without whose dedicationand commitment the project cannot be operationalized.- The people in the study villages in Chantaburi for finding a place for themboth in their homes and in their hearts.- The Ministry of Public Health for their hiehly esteemed technical advise.- The Mahidol University in its dynamism to provide necessary back-up support,- The ASEAN Training Centre for Primary.Health Care Development for itsunfailing guidance and direction; (operationalized, hearts, advise)- The Japan International Cooperation Agency for the much - needed andequally appreciated financial assistance; and, last but not the least to;- The Graduate Health Volunteers for spending one year of their youth in theremote villages, living under sparlan conditions in their effort to be leaders in Primary HealthCare Development.


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PrologueAcknowledgementThe ASEAN Training Center for Primary Health Care DevelopmentThe Japan International Cooperation AgencyIntroductionProject OverviewHealth profile-Chantaburi ProvinceProject Activities

Situation Analysis of Primary Health Care and CommunityDevelopment Activities in Chantaburi Province

Training of Graduate Health VolunteersResearch and Development ActivitiesSeminars

Summary of the Project ActivitiesProject MilestoneConclusionEpilogueAnnexes

Annex l: Publications on Research for Primary Health CareModel Development, Chantaburi Provinceby the ASEAN Training Center forPrimary Health Care Development

Annex 2: GlossaryAnnex 3: Project Financial Statement

The Authors

PageI47EIlot2

2627

4362E5E79396g799rol

101lo3ro4


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THE ASEAN TRAINING CENTER FORPRIMARY HEALTH CARE DEVELOPMENT(ATCIPHC)

IEil'lI I[S IASEAN Training Center for Primary Health Care Development (ATC/PHC)was established in October, 1982 as a part of the ASEAN Human Resources DevelopmentProject under the technical cooperation of the Government of Japan. A collaborative projectbetween the Mahidol University and the Ministry of Public Health, the ATC/PHC is supportedby the Royal Thai Government (RTG) and collaborating agencies. The ATC/PHC is workingclosely with the ASEAN Secretariat to the Committee in Social Development, Expert Committeein Health and Nutrition, the Japan International Cooperation Agency (JICA), the South EasrAsia Medical Information Center (SEAMIC), the World Health Organization (WHO), theUnited Nations (UN) health related agencies and concerned non-government organization (NGO)

The ATC/PHC functions as an international institution for human resources developmentwith the ultimate goal of serving as a fulcrum for exchange of knowledge acquired and exper-iences gained in the field of primary health care and social development among member'countriesof the ASEAN. The Center concentrates on a manifold of specific objectives : training of allcategories of health workers (from policy makers and policy makers to-be, down to the primaryhealth care cadres), enhancing their managerial potentials and functions; Jesearch and modeldevelopment for primary health care in the different levels of the health care delivery system;strengthening of infrastructure support to meet the training needs of the target population bothlocally and internationally among the neighboring ASEAN countries; and, the establishmentof local and international networks of information exchange on primary health care and relatedactivities.Administratively, the center operates under the Mahidol University, the forerunnerof medical and public health education in'Thailand. The Mahidol University has been namedin honour of the pioneering activities of H.R.H. Prince Mahidol of Songkhla in the establishmentof a system of medical and public health education in the country. H.R.H. Prince Mahidolwas the father of His Majesty, the King, Bhumibol Adulyadej the present King of Thailand.The Centre's policy is guided by the Executive Board whose membership comprised of theMinistry of Public Health, the Mahidol University and the Director of ATC/PHC amongstothers, serving as members of the Board.Of date, the ATC/PHC is in full operation, in anticipation of the multifaceted challengethat lies ahead; at the Mahidol University, Salaya Campus in Nakhon Pathom provincc ol'Thailand.

Over the short span of its five-year operation, the centre has proved as the ever-dynamietraining institution, it has envisaged to be; in the development of PHC cadres and of potentialPHC development managers and policy makers both locally and in the neighboring Aseancountries. Likewise, the centre has fulfilled its committment on functioning as a springboardfor resource mobilization and in the strengthening of regional cooperation and integratron.It has also prided itself with its role as a facilitator on technical cooperation and technologicaltransfer at intra-country and inter-country levels.

The ATC/PHC was established along side with four Regional Training Centres (RTC)at the request of the Ministry of Public Health. These four RTCs are located in Khon Kaen,Chonburi, Nakornsawan and Nakorn Srithammarat provinces.


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ffiffiffiWffiil#ffi Ciovernment of Japan through the Japan International Cooperation Agency(JICA) has committed itself to a dual channelled flow of support to the ATC/PHC : grant-in-aidand technical assistance. The grant-in-aid was mainly in the form of capital costs at the initialconstruction and setting of phase of ATC/PHC. The technical cooperation, on the otherhand, is concentrated on all necessary technical support in the operationalization of variousproject activities conducted by the centre. This includes costs in the conduct of trainingprogrammes and seminars, research, model development, equipment, fellowship and theassignment of experts.The JICA's technical assistance on model development for the PHC activities hasushered the formulation of the "Project on Research for Primary Health Care Model Develop-ment-Chantaburi Province", in January, 1985.


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INTRODUCTION---lI III ltne 1978 declaration of the Alma Ata member countries of WHO have sworn andsubscribed into the attainment of the goal of Health for All by the Year 2,000 (HFA/2,000)through primary health care approach. As a WHOmembercountry, Thailand was no exception.The country has very slowly but very steadily made considerable progress in saturating itsvillages with a variety of strategy in an effort to maximize PHC service delivery. Out of thesestrategies the concept of village health communicators (VHCs) and village health volunteers(VHVs) has evolved. VHCs and VHVs are selected members of their particular villages whohave indicated willingness, capacity and capability to facilitate health service delivery on avoluntary basis.After undergoing training programmes specific to their voluntary job description, aVHC is responsible for the establishment of a network of information, communication. and'education (IEC) for health; whereas a VHV in addition to his,/her IEC activities is expectedto render simple curative and rehabilitative medical care at the same time strengthening thereferral systems with local health authorities whenever attending to advanced and complicatedcases' Additional thrust in the field of research, specifically on model development for pHCactivities were given priority consideration, an example of such initiative has ushered theconception of the project on Research for Primary Health Care Model Development - ChantaburiProvince, otherwise known as the Chantaburi Model Development Project. The ATC/pHCin collaboration with the Ministry of Public Health, the Japanese Government through JICAand WHO, and in full awareness of the urgency of the need for conceptualizing an MCH andEMC model to enhance PHC service delivery, has launched the Chantaburi Model DevelopmentProject in January 1985.Located 245 kilometers Southeast of Bangkok, the Chantaburi Model DevelopmentProject not only seeks to strengthen over-all PHC activities, but also carries the additionalmandate of provision of training for newly graduated college and university students in an

effort to prepare them as potential leaders in health and health-related activities.Chantaburi has been specifically selected as the project site owing to its unique geo-graphical scattering of villages and houses within its rural communities providing a greaterchallenge in establishing networks for implementation of pHC activiries.


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10

tffiII .1 llg lproject on Research for Primary Health Care Model Development - Chantaburiprovince has begun its inception in January 1985, after a series of brain-storming session andconsultative meetings among ATC staff responsible for the project, concerned officials of theMinistry of Public Health and the local authorities from Chantaburi province.The over all goal of the project is the conceptualization and operationalization of aworkable model of PHC service delivery which is problem - specific, neecl-based and communityoriented to the general population of Chantaburi province with a thrust on maximum utilizationof existing community resources.The project has a four-fold objectives :L The study and development of a model to stredgthen maternal and child health(MCH) and essenrial medical care (EMC) activities in pHC :2. the conduct of a feasibility study on the efficiency and effectiveness of utilizinggraduate health volunteers (GHVs) in primary health care and community development :3' the study of management information system (MlS) applicable to the adminis-tration, management, implementation and evaluation of pHC activities : and,4. the study of the impact of socio-economic and cultural factors in referenceto the effective implementation of PHC services in chantaburi province.The project has five major activities :

I ' the conceptualization and operationalization of various model in PHC serviceinto consideration a comparative study in the light of utilization and non-utilization2. training of GHVs,3. research and development,4. seminars, and5. monitoring and evaluationThe project has been formulated over a total project life of three yearsapproximate budget of Thai Baht 1.7 million (US$65,3g4; :y l0 million) per year of

delivery takingof GHVs,

an


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1Ig*.8!*:il

/2EE


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12

EK$ptovince of Chantaburi can rightfully claim itself as a fruit basket of Thailand.Noted for its vast orchards of rambutan, durian, mangosteen, pineapple, a visitor is always welcometo eat into his heart's content these tropical fruits without payment, right within the backyard ofany orchard owner. However : it will not do justice to the province to highlight only on its fruit-bearingcapability, for over and above its fruit produce, Chantaburi also abounds in colored gems,precious rubies, sparkling toplzt midnight-blue sapphires and lush-green emeralds that attractboth tourists and traders alike. Adding to its economic potential are the rubber plantation thatabounds the province. chantaburi may therefore well be described as properous..

