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When will the mechanism of PHC (Primary Health Care) act? - the Case of Thailand - Masami Matsuda, Dr. Hlth. Sc. Prof. of Community Nursing, University of Shizuoka, Japan 1. PHC as an origin of the health rights issue of the late 1970' PHC (Primary Health Care) started to gain recognition after the famous Alma-Ata conference in 1978. The conference was jointly organized by WHO and UNICEF. After the Alma-Ata, the term PHC obtained citizenship in health professions and in the health policies of many countries. PHC appeared frequently in many declarations after the Alma-Ata, such as the declaration of Ottawa (Health Promotion) in 1986, which corresponds to changing health needs and life style, of Child rights in 1989, and of ICPD (International Conference on Population and Development) in 1994. ICPD refers to PHC in many chapters, which introduced sexual behaviors as an issue of reproductive health. Although, the PHC approach neither included life style, nor sex behavior in the late 1970's , PHC still had a landmark position in the field of health rights. The principles of PHC are well summarized in the following four components as defined by Kaprio; needs oriented, community participation, maximum use of resources, coordination/integration. These principles seem to naturally exist in most health activities, but in reality this is not necessarily so. PHC brought the issue of community participation into the health sector which was supposed to be controlled by health/medical specialists for a long time. Participation was restricted by a hostile political environment, especially the cold war between the east and west. Fortunately, in the field of health, because of PHC, many countries were able to adopt a policy of participation before the end of the cold war in late 1980's. The PHC approach almost reached its goal of "health for all" through various measures such as EPI (Expanded Program on Immunization), ORS (Oral Rehydration Solution), essential drugs, health volunteers, etc. The reason that "health for all" was not completely successful is the world economy was significantly affected by oil shocks as well as the fact that the 1980's were the decade of disappointment for development issues. In the field of health, the trend of improvement of health status in many countries was dramatic, but not so much as expected two decades ago. Then, the HIV/AIDS epidemic hit. The situation is getting more difficult year by year in most of countries. What can we do now? Here, I would like to show the experience of Thailand in 1970-1980, the era of Thai-PHC, before the HIV/AIDS epidemic. Table 1: PHC Project in Thailand Classified by Main PHC Activities
[ref. 7)]
2. Thailand, A Pioneer of PHC Thailand is famous for its success in the development and implementation of PHC. The government started PHC pilot projects as early as the 1950's. These included a Volunteer System for the Prevention of Malaria, which is the core of the Thai-PHC system. In the 1960's, health volunteer projects continued to be examined as Sarapee projects and this experience was integrated to the famous Lampang project. Those projects were supported by APHA (American Public Health Association), Hawaii University, founded by USAID. It didn't use the term PHC, but the content itself was similar to that of PHC. It is the same experience as Japan, that before Alma-Ata, there existed many activities on PHC in Thailand. The concept of PHC formulated at the conference supported those activities which already existed, and ensured political commitment in many countries. Based on those pilot projects, the Thai government started a national PHC program in 1977, one year before the Alma-Ata. It established the Office of PHC in the Ministry of Public Health in the 1980's, and over time many experienced personnel took the position of Director of PHC in the Health Ministry. This movement created more than 500,000 village health volunteers (VHV) throughout the country, established the drug co-op or fund in the community, and trained village leaders and monks who were influential people in the society. Through those activities the health status of Thai people improved significantly, as well as achieving most of the "health for all" goals in the last 20 years. What are the major reasons for PHC success in Thailand? 1)Political commitment: The Thai government officially supported these community health activities that would be beneficial to the health of the people, especially in rural areas and urban slums. It was the same in Japan, which held cabinet meetings on the social movement to control fly and mosquito populations through community participation in the early 1950's. 2)Human resources: The Thai government has an efficient system for accumulation of the experiences of technical staff in the health ministry. Several important personnel, who had a lot of experience with PHC in rural areas, came into important positions in the Health Ministry afterwards. The human resource recruiting system also saved the crisis of HIV/AIDS epidemic in the 1990's through a 100 percent condom use program by bringing innovative personnel from rural areas to be new directors in the central ministry. 3)International support: The conference also convinced technical personnel, who were opposed to the participatory approach, of PHC's credibility. Funds for the projects were provided by various international agencies, including JICA (Japan International Cooperation Agency). This support created the ATC/PHC (ASEAN Training Center for PHC Development) project at Mahidol University and provided the Ministry of Public Health with the framework for partnership and collaboration between recipients and donors such as Tokyo University and the National Institute of Public Health. ATC/PHC later became an institute in the university, namely AIHD (ASEAN Institute of Health Development). This support from those agencies continued during the HIV/AIDS epidemic of the 1990's. For example the Thai-Australian project called NAPAC (Northern AIDS Prevention and Care Program) which had supporting efforts to empower both local GOs and NGOs. 4)Unity in diversity: There were more than 300 PHC projects in Thailand. Each project tried to find a way to strengthen the PHC system from a different point of view. These efforts brought frequent information exchange among the people concerned and created the basic identity of Thai PHC which preserves the diversity of Thai culture. Table
2: Ratio of Health
Manpower to Population in Thailand
(Source: Health in Thailand
1991, 58, Ministry of
Public Health)
Table 3: Major Health Index
in Thailand
(Source: Health in Thailand
1991, 58, Ministry of
Public Health)
3. Current importance of PHC in the world of Asian people and cities 17 years have past, and people still refer to PHC. Why? There are several reasons why PHC is on a trial basis in many countries after Alma-Ata. In the countries where PHC is well established, thus having good health care infrastructure, HIV/AIDS related problems are rather modest. This is apparent in countries where PHC was functioning before the HIV/AIDS epidemic. Here people are more able to cope with other diseases such as TB/HIV. PHC is closely related with urban slums. If conditions for people in rural areas were those of poor education, low economic standard and insufficient health services, then families soon break down. These conditions lead to the migration of under educated young people from rural areas to urban slums. PHC could provide measures not only for urban slum health but for the reduction of slum areas.
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