The Province has a total estimated population of 374,560 and an estimated land areas at6,000 sq. kilometer. It receives approximately eight months of rainfail per year.Geographically, the population are scattered amidst fruit orchar.ds and gem-pits renderingcommunication and access to health services, difficult. People have always been trade-orientedleaving no time for commercial{ype of activities. Livelihoods take people away from home duringthe entire waking hours, hence the lack of stamina and disinterest for coqgregation and community-oriented projects. In addition, there is a high migration rate as a result of existing job opportunites,the migrants being not only economically disadvantaged but also ignorant as to accessibility ofhealth care facilities and indifferent to any participatory movement in their rew communities.


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13

ORGANOGRAM OF THE PROVINCIAL ADMINISTRATION

It.!T ----IIIII

IIII

Line of administrationLine of coordination and/or supervision


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t4

r-la--IFHHj-rr-Fi-azts&Irdlt(HFrt\t''rfrFFHaFlzFrQz-


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15

ORGANOGRAM OF THE PROVINCIAL HEALTH OFFICE

STD* : Sexually Transmitted Diseases


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17Demographic DataPopulation by Age Group and Sex (1986).Total PopulationMale

Female398,937202,799196,138

Age Male (90) Female (90) Total (90)0-45-9

l0-14t5-2425-M45-59>60

4.575.325.36

10.1913.556.993.27

4.445. l65.68

10.93t3.927.233.39

9.0110.48I1.0421.1227.4714.226.66

Total 49.25V0 50,75V0 100.0090

The above table indicates that population belonging age group 25-44 comprises the highestpercentage and those belonging 60 and above comprises the smallest percentage

HEALTH PROFTLE (198s)Health resources and health manDower

HealthResourcesDistrict

RegiohalHospital

DistrictHospital

MedicalCenter

HealthCenter

CommunityPublicHealthOffice

MuangTa-maiLam-singhKlungPong-Num-RonMa-Kam 6

II

IIIII

l329

6t2l3l3Total 86


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t8

HealthManpowerDistrict Doctor Nurse

Public HealthOfficer * Doctor NursePublicPop.n Pop.nHealthOfficerPop.n

MuangTa-maiLam-singhKlungPong-Nam-RonMa-Kam

65 2822t2l9l9523ll0

656522292736

l:1,458 l:366 l:1,458l:56,207 l:9,367 l;1,729l:30,222 l:3,358 l:1,373l:49,366 I :5,485 l:1,702l:13,902 l:3,022 l:1,878l:42,639 l:4,263 l:1,184

Total 345J 244 l:5,319 l:1,156 l:1,634*Public health officers include ssnitarians and midwives.

PRIMARY HBALTH CARE HEALTH MANPOWERVOLUNTEERSVillage Health Communicator (VHC) and Village Health Volunteer (VHV) Coverageby District/Tambon/Village

VHC Coverage VH! CoverageDistricl Tambon Village Tambon Village No.of

vHcTambon Village No,of

vHvMuangTa-maiLam-singhKlungPong-NamRonMa-Kam

9197l0o

8

78r8838836784

646l4s2247


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T9EXISTING HEALTH CARE FACILITIES

Table 1.3 Health Care Facilities

TypePublic Health CenterHealth CenterCommunity HospitalRegional Hospital

Pregnant women seldom avail of existing ante-natal facilities hence there is inadequatecoverage with tetanus vaccination and poor nutrition information which have negative effects toboth mother and child. This lack of utilization of existing health facilities may be attributed eitherto lack of adequate information on the part of the mothers or on apparent inaccessibility of thehealth facilities

Table 1.1 Nutritional Status of Children Age 0-5 Years

683fI

Cetcgory No. Volst degree malnourished2nd degree malnourished3rd degree malnourishedNarmal

4,691436l0

17,219

20.91.90.1

77.lTotal 22,356

The present nutritional status of children under 5 years of age leaves much to be desired.Although there are statistically insignificant number of cases suffering from 2nd degree and 3rddegree malnutrition,20s/o of these children are within the lst degree malnourished bracket.

100

PRIMARY HEALTHNutrition CARE ACTIVITIES BY DISTRICTNutritional Surveillance DataDistrict Number of Tagetgroup, under 5yrs.old.

Number of Targetgroup weighing byVHC/VHVPercentage of

coverage

MuangTa-maiLam-singhKlungPong-Num-ronMa-kam

6,6076,',?411,9823,6386,3702,818

4,9646,6501,8793,6285,6792,766

75.198.794.899.789.298. l

Total 2E,156 25,566 90.E


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20Immunization

Percentage of Coverage as Compared with the Target GroupDistrict BCG DPT oPv Measles Rubella TT*MuangTa-maiLam-singhKlungPong-Num-RonMa-kam

258. I I7 5.7386.6967.95

I 10. l464.77

86.2486.1 183.379s.3482.1974.70

85.8785.0982.4890.4382.99'73.29

51.3256.3470.9s60.8547.2442.96

60.3569.0856.0897.2289.8464.32

tr7.2l45.6354. l054.0056.1 130.70

Total r24.80 84.86 E3.92 49.22 75.40 43.83* Tetunus toxoid in pregnant womenFamily Planning

No.of Acceptors Rate of activeusersDistricl No.Targetgroup Temporarytype Permanenttype

MuangTa-maiLam-singhKlungPong-Num-RonMa-kam

12,23913,0053,7536,6448,8675,157

7,4557,2492,3003,8435,1942,952

2,3413,519

9351,5902,154I,178

80.049082.809086.2OVo81.7'lolo82.87V080.0990

Total 49,665 28,993 ll,717 82.0090NB. Target groupTemporary =Permanent =

Sanitation and Water supply

Married women of reproductive age (15-44 yrs.)IUD., Pill, Depo injection, NorplanrVasectomy, Tubal ligation

Total numberhouseholds (house)

Latrine Adequate drinkingwateristrict with Vo withMuangTa-maiLam-singhKlungPong-Num-RonMa-kam

9,32315,3964,5145,944

I 1,3336,799

7,7546,81I3,5363,4403,1 l53,550

83. l744.2478.3357.8727.4952.21

5,8043,9333,0972,4956,227

556

62.2525.5568.6041.9854.95

8. l8Total 53,309 2E,206 52.9r 22,112 4r.4E


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21Health Education in the Village

Health l-ducation by Health Official (times)Dislricl Ocl Nov( r9Es) Dec Jan l'eb Mar Apr May Jun( 1986) July Aug Sep Totrl

66 666183 1502464 46454 6744l 60447 655

55 51 52 60 58 61 59 50 52l2t t24 109 tt2 I l8 I l5 l2o t26 tzg37 38 39 37 26 39 35 34 5356 54 58 56 55 57 58 56 5750 51 49 52 51 53 52 51 5353 5't 58 54 s5 56 55 55 56

50t20385650

54

J2I2>39)t5l55

MuangTa-maiLam-singhKlungPong-Num-RonMa-kam

Total 372 376 373 374 37E 373 381 444 4565

Health Education in the Village by ! HCl! H! (times)Oct Nov

( l9E5)Dec Jan I'eb Mar Apr May Jun

( l9E6) J uly Aug Sep Tolal54 6354 636105 t24Bt2 23648 53757 6294t 504

53 sl 55 53 52 54 5l s2 53 56 5253 51 55 53 52 54 5l 52 53 56 52104 to2 106 103 103 t06 t04 103 105 104 10319 20 2l 20 2t 22 20 20 2t 22 t844 45 43 46 43 45 42 46 45 46 4452 53 5l sZ 53 54 50 51 51 53 5l42 43 41 44 42 43 44 40 4t 42 4l

MuangMuangTa-maiLam-singhKlungPong-Num-RonMa-kam

317 37m2J1712ll14lE1714otal 314


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23

MAP OF THB STUDY TAMBONS

o*9n'rycc

1985-1987 Research areasin Chantaburi Provincea Areas with GHVso Areas without GHVs


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THE MAHIDOL UNIVERSITY

rilm,r:r] nulk"t'rDr. lVqtth Bhamorapravati, RectorMahidol University

THE MINISTRY OF PUBLIC HEALTH

Dr. Amorn Nondasuta, former PermanentSecretory of State for Public Health who hssgiven his whole - hearted support to the conceptof PHC model developmentTHE ATC/PHC

From left to right, Dr. Som-arch Wongkhom-thong, project operqtion manoger, Dr. OrapinSinghadej, associute director with Dr. KrqsaeChanowongse, director of ATC/PHC

AND, THE JAPAN INTERNATIONAL COOPERATION AGENCY

HAS l-n LJN('Hl:l)(

Prof. Masami Hqshimoto, Japanese NationalTeam Lesder on ATC/PHC project receivingq token of appreciation from Dr. Som-qrch'fFIE PROJIC'I ON RtrSI]Alt('tl l;OR I'HC MODELHAN'l'AIIURI PROVIN('lr IN .InNUARY l9u5 DEVELOPMENT,


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i.ll:,\ ll1 i i: \ "" t.\.f$$- ${a }}$f.{}\ *,\,{:R,.CHANTABURI . THE FRUIT BASKET OF THAILAND

An abundance of tropical fruits - durisn,mangosteen, rambutqn qnd othersTNCOME TOPOGRAPHY

MIGRATION

A large number of poor migrants come to thearea each year

Rubber trees qre also a major source of income The house are sparsely distributed

RL,LIGION

Buddhism is the principal religions belief


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SELECTION OF GHVs

\heir com-he candidates sitting for their written exams Interviewing the candid(ttes for tmit tment and leadershipOF GHVsRAINING

Successful candidqtes receive theoretical traininson PHC's community development at ATCPHCTaking notes.........

STUDY T'OUR

Exposure of the GHV with the villager duringtheir study tour Surprised to see sppropriqte technology, ,,bio-gqs" ........ how the villagers turn animal fecesto energy


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They always work closely with the health centerstaff They also communicqte with other officers

He begins his activity by conversing with thevillusers ......familiarizes herself with the community

It's time to introduce social change. ',We haveto organize our community..," Discussion with the villogers on strengthenin7com munity orgsniza t ion


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()ryutti:.ittg d Iroinittg course Jitr tha villttgers

I ) r o trt r t t i n g I o ca I a p p r o p r ia t e t ec' h tt o kt gy

Promoting efJ'ec'tive communical ion t hroughvilloge broadcosting statio n

Explaining the necessity of cooperative move-tnent

n PHC family model initiated by a CHV aJterreceiving the certificate from the governorT'he CIIV also heals


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Dr. Som-boon Kietinun, teom leqder of MCHresearch in a resular visit to the heqlth center Dr. Som-qrch Wongkhomthong, project opero-tion manager in front of the field stotion

Asst. Prof. Boonyong Kiewkqrnkq givingqdvice to ensure technology transfer ut thevillage level.A dentist with the ossistance of a GHV de-monstroting dentql educotion in the communily.

Dr. Som-boon Kietinun promoting "The FourHesrt Chamber Community DevelopmentCampaign".

The border soldiers also playing an importantrole on community development activities.


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Dr. Krasae Chanawongse openingat RTC Chonburi

Members of the research teams from the pro-vince

Regular meeting ot the provincial public healthoffice.

the setninar Dr. Chalong Kuan-Har and Dr. BooncheiBhoomboplab from the Chantaburi provincialpublic heqlth office.

An informal night-session among stsff atSomdej hospital, C honburt


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.tHF. SENIINAR ATKRATI\G W A'TI'R} AT,t-

Presen to t ion o f resea rc h ac t iv i t ies

Group presentation by the CHVs and a researchteqm leader

I understqnd

That's funny!I don't think I agree with you

Recrestion at night after a long doy of dis- All work ond no play makes the teams dullcussion and insctive.


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THEY CAME TO VISITTHE PROJECT

Dr. M. Matsuda (left) ond Mr. M. Nqkamura(right) in site assessment visit to Chantaburi Japaness journalists from Mainichi DailyNewspaper and Tokyo Newspaper observingGHV activities

ASEAl,l representatives joining the fieldacl ivit ies MPHM students conducting field study inChsntaburi

A group of medicol and nursing students fromJapan on their way to Chantaburi Dr. Msrk Belsey, chief, MCH/WHO Heud-qusrter Genevq giving expert advice to theresearchers.


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THE END OT THE SECONI)YEAR ACTIVITIES

Dr. Antorn Nondasulu, 7-he forrner PermunenlSec'retary of Public Health and Dr. SuchintPhalapornkule, the Deputy Secretury listeningto the proje('t briefing at Chuntuburi

Presentution oJ evuluation oJ'the proJe('!uctivities by the evaluution team J'rom theI'-ut'ulty, oJ Publit' Health, Muhidol University

Dr. Nutth Bhurnarapravati and Dr. KrasaeChunuwongse reviewing the GHVs performanceund the reseurc'h uctivities

A GHV receiving certificate from the RectoroJ Muhidol University

AJter one year oJ' being GHVs, they are reuclyto be Health For All leadersGruduution day


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The editoriql staff from left to right; Dr. KrasaeChanawongse, director of ATC/PHC, Dr.Rosa Corqzon F. Cosico, Visiting ProfessorFaculty of Social Science & Humanities, Mohi-dol University and expatriote consultant to theResearch for PHC Model Development Pro-ject Chantaburi Province and Dr. Som-qrc'hWongkhomthong, the operq!ion munager ofthe project.


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25

PROJECT ACTIYITIES


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27

SITUATION ANALYSIS OF PHC AND COMMUNITYDEVELOPMENT ACTIVITIES IN CHANTABURI PROVINCEASSESSMENT SURVEY OF THE STUDY VILLAGES ON PRIMARY HEALTHCARE (PHC), MATERNAL AND CHILD HEALTH/FAMILY PLANNING (MCH/FP),

ESSENTIAL MEDICAL CARE (EMC) AND COMMUNITY DEVELOPMENT (CD) IN THESTUDY VILLAGES._ CHANTABURI PROVINCEIn September 1985, as the project enters its first year of operation, the first group ofGraduate Health Volunteer (GHVs) in collaboration with a team of researchers*...'...conducteda baseline survey for data gathering on various aspects of PHC, MCH/FP, EMC and CD activitisin the 168 villages involve in the project.

Basic information on the sample villages were collected utilizing form ATC/CMD 003**.......and ATC/CMD 004 'r'**..... this survey covered 168 villages, 23 sub-districts and 6 districts.An assessment of the extent and the nature of participatory activities of the villagecommittees were likewise studied and analyzed in an effort to measure community involvementand community commitment in community development.* Comprised of ATC/PHC staff, the PCMO staff and the provincial hospital staff*'t ASEAN Training Center/Chantaburi Model Development/O03(Data collection form Village Committee)ASEAN Training Center/Chantaburi Model Development/OO4(Data collection form foi Health Centre)*tr*

BASIC VILLAGE DATA IN CHANTABURI PROVINCBThe population distribution of the research areas was noted and the data according to

different categories, is presented as follows:Table 2.1 Population in Research AreasItem slo

HouseholdsFamiliesPopulation0 - I yearsI - 4 years

5 - 9 Yearsl0 - 14 years15 - 24 years25 - Myears45 - 49 years50 - 59 years60 yearsWomen in Reproductive Age

(15-45 years)Married WomenNewborn babies

14,93317,27777 511

1,6055,4778,2749,314

16,637t9,9365.,6525,7454,893

17,753ll,ln

1,597

2.17.1

10.712.02t.425.',l

7,37.46.3


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28Item

MalgFemale

DeathMaleFemaleHealth personnelVHCVHVMalaria VolunteersVillage Health CrafrsmanTBAMonks and others

School ChildrenPre-school childrenElementarySecondary and up...

N:819778

420245175

|,6921,339

169l0l4230t2

12,881473t2,o9l317

Vo

51.348.758.341.779.110.05.92.5l180.75. t

93.92.4

SPATIAL DISTRIBUTION OF HOUSESAs mentioned previously, one particular problem in community health development inChantaburi province is the scattered location of houses. The folowing table shows the distributionof households in the sample villages:Table 2.2: Distribution of house in the study villages7590 as one As several Sparse No answer TotalModel 4!-----JroupsN alo N Vo N Vo N-qo

I234)6

t49;7

40.0 t6428.6 t2ll4.6 1331.8 5

45.7 523.537 .5 l16l.l 729.5 2122.7 l0

t4.334.438.947.745.5

13

8

76.8

18.2

35t732l84422

Total 32 l9.l 6l 36.3 s4 32.1 2l 12.5 168It must be said that the majority of villages in all six categories show a pattern of housesdistributed either sparsely or as several scattered groups. ..


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29

WATER SUPPLYThe villages were further studied for identification of water sources and it was observedthat less than 7090 of the study villages have sufficient water supply systems. The detailsmay be seen in the following table.Table 2.3 : Water Source and Supply in Dry Season

Model Natural walel Soulces Constructed \[ ater S0urceo.ofvil-lages

vit-lages

Vo Suffi- Vo No.ofcient watersource

s/o Suffi- ulo No.ofcient waters()urce

vil-lages

I23

)6

35ll5Zl84422

JIIJ)zt8JOtt

2la8l0l9o

8555l86

20l1398

Jt)Iti

* 88.67 6.5100.0

t00.08t.877.3

*6'7.769.225.055.652.83 5.3

*48.647.156.155.652.354.6

+47.162.521 .850.078.350.0

))20492450l9

l76

t8l0ZJt2

Total 49.7 2t7 52.4 41 53.1 |]4

The table showed that 88.690 are dependent on natural water supply of which only6'l .70/o of the population find their water supply adequate. This inadequency has provided agreat room for health problems. Those who can afford have to buy water from outside theirvillages, whereas those who can not have to make the best out of their available supply. Thewater problem may also be a great contributory factor to the high incidence of ,diarrheal diseasesamong the under five age groups.

OCCUPATION/INCOME/RESOURCBS ANDENTERPRENEURSHIP ..Further exarnination of the communities revealed that the principal occupations were vegetablefarming and fruit growing followed by rice farming, as shown below:

IJ7.540

Table 2,4 : Occupation of the study communitiesOccupationVegetable crops farmingFruit growingRice farmingRubber plantation/ForestryFisheriesCottage IndustryOthersTotal

Vo

27.626.519.79.1J. t2.r

I 1.3100.0


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30On examination of the yearly income of the study population, it was found that villagersin this region were relatively well off and prosperous. The majority of households earn more

than 10,000 Bahts a year and it was only 5.490 that have an income of less than 10,000 Baths a year.LAND OWNERSHIP

Assessment of land ownership revealed that a large portion of the sample households havetheir own land area. There are also some who had to farm on borrowed land space.Table 2.5 : Land ownershiP

Ownership statusOwn landOwns and borrows landBorrowed landOthersTotal

o/o86.84.6

6.02.6100

It may be deduced that the community values ownerships of land and property. It canalso be assumed that a great majority of the community are financially stable as the land they ownedare either farmed by them or leased out as a means of livelihood.

As regards to identification of resources and enterpreneurship in the village, the privatesector was studied and the existing type of enterprises were found to be mostly food and grocerystores(84.9g0). Rice mills comprise 8.390, shops that retail agricultural products 5.690. The differentkinds of shops and stores are an shown below:

Table 2.6 : Types of shops in the villageTypel. Crocery stores2. Food stores3. Motorcycle repair shoP4. Agricultural tools shoP5. Electrical appliances repair shop

Average no.per village4.41.70.40. l30.1


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31

PUBLIC FACILITIES/SERVICESData was also obtained on the availability of public services in the study village. Thefollowing table show that less than half have primary schools and temples. Only 23.8Vo ot

"'illages had an information center and there were assembly halls in only 16.790 amongst thetotal number of villages. Further details may be clarified in the following table:Table 2.7: Public Services in the village.

Public Facilities

Primary SchoolTemplesReading CentreVillage HallHealth CentreKumnan OfficeRice BankMiddle SchoolTambonDevelopment CenterTambonAgricultural CenterBuffalo Bank

Villages withfacilities

Established duration (years)l-5 6-10 l0 and more

N/U6940282718955

^

I

olo

41.74t.l23.8t6.'7l6.l10.85.43.03.02.40.6

N

2.AJ+IJ2692tI

2I

Vo4.32.9

15.0t7 .9

J. t22.2

60.0

olo

2.985.046.4

7.4JJ.J10.040.020.050.0

100.0

NJ26I4

67 55.765 94.2l0 35.724 88.98 44.43 60.0I 20.02 50.0

Total r00.0 1) 180 65.2It could well be that a combination of factors such as the scattered location of housesand a relative lack of public facilities foster an obstacle towards communal closeness and

social organization, in spite of the apparent economic wealth of these areas.

SOURCES OF PUBLIC INFORMATIONTable 2.8 : Major source of information in the study villages'

Major source media

E.76.1

l. Radio2. T.V3. Newspaper4. Temple5. Villagers

79.814.94.20.60.5

Total 100.0


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32The communities were also studied in order to identify the major source of informationfor the villagers. lt was found that the primary media was the radio (i.e. 79.890). This wasfollowed by television, representing some of the more affluent groups.' It was interesting to

observe that only a very small percentage (0.690) stated receiving information from the templeand other villagers. In this respect, these areas may by noted as being rather atypical whencompared to the average rural society. Details are shown in the foregoing table.

Table 2.9 : Development Funds and Organization in the Study VillagesTotal

N No.pervillage

Established period (years)l'undsand Organizations l-5 6-10 l0 and morel. Health (total)l.l Drug Cooperatives1.2 Sanitation Funds1.3 Health Card Fund1.4 Nutrition Funds1.5 OthersNon-Health (total)2.1 Agricultural Cooperatives

2.2 Savings Cooperatives2.3 OthersOrganizations (total)3.1 Village Committees3.2 Housewife group3.3 Agricultural Youth group3.4 Funeral group3.5 Youth group3.6 Village Scour

210I t3253l25l628l0

9933016688l98

26

0.70.10.20.10.020.10.050.050.990.50.10.10.050.2

I2

A

2III

't4

70.0

l.lr 3.0

r5.3

lll25JI25

z1

98.2100.0100.0100.0

20.07l .8

162 9'7.685 96.6r 9 82.6l8 94.71 8'7 .58 30.8

1.8

10.0 722.2

1^L.+

4.45.3

12,553.9

2.

3.

4Total number oJ villages : 168

It can be seen that the agricultural cooperatives and related groups are the oldestorganizations, as depictive of the central region. The second leading sector is the drug cooprn:tives which are observed as being the oldest and comprising the highest number of health I'unds.Next, the existence and status of village development plans wcre assessed and l'indings

state that lhe majority of villages i.e. 86.3o/o has plans for four.or less, development acti\itics.As far as completion of tasks were concerned, only 30.3olo of the plans in these groups havebeen finished, and a large majority hal'e not been started yet. Unfortunately, data was notavailable to examine the impact of those plans that were accomplished, in terms o1' success andfailure.


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33ILLNESS BEHAVIOUR OF THE COMMUNITY

Investigation was carried out as to the preferential attitude of the community in seekingadvise,/curative measure for common illnesses in their family.

Table 2.10 : First choice of treatment for common illnesses

l Health centre2. Consult VHV or drug cooperatives3. Self-treatment or buy from drug store4. Private clinic/private hospitals5. Community hospitals6. Others

4t.726.22t.44.84.71.2

Total 100.0The above table revealed that illness behaviour, ie, in term of first choice of consultation,

the study population had listed the health centre as their first choice, follow by the VHV ordrug cooperatives. Drug cooperatives are store outlets for essential drugs in the country. Thesestores are usually supervised by the village head who is responsible for the logistics of drugsupply and distribution to the sick villager. Essential drugs for common illnesses are dispensedat a nominal price, the proceeds of which are utilized as revolving fund to ensure availabilityof drug supply in the community. The drug cooperative functions under the over all responsibilityof the Health Center within the locality.HOUSEHOLD DISTANCE FROM THE NEAREST HEALTHFACILITY

Table 2.11 : Distance from the nearest health centre.


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34COMMUNITY PARTICIPATION

ln an effort to assess the extent of community participation and the amount ofcommunity involvement in the study villages, several studies were undertaken by the GHVsand the research teams involving the village commirtee (VC). The VC is composed of villageheadmen and clutstanding and dedicated villagers in service to the community. The followingtable shows the frequency of cooperation given by the village committee (VC) to the VHVsand VHCs.

Table 2.12 : Frequency of Cooperation Given by the Village Committee to VHVs andVHCs

Full Participation Giving SupportFrequency NVoNo/oNone 50 29.8 62 36.9Once 43 25.6 26 15.5Twice 29 17.3 31 18.5Three times 20 11.9 25 14.9Four times 15 8.9 12 7.1Five times 2 1.2 8 4.7Six times 5 3.0 2 1.2Seven times 4 2.4 2 1.2

Toral 168 100 r6E r00Subsequently, analysis showed that as the mean, one Village Committee would participatefully in 1.7 activities and the same number was state (i.e. 1.7) also for the activities that weregiven support.

COMMUNITY ACTIVITIES GIVEN SUPPORT BY THEVILLAGE COMMITTEEAs regards to the type of activities where the Village Committee members gave support

or cooperated fully, the majority was concerning the setting up of the community financingmechanisms (i.e. 46.40/o). ln 42.9V0 of the sample areas, Village Committee members also gavesupport for nutrition surveillance. The details are as shown below:Table 2.13 : Type of Activities Given Cooperation by the Village CommitteeActivities Full Participation Supported No. Participation

l. Establishing community Funds 46.4 19.0 34.52. Weighing children I l.9 42.9 45.33. Preparing supplementary food 5.4 19,6 75.04. Promotion of medicinal herbs 6.0 10.9 83.15. Birth survey 26.8 13.7 59.56. Death survey 26,8 14.9 58.37. Providing health information 24.1 28.0 47.78. Analysing and solving health problems 27.4 17 .9 54.7

Total 21.5 20.6 s7.9


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35From tl.re above table, it can be seen that with most of the villages, the Village Com-

mittees were rather inactive in health development and health promotion activities.Consideration was also given to the frequency of Village Committee meetings and it

was observed that in most of the villages, VC meetings were held regularly, complete with aschedule and recorded minutes. The only discrepancy noted was the irregular attendance ofsome of the committee members. (see following table).

Table 2.14 : Village Committee MeetingYes Total

VC Meeting Informationl. Meeting schedule I 182. Meetings held according to schedule 1073. Regular attendance 174. Regular recording of minutes 128

70.263.745 .816.2

29.88.65t.26.0

l35

30

50488610

- 168 100.07.7 168 t00.03.0 168 100.0t7.9 168 100.0

The irregular attendance of some members of the Village Committee may be attributedto either lack of time to spare owing to their busy work schedule or a lack of enough motivationto be totally involved in community health and development activities.On further examination of the study villages it was revealed that at the most, there isone fund or less, for every ten villages. This typifies a lack of social organization amongstthese villages. The findings are presented as follows :

Table 2.15 : Status of Village Development PlansNo. of VillageDevelopment

PlansTotal PlansNo. of Acc


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37ECONOMIC STATUS OF THE VILLAGES

The following table illustrates the average yearly income of the villagers under theresponsibility of the VHCs/VHVs :Table 3.1 : Average Yearly Household Income of Villages

Baht PercentageLess than 10,00010,000 - 50,000More than 50,000

'7.677.415.0

It can be seen that the majority of households have an income between 10,000 and50,000 baht. (US$ 370-1,850, Y 58,800-294,117)BASIC INFORMATION ON VHCS AND VHVS3.3.1 Period of Volunteerism

Most of the individuals (89.490) have been working 0-5 years as VHCs or VHVs3.3.2 AgeThe majority of VHCs/VHVs (64.9V0) are younger than 34 years, while very

few (1.490) are aged 60 and over.3.3.3 Highest Educational AttainmentApproximately 96.6V0 of the VHCs/VHVs have completed primary school,

while only .8% have gone beyong secondary school.3.3.4 OccupationAgriculture is the predominant livelihood for VHCs and VHVs. Overall, 84.890

are involved in food production : 44Vo in fruits, 20.190 in rice farming and 20.7V0 in othercrops, respectively.

3.3.5 Number of Assigned HouseholdsMost VHCs/VHVs have either l0-14 or 5-9 households (4190 and 39.lVorespectively) under their jurisdiction.3.4 Flvaluation of the activities of VHCs and VHVs3.4.1 llducating the VillagersIn this study, the educational activities of VHCs and VHVs were analyzed basedon their regular functions as recommended by the Ministry of Public Health (MOPH). Theireducational functions are classified into 25 activities within the eight components of PHC asfollows :I. Food and Nutrition Educational Activitiesl. lntroduction of nutritional supplementary food

2. lntroduction of appropriate infant feeding3. Recommendation for weighing of all children aged 0-5 years4. Recommendation for growing vegetables*ASEAN Training Cente/Chantaburi Model Development/002(Data Collection form for VH Vs/ VHCs)


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38II. MCH Care Educational Activities5. Promotion of antenatal care6. Recommendation of tetanus vaccination for pregnant women

7. Promotion for giving birth at the health centers8. Promotion of child health examinationIII. Family Planning Educational Activities9. Promotion of family planning education10. Information on various methods of birth control

I l. Information about sterilizationIV. Environmental Sanitation and Garbage Disposal Educational Activities

12. Promotion of house cleaning13. Promotion of appropriate sewage disposal14. Promotion of organic fertilization using garbage and fecesV. Clean Water Supply Educational Activities15. Information on the consequences of drinking contaminated water16. Information on water purification17. Promotion of improvement in sewage systemsVI. ImmunizationEducationalActivities18. Promotion of infant immunizations19. Recommendation to behead suspicious animals for rabies examination20. Promotion of tetanus vaccination for pregnant womenVII. Local F]ndemic Disease Control llducational Activities21. Promotion of common disease prevention22. Education on self-treatment for simple illnessesVIII. Drug Cooperative Educational Activities

23. Promotion of the merits of drug cooperatives24. Promotion of the utilization of drug cooperatives25. Promotion of the referral system from drug cooperatives to the health centersBy analyzing the 25 educational activities of the VHCs and the VHVs according to theeight elements of PHC, it was generally found that the VHVs have performed these activitiesmore often than the VHCs (see table 3.2)


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403.4.2 Participation in Health ActivitiesAccording to a recommendation by MOPH, l9 areas have been set as guidelines for

activities of VHCs and VHVs. They are :i. Weighing all children aged 0-5 years3. Appointements for antenatal care4. Appointments for vaccination of pregnant women5. Appointments for infant vaccinations6. Establishment of the health card fund7. Establishment of a sanitation fund8. Establishment of drug cooperatives9. Treatment for minor illnesses10. Selling drugsI l. Teaching about drugs12. Distribution of pills13. Distribution of ORS14. Taking blood for malaria examination15. Promotion of medicinal herbs16. Birth survey17. Death survey18. Government information dissemination19. Recording of activitiesTable 3.3 : Participation in Health Activities By VHCs/VHVs

VHCs VHVs P-ValueActivities Always Sometimes Total Always Sometimes Totall. Weighing all 49.3 3l.l 8l.l 75.6 20.7 96.3 0.0001*

children aged 0-5 yrs2. Production of 13.6 20.3 33.9 19.5 20.0 47.5 0.0290supplementary foods3. Appointment for 22.7 28.0 50.7 26.8 35.4 62.2 0.1719antenatal care4. Appointment for 21.0 29.0 50.0 41.5 25.6 67.1 0.0006vaccination ofpregnant women5. Appointment for 3l .5 30.4 6l .9 36. I 9.6 65.7 0.0067infant vaccinations6. Establishment of 8.7 4.2 12.9 2.0 3.7 25.7 0.0225the Health CardFund7. Establishment of a l0.l 9.1 19.2 18.3 8.5 26.8 0.1437sanitation fund8. Establishment of 49.7 19.6 69.3 63.4 13.4 76.8 0.2981Drug Cooperatives9. Treatment for I I .5 25.2 36,7 43.9 35.4 '79.3 0.0000minor illnesses10. Selling drugs 8.0 I 1.9 19.9 50.0 I 1.0 61.0 0.0000

I l. Teaching about 17.8 39.2 57.0 29.3 84.2 54.9 0.0000drugs


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41

Activities VHCs VHVsAlways Sometimes Total Always Sometimes Total

P-Value

12. Distribution of pills13. Distribution of ORS14. Taking blood formalaria examination15. Promotion ofmedicinal herbs16. Birth survey17. Death survey

18. GovernmentInformationDissemination19. Recording ofactivities

0.35.28.43.5

t9.216.839.9

27.3

3.57.06.67.3

22.4I 5.026.2

29.0

3.812.2r 5.010.84t.631.866. l56.3

15.952.418.36.1

37 .834.161.0

35.4

13.4t7 .l14.6

t.J30.529.319.5

42.7

29.3 0.000069.5 0.000032.9 0.0012t3.4 0.219868.3 0.000263.4 0.000080.5 0.017578. I 0.001 5

Overall, it may by deduced from the above table that VHVs have performed all of thel9 activities more often than the VHCs. These differences are statistically significant at thelevel of oC :0.05 on the Chi-square test for most of the activities except:activities number three(appointments for antenatal care), number seven (establishment of a sanitation fund), numbereight (establishment of drug cooperatives and number fifteen (promotion of medicinal herbs).The percentage of the VHCs who participated in the l9 activities ranges from approxi-mately 3.890 - 8l.l9o. The activity which is performed most often is number one (weighingall children aged 0-5 years) and the least performed activity is number twelve (distribution ofpills).

The percentage of the VHVs who participate in the l9 activities ranges from approxi-mately 13.4Vo - 96.3V0. The most often performed activity and the least often performedactivity are the same as the VHCs, that is; weighing the children and the distribution of pillsrespectively.Conclusi on / Recommendations on the Evaluation of VHCs andVHVs Primary Health Care Activities in the Study Villages

Based on the foregoing findings it was concluded that there exist a general deficiencyin the dissemination of health edu-cation information and in the VHCs and VHVs participatoryrole in community and health development which may have been the result of an apparent lackof knowledge among them on critical issues in relation to maternal and child health care. Therecording and reporting systems were not satisfactory, nor were growing importance of tradi-tional medicine.In general, insofar as MCH/EMC is concerned result showed that VHVs were moreinformed and have better attitude about MCH compared to VHCs. Most common disease

attended to was, malaria (57 .lVo) : the least was tuberculosis (390). The three most commoncomplications of pregnancy were ; Abortion (l7.9Vo), Caesarien Section (17 .lVo) and Prematuredelivery (9.390). Among the under five age group, the three most common diseases were;diarrheal diseases (25.890), malaria (18.890) and laboured breathing (l4.l9o). These was a


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42reported mortality of 20Vo during the study period. Of these 61.890 were male and 38.290female. Age specific death percentage were; below l5 (l1.2Vo), 15-69 (20.4v/o) and above 69(31 .4Vo).

From the above conclusion it may be strongly recommended that VHCs and VHVsknowledge, attitude and practice as regards to existing MCH problems be improved for a moreeffective health promotive and curative role in the village. Likewise the system of recordingand reporting has to be periodically monitoreci to assure accuracy, and lastly, that the VHCsand VHVs be given additional information on the extent and limitation of herbal medicinesavailable in their respective village of responsibility.

SURVEY OF THE KNOWLEDGE, ATTITUDE AND PRACTICE(KAP) OF WOMEN IN THE REPRODUCTIVE AGE, GROUPON MCHA total of 945 married women in the reproductive age group (15-44 yrs.) were interviewed.83.990 of the sample were less than 35 yrs. old. 77.6Vo have completed primary school. Majoroccupations were rice farming (23.3V0), farming other crops (1990) and growing fruit trees(1990). Approximately 54.3V0 of the husbands were within 25-34 yrs. Income varies frombelow B 10,000 to a maximum of B 50.000 per annum. The average number of children inthe sample family were 2.It appeared that the proportion of women who have the proper knowledge, attitudeand practice in regard to MCH care is much lower than VHCs/VHVs. Except in some aspectof understanding child development. This phenomena could be attributed to direct experiencesby the mothers during child rearing. 72.9o/o of the respondent had taken their children forvaccinations, however : there is an apparent lack of knowledge on the importance of immuni-zation. 87.3V0 were alcoholic beverage drinkers. 9l .7Vo were non-smokers and 88.390 neverused insecticides during their pregnancy. Nutritional behaviour during the prenatal periodwas inadequate among the majority of the respondents. Almost all professed knowledgeto the danger of the practice of induced abortions, however: majority do not understandthe life-threatening danger nor the symptomatic manifestations of toxemia of pregnancy(97 .lVo), cervical carcinoma (9390), puerpueral sepsis (94.390) and post partum hemorrhage(9l .7Vo) when these diseases,/manifestations were asked of them using simple terminologies.


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TRAINING OF GRADUATE HEALTH VOLUNTEERSSelection and Training of Graduate Health Volunteers (GHVs)

The recruitment of GHVs started in May 1985 by newspaper advertisements and univer-sity bulletin announcements. It must be mentioned at the outset that preference for GHVsselected are given to those, who are not graduated in health or health-related field. This may bean innovative approach to the usual standard criteria for health volunteer workers. This com-pletely new approach is based on the concept of the preparation of leaders in health. Tappingthe group of young and educated volunteers who have completed their Bachelor's degree, atthe height of their stamina and the prime of their ideology will produce a multiplier effect onthe number of potential health leaders imbued with first hand knowledge about health, healthservices and ultimately health service delivery.During the process of selection, the project implementors were constantly aware thatthese volunteers will have to commit themselves over a year to serve a community whose populationthey do not know, whose needs they are not familiar with and whose health problems they areeven more strangers to, hence; it becomes imperative that extreme care and a highly circumspectattitude be excercised throughout the selection process and as the project is implemented aconstant monltoring is of priority requisite.The Selection ProcessA GHV inorder to qualify for selection should have a Bachelor's degree on any of thefollowing fields-political science, education, English, Geography, communications, sociology,etc. in addition to an expressed desire and interest on health and development activities. A totalnumber of 675 applicants responded in 1985 and 1,024 applicants in 1986.A written examination on the understanding of health and community developmentactivities, the importance of health to the population at large, civic involvement, communica-tions ability and strength of leadership is given to the candidates, reducing the number ofcandidates to 150.Individual interviews were than conducted inorder to assess leadership potential,maturity and extent of commitment among the candidates, from which 15 candidates and 25alternates were finally chosen to undergo the first three week training course.The Training Programme

The training programme may be categorically subdivided into : theoretical and practicalcomponents for a total duration of eight weeks.The initial three weeks is devoted to the theoretical aspect of primary health care andhealth related activities including community development. The objectives of the project hasbeen discussed in great detail to enable the GHVs to self-assess their extent of interest and theirdegree of commitment.Of the original l5 chosen for the job during the second year of project operation, 12decided to stay. The 3 drop-outs were then substituted with the same number of alternates.The fourth week of the theoretical component of the training process is spent on a study-tourof several provinces located in the eastern part of the country where the GHVs had a first-handexperience of how community-oriented activities are carried out. They were specifically broughtto withness places with successful achievement on community-oriented activities.

The practical component of the training programme is held in Chantaburi province.Following a formal introduction to the area, the GHVs received two weeks of instructions onmaternal and child health care and one week of training on emergency interventions at theCommunity Hopital. This one week of training also incorporates knowledge on primary health


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44care activities and the proper referral channels. Their fourth and final week is spent on theirfuture site of assignation.

Thus the GHVs have been given a realistic job preview for each model area and as agroup were allowed to make their decision as to who will be preferable to what situation.The RemunerationEach GHV is given a monthly subsidy of three thousand Bath (p 3,000) equivalent to

an approximate one hundred fourty five dollars (US.$ 145.00 , Y 17 ,U7) to cover living expenses.Likewise a motorcycle is provided to facilitate outreach to the scattered household.The Expected OutcomeIt is envisaged that through the variety of educational experience the GHVs have beenexposed to during their academic years; an interplay of social science, formal training in politicalscience, geography and topography and their interaction with researchers and the community;an innovative model for PHC activities will be realized both creative and practical and tailored-cut to meet the felt and unfelt needs of the people at the grass-roots level. Concurrently theGHVs will be given a chance to evaluate there own orientation under an aura of complete in-dependence. The GHVs able to develop their decision-making capabilities and identify theirown strengths and weaknesses and ultimately re-inforce their self-confidence while developingfull leadership potential in health and in their respectively chosen field of endeavors.The Process of Evaluation

Progress of GHV activities will be closely monitored by the research team in collaborationwith the Project Manager.The different parameters for measurement of the effectiveness of the GHVs are :l. perception of his/her leadership role by the community2. final written report3. his/her productivity as perceived through process indicators by the Village Com-mittee, village health communicators, village health volunteer and on-going health developmentactivities in his/her village of assignation; and through health indicators (birth weight, infantmortality, maternal mortality, malnutrition cases). However; not all favorable perceived resultsmay be solely attributed to the GHVs, hence the limitation of measurement by health indicators.

Theoreticaf Training at ATC/PHC (May 1-23, 1986)(Example of GHVs Batch II training program)Dav Session Hrs. Lecturer(s)Module l.Problems of Developing Countriesl. Orientation2. Mahidol University and theGHV training program3. Problems in developing nations andthe roles of GHV's4. Socials (getting to know each other)5. The national health policy in the VIEconomic and Social Development Plan

6. Concepts and principles in theintegrated rural developmentand concerned organizations3. 7. Nat'l economic problems andthe necessity of rural development.

Title

2.

aJ-JNational 3

ATC staffThe Rector of M.U.

ATC staffATC staffHealth PlanningDivision, MOPHNESDB

NESDB


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45

8. Social problems andrural developments

3 Social Science Dept.M.U.4. 9. Educational problems and the 3 NESDBnecessity of rural developments10. Group activities 3 -I l. Summary of the module l. llz ATC staffModule 2,PHC5. 12. Concepts and principles of pHC 3 Office of pHCMOPH

13. PHC strategies 3 Office of pHC.MOPH6. 14. PHC & QoL movement 3 Representative fromQOL committee,NESDB15. Health educarion in pHC 3 Faculty of pH7. 16. MCH in PHC 3 Faculty of pH17. Health Card Fund 3 Representativer fromHCF committee.MOPH8. 18. Expanded Immunization in PHC 3 CDC. MOPH19. Environmental sanitation in PHC 3 Faculty of pH9. 20. The provision of essential drugs in 3 Government phamaceuthe community tical Bureau

21 . Treatment of common diseases 3 Folk Doctor Magazine10. 22. Dental Health in PHC 3 Dental public HealthDivision, MOPH23. Mental Health 3 Mental Hospital,MOPHll. 24. Nutrition in PHC 3 Division of NutritionMOPH25. Self-manged PHC village and 3 MOPHMini Thailand Project26. Summary of Module 2 lY, ATC staffModule 3 Rural Development12. 27 . The utilization of BMN 7, 2, 3 3 ATC staffforms for community survey28. Community preparation 3 ATC staff13. 29. Community diagnosis and 3 ATC staffplanning in the community30. Leadership in rural development 3 The Center forContinuing Education,MU


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46t4. Human relations for rural development

Summary of Module 3Closing ceremony for the training

STUDY TOURThe programme consist of one day study-tour in various areas of successful PHC servicedelivery. The objectives of the tour is to expose the GHVs to actual implementation of PHCand rural development programme, learn various strategies and be zible to device their own

strategies in accordance to the needs of the population in their community of assignment.FIELD TRAINING IN CHANTABURI

Thisconsist of a one month programme of activity divided as follow :- Two weeks training on health center activities, including; MCH and EMC, treatment,prevention and control of common diseases, referral system and the mechanics of rural develop-ment. - One week training at the community hospital- One week training at the health centre

ON THE JOB TRAININGThe longest and most important part of GHVs' training is the actual field operation.This lasts for nine months during which the GHVs put all of his theoretical knowledge intopractice. The GHVs are expected to learn and apply the mechanics of good public relations and

maintain colaborative working relationship with the villagers, the village committees, the researchteams and with the health and other concerned government agency personnel. They will haveto face and cope with day-to-day constraints in the implementation of their activities. Moreover:they are envisaged to formulate solutions to constraints and recommendations to the next batchof GHVs for a more successful programme delivery.COST OF TRAINING

An application fee of f l0 (US$ 0.37, Y 58) and and examination fee of I :O (US$ l.l l,Y 176) has to be paid for by every applicant.The ATC/PHC is responsible for the entire training expenditure in addition to amonthly allowance of B 2,500 (US$ 92.59, Y 14,700) for each candidate qualifying for the postof GHV.MONITORING AND EVALUATION

As was previously indicated the thrust of the project is on the GHVs in their projectedrole as an additional support system strengthening the existing primary level of the health careinfrastructure in an effort to optimize primary health care service delivery.

The GHVs can spell the difference between the failure and success of the project, hencecareful periodic monitoring of their activities is considered critical.

The GHVs are expected to perform a number of activities in addition to their functionalrole in the delivery of preventive, curative and rehabilitative health services to the community.Periodic reporting of their activity through written records in what is known as a GHV "diary"(which is actually an ordinary note book provided for by the project operation staff) and formalwritten reports sent to the ATC/PHC will be a good indicators of the GHVs efficiency. Per-formance Evaluation Survey will on the other hand, enable the project staff to measure the GHVseffectiveness as perceived by the community they serve. This method of evaluation will be a

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3 ATC staff3 ATC staff


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47good indicator as to the leadership potential of the GHV.Much as they are vital to the sucessful project implementation, not only the GHVs areto be monitored and,/or evaluated. Each and every component activity will be periodicallyfollowed up. Research teams are expected to submit research reports/results. Project milestoneswill be extablished for ease of surveillance of the major events related to the project implementa-tion. The rate of project delivery will be measured in accordance to percentage of funds disbursedper project activity as stipulated over a time plan of operation.Monitoring and evaluation will always be a vital project component in this particularproject as they are in the successful implementations of any project.REPORT OF THE FIRST BATCH OF GRADUATE HEALTHVOLUNTEBRS (1986-S6)

In April 1985 : 675 young Bachelor of Science degree holder had responded to theadvertisement of ATC/PHC Mahidol University for volunteer health workers in the provinceof Chantaburi. After a rigid screerting process which consisted of both theoretical examinationand personal interviews, l5 were selected for the post of GHV and 25 as alternate, to undergoan 8 weeks training programme.The following are the final list of GHVs who have completed their one year stayin Chantaburi province, their final report of problem assessment and their commendableattempt at problem solving of perceived constraints to PHC service delivery existing in theirrespective areas of assignation.Names of the first batchNamel. Miss Kannika Promsao2. Miss Kanjana Prepree3. Miss Chanalai Lertpraplut4. Miss Chamaiporn Srikanok5. Miss Nareerat Samrongrak6. Miss Panpit Toprakone7. Miss Plernsiri Sirisampan8. Miss Rungnapa Srisad9. Miss Somruedee'Sarapirom

10. Mr. Surasak Jamcharoenll. Mr.Somsak Sriwatanatakul12. Mr.Suchat Titayanpong13. Miss Supis Puhin

Graduate Health VoluntersAcademyChiang-mai UniversitySuansunanta Teacher'sCollegeSrinakarinvirote UniversityKasetsart UniversityRamkamhaeng UniversityRamkamhaeng UniversityChulalongkorn UniversitySrinakarinvirote UniversitySrinakarinviroteUniversityRamkhamhaengUniversityChiangmai Teacher's CollegeChulalongkorn UniversitySrinakarinviroteUniversity

Working areaTambon ZuengTambon rKlongnaraiTambon SlangTambonTakientongTambonSanamchaiTambonNongtakongTambonChangkamTambonPlubplaTamboonWanyaoTamboonSampeenongTamboonKanghangmeawTambonPatongTambonTakadngao


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4814. Miss Ajima Jinwala15. Miss Usa Khiew-rod

SrinakarinviroteUniversitySongkhlanakarinUniversity

TambonSaikaoTambon rKoa-perd

As part of their theoretical training the GHVs, were guided in the presentation oftheir reports to include the following salient expects :- geography- main occupation- problems in primary health care development- perceived role of the GHV in primary health care and community developmentactivities- accomplishments in their community of assignment- constraints encountered during the period of assignment- suggestions ,/ recommendationThe GHVs were provided with a notebook which serves as their diary wherein theykeep note of their activities.The report submitted by the GHVs will be an indicator of their performance inaddition to their interaction with the researchers, the village population and the healthcentre staff. An evaluation of the GHV performance will be conducted at the end of theirassignment.Any GHV found to the highly competetive, totally dedicated and willingly committedto his community of assignment has a chance to compete for the post of senior GHV. The

senior GHV will exercise supervisory functions over the second batch of GHVs. A seniorGHV will receive a monthly subsidy of Baht three thousand five hundred (ts 3500) which isequivalent to US $ 129.62 Y 20,500

CONCLUSION DERIVED FROM THE GHVs REPORTThe following report has been the result of a cumulative experience during the eightmonths assignation of a group of young, educated and hard working GHV in their respectivevillages of assignment. The views and opinions expressed were strictly of the GHVs and notof the project personnel.

COMMUNITY PROBLEMIt is obvious that the topographical location of houses in Chantaburi has greatlydisadvantaged the health service delivery system. This has even been compounded by aninherent lack of interest in health and community participatory activities brought aboutby ignorance, high migration rate and the villagers total absorption in their jobs. Anothergreat handicap is the insufficiency of water supply causing health problems to remainunabated.PROBLEMS THAT THE GHVs HAVE ENCOUNTEREDIt is noteworthy that the report incorporated experiences that varied from lack ofidentity, with the consequent feeling of insecurities and inadequacies at one extreme.; and atotal command of the community, from problem identification to problem solution; atanother.


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50as an adviser on the organization & management of community development fundas an assistant in the strengthening of health center information systemas a disseminator of health information to VHCs / VHVsas a supervisor to VHCs / VHVs performanceas a motivator to community participation in health and health-related activitiesas a participant to meetings, and other community development activities

GHV's Accomplishment in the Community of Assignment- Participated in road and bridge repairs- Promoted supplementary food preparation by demonstration and nutrition education- Reviewed the neglected drug fund- Conducted health education lecture both in the community and in school- Facilitated communications between villagers and health centre officials* Home visitation- Conducted special immunization campaign in highly remote village (tetanustoxoid to pregnant women and immunizalion against common childhood diseases to childrenunder five years of age)- Sppervised VHCs / VHVs activitiesSuggestions / Recommendations

- Strengthening of leadership role of village leaders- Improvement of collaborative activities among community leaders, health authoritiesand various government officials.- Repair of roads and bridges- Recruitment of an agricultural consultant to improve technology and produce

Tambon Koa-Perd - Lamsingha District - CHANTABURIMiss Usa Khiew-rodProblems in Primary Health Care Developmentl. High rate of migration causing difficulties in disease control2. High incidence of venereal diseases due to the presence of massage parlours / bars3. High incidence of haemorrhagic fever. Insufficient water supply forces the villageto store rain water in container jars which are good breeding places for dengue-causingmosquitoes4. Poor sewage disposal5. Poor roads6. Poor community participation7. Poor organization of health center staff / health centre activities8. Inefficient supervision of health centre staff by their superior officersPerceived Role of GHY in Primary Health Care and Community Development

as coordinators between the.community and the health authoritiesas motivators in community development activitiesas supervisors of VHCs and VHVs

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51Constraints Encountered During the Period of Assignmentl. The GHV is perceived as a fault-finder by health centre personnel2. The GHV owing to his frequent questioning and consulting is made to feel to bemore of a liability than an asset by the health personnel as GHV tends to interfere with theirdaily activities.3. The villagers regard them as medical doctors, inability of the GHV to meet theseexpectation has led to frustration and distrust of GHV by the community.GHV's Accomplishments in the Community of Assignment- Participated in solving managerial problems related to community funds.- Encouraged community leaders in strengthening their roles on health anddevelopment activities- Surveyed and collected health statistics for use as baseline data in planning healthactivities- Liased with other health organigations in the conduct of health and health-relatedactivitiesSuggestions / Recommendations- Orientation of community leaders on their role on leadership for health- Promotion of the concept of team work to strengthen cooperation and collaborationamong GHV and health centre staff- Dissemination of information on the health significance of community organizations

- Improvement of the existing supervisory methodology favouring unannouncedsupervisory visit perceieved as more effective than the present planned visit.- Promotion of secondary occupation during off - planting / harvesting - seasonsfor income generation and as a deterrent to frequenting bars / massage parlours- GHVs should be based in the villages and not in the health centres so as toavoid unaccessary expectations from the villagers leading to frustration and distrust. Livingwith the villagers will allow a greater interaction between the GHV and the community.Tambon Kang Hang Meaw. Tamai District - CHANTABURIMr. Somsak SriwatanatakulProblem in Primary Health Care Developmentl. Poverty2. Poor communications3. Crimes and assault mostly due to land dispute4. Illiteracyperceieved role of GHV on Primary Health Care and Community Development

- as a coordinator between the community and the government sector- as a source of knowledge and information regarding health and communitydevelopment activitiesas a social agent of change among the villagers and the village leaders- as a model of good health and high morale to the members of the community


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52Constraints Encountered During the Period of Assignmentl. Lack of public interest on health2. Inability to perceieve GHVs role by community / government officials hence thedifficulty of coordinating activities for them3. Communication gap due to the sparsely distributed household and the presenceof hill / hillocks4. Lack of means of tranportaion5. Weak performances of VHCs / VHVs6. Lack of community participation by the community leaders themselve,7. Frequency of migration and high mobility compounding the problems ofcommunications and follow-upGHVs Accomplishments in the Community of Assigment- Gave health education lecture on MCH / FP and PHC- Advised on proper waste and sewage disposal- Exemplified benefits derived from community participatory activities and communitydevelopment funds- Liased between the village and concerned government officials on matters of healthand health - related activites- Participated in meetings with the 4 major ministriesSuggestions / Recommedationsl. Need for a working manual for GHVs2. Need for a vehicle for access to remote areas3. Need for additional information on communities that are highly inaccessible

Tambon Sanamchai. Tamai District. CHANTABURIMiss Nareerat SamrongratProblems in Primary Health Care Development

l. Lack of adequate prenatal, delivery and postnatal care including family planning2. Maternal and child malnutrition due to lack of nutrition education3. Lack of knowledge on the nutritional values of breast feeding, appropriate kind ofweaning food / breast milk substitiltes4. Poverty compounded by poor communication facilities5. Lack of community participation6. Poor coordination of health centre activities giving rise to frustrations and distrustsamong health center clients7. Lack of full comprehension by VHCs / VHVs on their role in health servicedelivery


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53Perceived role of GHv on primary Health care and community Development

- as a participant to problem - identification and analyses- as a coordinator between health officials and the members of the communitv- as a coordinator for village health activitiesas a support system for a more effective perfomance by health officials- as a supervisor and evaluator in the management of community fundas a supervisor and evaluator of VHCs and VHCs performanceas a participant to meetings of health officials- as a stimulant to community participation- as a disseminator of health information- as a participant to community development activitiesconstrainst Encountered During the period of Assignment _ mentI ' I-ack of decision - making authority, decision making is being relegated tohealth centre personnel2. Lack of vehicle3. Lack of constant contact with inaccessible communities for fear of safetv4. Lack of community participation5. Poor perception of the GHV's roles by VHCs / VHVsGHV's Accomplishments in the community of Assigment ment- Gave health education lectures- Lectured on environmental sanitation- Lectured on benefits derived from community funds- Acted as coordinator between the communily and government officials- Acted as trainer in training courses held in the Tambons- Participated in meetings among the four major ministriesSuggestions / Recommendationsl. Need for a vehicle2. Training on curative services for GHVs3. Decision - making authority not to be a sole prerogative of health centre officials4. Provision of a GHV workins manualTambon Nong Ta Kong. Pong Nam Ron District. GHANTABURI

Miss Panpis Toprakone.Geography :

General area is composed of hills and plains, Communications is feasible and thehouses are located in big groups. This area is a frontier near to cambodia.People are local villagers, they speak Ka-maen language, while the others are migrantsfrom Northeast of Thailand.Occupation - Agriculture and labour


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Problem in Primary Health Care developmentl. Sparse distribution of household2. Poor agricultural technique3. Poverty and poor health status4. Lack of knowledge on the importance of community development5. Conflict between villagers and health officials responsible in the area6. Problems between the migrants and the local residents7. Illiteracy8. Lack of participation from government officials

Perceived Role of GHV on Primary Health Care and Community DevelopmentActivities- To explain the GHV role to the villagers for better understanding of his ,/ her presencein the community- To make the people realize the importance of knowing their health problemsand to help them analyze and solve those problems- To participate in community development activities- To coordinate health and health-related activities among different categoriesof government official assigned in the locality

GHY's Accomplishment in the Community of Assignment- Participated in Tambon council and village committee meetings- Supervised VHCs and VHVs and the drug funds- Coordinated with the mobile medical unit of the provincial health office- Demonstrated supplementary food preparation with agricultural officers- Home - visitation- Conducted school health care service- Conducted training programme on MCH / Fp / EMC for VHCs / VHVs- Improved the physical set-up of the health center and its surroundings

Constraints Encountered During the Period of Assignmentl. Misunderstanding between GHV and health centre staff due to poor delineationof role and activities of GHVs2. Lack of means of transport for GHV3. Lack of interest among villagers on community development4. Lack of understanding of GHV role by the community5. Irresponsible performances of VHCs / VHVs6. Poverty

Suggestions / Recommendations- Increase the responsibilities of government officials on community development bytarget - setting on important community activities- Increase the knowledge and understanding of the community on the importanceof community development activities- Improve knowledge of VHCs / VHVs on their role and responsibilities in healthand community development


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56- Provide GHVs with operation plan to assist them in the performance of theirdaily activities- GHV should consult health centre staff if problems arise during their performance- Researchers should explain in detail their research activities to the health staff- Researchers should invite participation among GHVs and health staff during theirmeetings- Researchers should give support to GHVs in the performance of their researchactivities

Tambon Chang-Kham. Ta Mai District. CHANTABURIMiss Ploensiri Sirisempan

Geography :Health centre located far from the main road (about 8-9 km.)

Occupation : Agriculture, gardening, fisheryProblems in Primary Health Care Developmentl. Lack of communication between the villagers and the health centre staff2. Non - participation of health official with VHCs / VHVs activites3. Lack of knowledge on the importance of adequate pre-natal care4. Poor understanding of GHV role in the communityPerceived Role of GHV on Primary Health Carre and Community DevelopmentActivities

- To join the health officials in the identification, analyses and problem - solvingof community health problems and in the preparation of the community- To coordinate between government and NGOs on health and health - related activities- To coordinate PHC activities among the community and the health officers inPHC activities- To encourage health officials in the use of innovative approaches in health servicedelivery To motivate community participation in PHC activitiesTo submit periodic performance reportTo disseminate knowledge on PHC to VHCs / VHVs and evaluate their performanceTo participate in community development activitiesTo participate in follow - up and evaluation of fund management activitiesTo strengthen health centre management information systemTo act as health educator to the villagersTo go on home visitationsTo keep the health centre clean

GHV Accomplishments in the Community of Assignment- Assisted the auxilliary health midwife in MCH / PHC activities- Assisted in the baseline survey- Acted as a health educator- Participated in religious ceremonies- Participated in supplementary food preparation and other nutrition-relatedactivities


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constraints Encountered During the period of Assignmentl. Health centre charged fees for consultation as a result of which people are discouragedto seek medical advise unless in extreme cases of emergency2. Lack of means of transportation3. Poor perception of CHV role by the health centre staff

Suggestions / Recommendations- More frequenr home visitation for better coverage- Provision of an outline as a guide to daily activities- Greater emphasis on the practical aspect of the training program- Meeting time and dates should be fixed in advance- The format of the meeting should be based on participatory discussion and notjust presentation- Need for a sphygmomanometer to enable GHV to take blood presure readings- Need to function as a VHC to motivate VHC in the performance of theiractivities

Tambon Wan-yao. Klung District. CHANTABURIMiss Somruedee SarapiromGeography :

Health centre located beside the main road so communication is feasibleProbiems in Primary Health Care Developmentl. Lack of interest in health and hygiene due ro lack of knowledge2. False beliefs / rraditioni on matrers related to health practices3. weak community leadership and poor community participation4. Lack of trust on health official5. Insufficient water supply6. Poor family planning acceptance due to lack of interesrPercived Role of GHv on primary Health care and community Development- as a health educator and informer - to correct false beliefs and superstitionsabout health problem- as a supervisor to VHCs / VHVs- as an advisor in the construction of tanks for water storase- as a family planning motivator- as a liason between health official and villagers to re-instore the trust of thevillagers on their health officers

- to assist in the selection of potential replacement to the present village head manwho has shown little interest in his communityGHV Accomplishments in the Community of Assignment- Assisted in MCH data collection- Supervised VHCs / VHVs


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58Home visitationsSchool health educationFP motivations

Constraints Encountered by GHV During the Period of Assignmentl. Lack of transportation facilities2. Lack of interest among the affluent member of the community on GHV activities3. Disrruption of GHV activities due to frequent absence of health centre staffSuggestions / Recommendations- Better explanation of GHV role to health officers- Participation of GHV in all health centre activities

- Better understanding by GHV of community development fundsBan Ta Moon Health Centre. Tambon Sai Kao. Pong Nam RonDistricts. CHANTABURI Miss Ajima JinwalaGeography :

The health centre is responsible for 5 villages, in which the houses are far apart.The problem is in the difficulty in gathering people to organige health activities.

Problems in Primary Health Care Development1. Poverty giving rise to malnutrition, disease and inability to participate

card fund2. Lack of information and communications due to poor media facilities3. Poor community participation as majority of the population are migrants4. Poor environmental sanitation

GHV accomplishment in the Community of AssignmentExplained the importance of membership to the health card fundParticipated in MCH / nutrition and other health centre activitiesSupevised VHCs / VHVsStrengthened health centre management information system

Constraints Encountered by the GHV During the Period of Assignmentl. Poor understanding

Primary Health Care a Continuing Challenge

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